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introduction human immunodeficiency virus epidemiology is disproportionately higher among various populations especially among the key populations compared to the general population the proportion of new adult hiv infections among key populations and their sexual partners was about 70 globally and 51 in subsaharan africain in 2021 1 several factors have been reported to fuel hiv across different populations and regions controlling and preventing hiv infection programs must be based on an intervention that works and based on need with focus on key populations and driver of the hiv epidemic hiv interventions that address the specific needs of key populations are vital to prevention efforts as countries work towards achieving both generalized and concentrated epidemic control female sex workers are among the key populations with higher vulnerability to hiv infection with an estimated 118 prevalence globally higher than the general population 23 similarly the rates of hiv among fsws are estimated to be 30 times higher than that of the general population especially among especially in lowand middleincome countries 14 a disproportionate burden of hiv infection is concentrated in subsaharan africa where an estimated 293 of sex workers are living with hiv with a prevalence of hiv infection among them estimated to be 26 times higher than that of the general population 5 data evidence indicated that about 80 of new hiv infections in nigeria were reported to be due to unprotected heterosexual sex with the majority of this occurring in key affected populations including fsws who account for about 39 of the new hiv infections in nigeria which could be due to only about 23 consistent condom use 567 generally there is evidence that sex work is often anchored in poverty victimization genderpower imbalances and lack of opportunities for those involved 689 the high hiv prevalence among fsws can be attributed to several factors beyond their control some of those factors include the inability of fws to negotiate consistent condom use with their clients occasional condom bursts during sex with partners with unknown hiv status getting used to certain clients leading to false trust and confidence accepting unsafe sex as safe sex and genderbased violence associated with fsw trade 391011 implementing strategies and interventions that prevent hiv infection among the fsws who a vulnerable subpopulation are will protect them and in turn reduce hiv transmission among the general population 12 for example firstly behavioral interventions such as the appropriate and consistent use of male or female condoms have been shown to reduce hiv transmission and decline hiv incidence rates across the world 13 14 15 16 however concerns have been raised that sometimes condoms may not be used for several reasons such as in rape cases personal choice or condom breakage 171819 in such situations the probability of hiv transmission may be reduced if the fsw is on prep the use of prep among fsw would be a game changer as they can control its use by taking it before they have contact with their clients several studies have reported that fsws who had a condom burst or been engaged in unprotected sexual exposure with clients with unknown hiv status didnt use postexposure prophylaxis and were not on prep to prevent hiv infection 171819 this shows that there is a gap in awareness willingness and practice of prep among this subgroup of the population literature evidence is rare on the awareness willingness and practice of prep among fsws in nigeria probability because the prep initiative was recently scaled up as one of the hiv prevention interventions secondly onestop shop is a communitybased antiretroviral therapy clinic model to improve hiv prevention and treatment cascade for key populations oss provides integrated services for hiv testing and services sti treatment clinical referrals and art to kps living with hivaids under one roof while protecting their privacy which is effective in reducing barriers to retention and adherence 20 therefore it is justifiable to assess the awareness willingness and practice of prep use among this highrisk group about two years after the introduction of prep the objective of this study was to determine the awareness willingness and practice of prep among fsws in uyo akwa ibom state the results from this study are expected to guide policymakers in the development of health education tools to strengthen fsws education to improve their awareness of prep and guide them on the usemisuse that may result in hiv drug resistance the findings will also be useful to hivaids funders and implementing partners in ensuring a kpsensitive approach to prep implementation thereby contributing to hiv epidemic control method study sites study design and study populations study site the study took place at uyo oss in akwa ibom state nigeria the oss provides prep to fsws and other kps as a core component of a comprehensive hivsexually transmitted diseases care and prevention package as part of primary prevention intervention the clients are counseled to use protection while having sexual exposure to balance counseling with practice the program provides condoms to the clients occasionally the clients have accidental unsafe sexual exposure due to drunkenness rape or condom burst or other reasons in such circumstances they are given postexposure prophylaxis as a preventive measure study design the study was a crosssectional survey carried out among hivuninfected fsws who received health promotion and prevention services at the one stop shop in uyo akwa ibom state southsouth nigeria between june and august 2020 study population the study participants consisted of all hivuninfected fsws who received health promotion and prevention services at the one stop shop in uyo akwa ibom state southsouth nigeria between june 2020 and august 2020 inclusion and exclusion criteria inclusion criteria the criteria for inclusion of participants were 1 participants must be female sex worker who uses the art services of the uyo oss confirmed hivnegative 2 participants are 18 years of age and older at the time of recruitment in the study exclusion criteria the exclusion criteria were those who were nonfemale sex workers not using the art services of the uyo oss were hivpositive and were less than 18 years of age and did not consent to participate were excluded sample size determination determination of the sample size for the study was done using the formula by 21 specifically the formula is 𝑛 𝑍 2 𝑝𝑞 𝑑 2 n desired sample size z the value of the normal deviation corresponding to the 95 confidence interval pthe proportion in the target population estimated to have characteristics being measured we adopted 72 knowledge d the error margin tolerated at 95 degree of confidence 005 this means 𝑛 2 2 𝑛 3841 × 02016 0025 𝑛 0769 0025 n 310 the minimum sample size was 310 however the sample size was adjusted for an estimated 15 number of participants to account for the attrition rate considering the challenges of discrimination and police harassment of the population studied that makes them scared always and highly mobile n 357 ethical considerations and consent ethical clearance for this study was obtained from the akwa ibom state ministry of health research ethics committee with approval number akhrec19721034 subsequently individual participants informed consent was also obtained to ensure that the study participant acknowledged understanding of the research study aims and objectives and understood that they can withdraw at any time with any negative consequence concerning the art health promotion and other services at the oss facility sampling method the selection of the study sample was done through multistage sampling firstly systematic random sampling procedure this was followed by a simple random sampling technique that involved the assignment of sampling units from the target population with an equal and known nonzero probability of being selected we used this sampling technique to ensure that female sex workers visiting uyo oss were independent of previous sampling units which will eliminate systematic bias from the selection procedure interview process and procedures those who met the inclusion criteria and consented to participate in the study were interviewed in a private room during the interview we explained the details of the study including potential risks and benefits of participation contact details were provided in case participants had further questions or comments relating to the research study data collection instrument the instrument used for this research study was a semistructured researcheradministered questionnaire to collect quantitative data the instrument sought demographic variables of the participants knowledge of willingness to use and practice prep pretesting of the questionnaire was done on 36 fsws in an oss in eket akwa ibom state the pretested data were collected before actual data collection to ascertain homogeneity and clarity of the questions and data collection procedure the questions in the questionnaire that were clear to the pilot participants were rephrased the pretested data and information were not included in the studys final data analysis an informed consent form was attached to the questionnaire which was given to the study participants those who qualified and consented to participate in the study were interviewed in a private room during the interview details of the study were explained including potential risks and benefits of participation contact details were provided in case participants had further questions or comments relating to the research study the first three sections of the questionnaire consisted of twelve singleresponse questions about the sociodemographic information and sexual orientation of respondents the study participants were asked to choose a response to questions on age marital status level of education religion duration of sex work average clients load boyfriend relationships condom use and involvement in anal and oral sex which were used to develop a profile on the respondents to establish independent variables for the study the second three sections of the questionnaire consisted of singleresponse questions about awareness willingness and practice of hiv prep respondents were asked to respond to questions on the effectiveness of prep as a preventive measure against hiv transmission to determine willingness to use prep the respondents overall awareness score on prep practice to identify selfassessment score on pep awareness as an impact on prep practice and their view on the use and willingness to recommend prep to prevent hiv acquisition to ascertain the willingness and practice of hiv prep find attached a copy of questionaries prep awareness and classification awareness score on prep was assessed using the knowledge variables with a score of 1 assigned to each correctly answered ranking done based on the total scores of respondents the total score was generated and the percentage score was categorized as 50 not satisfactory 50 to 75 fair 75 to 100 satisfactory a respondent scoring 75 or more was considered to have adequate awareness of prep willingness to use prep data collection and classification willingness to use prep questions were not structured using the likert scale for response instead the responses were structured using binary response ie yes or no when the respondent gave a correct response to questions she scored 1 point as shown in this section the total score was generated and computed as a percentage score the percentage score was categorized as 50 not satisfactory 50 to 75 fair 75 to 100 satisfactory a respondent scoring 75 or more was considered to have an appropriate willingness to use prep the practice of prep data collection and classification the practice of prep was assessed using the practice variables with a similar score and ranking based on the total scores of respondents the total score was generated while the percentage score was categorized as the total score was generated and the percentage score was categorized as 50 not satisfactory 50 to 75 fair 75 to 100 satisfactory a respondent scoring 75 or more was considered to have good prep practice data management and confidentiality data collected were extracted from the questionnaire coded and entered microsoft excel 2016 reviewed and cleaned to ensure the correctness and completeness of all variables collected to ensure confidentiality of participant information all data collected were deidentified and only serial numbers and coded numbers were used for data collection hard copies of data collected were locked in a cupboard and soft copies of excel file were saved in a passworded computer and access was s restricted to research team members only the cleaned and verified excel file was exported into the statistical package for social sciences version 200 for data analysis all categorical and ordinal data were presented in the form of frequencies and percentages while the age of the participants was summarized as means and standard deviation median and interquartile range for the descriptive analysis for the inferential statistics multivariable logistic regression analysis was employed to explore the association between prep and independent variables of interest at a probability of 5 level of significance and 95 confidence interval for all variables results of a total of 357 participants interviewed all participants consented and participated in the study with a 100 response rate however following data review and checking for correctness completeness and consistency of data a few responses with incomplete data were removed therefore only 344 responses were included in the data analysis sociodemographic characteristics of study participants in oss uyo akwa ibom sociodemographic characteristics of the respondents summarize participants age marital status religion educational status and years in the practice of sex work the mean age was 2906 ± 520 with about a third of the respondents being within the age range of 2529 the majority of the respondents had never been married and there was a comparable number of fsws with twelve years of secondary more than onethird and over twelve years of postsecondary education about threequarters of the respondents had practiced sex work for 5 years or less a high proportion of the respondents had adequate awareness of prep while a small proportion of less than onetenth of the respondents had an appropriate willingness to use prep common factors reported by respondents that may affect the use of prep were condom usage lack of knowledge about prep fear of side effects from the drugs and traditional beliefs associated with hiv infection less than half of the fsws reported that they had ever used prep the most common reasons reported for previous use of prep were that clients did not want to use a condom clients paid more not to use a condom and respondent decided not to use a condom association between awareness of prep and demographic characteristics in oss uyo akwa ibom analysis of the factors contributing to the awareness of prep among fsw in association with sociodemographic characteristics of respondents associated with adequate awareness of prep three factors namely age marital status and years in sex work were significantly associated with adequate awareness of prep among the study respondents this means that fsws in the age range 25 34 years are more adequately aware of prep than those 34 years of age participants who had never been married were three times more aware of prep compared to those who had ever married fsws who have had ≤5 years in sex work were 262 times statistically significantly more aware of prep compared to those who had 5 years in sex work association between awareness of prep and selected variables fsws who are aware of postexposure prophylaxis were one time more adequately statistically significantly aware of prep than those not aware of pep there was no statistical association with the other variables association between willingness to use prep and sociodemographic characteristics we found that none of the five sociodemographic characteristics of the respondents analyzed were statistically associated with the willingness to use prep if it was offered to them association between willingness to use prep and selected variables in oss uyo akwa ibom when willingness to use prep was compared with factors associated with sex work three of them weekly client load number of firsttime clients per week and condom use were significantly associated with willingness to use prep further respondents with a weekly client load of 011 clients were 1 time less willing to use prep if it was offered compared to those with 11 clients similarly a respondent that sees 011 clients weekly was 1 time less likely to use prep compared to one with 11 clients however those who see 07 firsttime clients per week were four times more likely to be willing to use prep compared to those who see more than 7 firsttime clients per week an fsw who used of condom during sex was one time less likely to use prep as compared to those not using a condom during sex relationship between practice of prep and sociodemographic characteristics in oss uyo akwa ibom none of the sociodemographic characteristics of the respondents was associated with the practice of prep table 7 a respondent who sees 01 boyfriend client per week was two times more significantly to practice prep as compared to that with 11 clients fsws who engage in unprotected sex when given incentives was one time less likely to practice prep compared to those who did not engage in unprotected sex there was significant difference among fsw acceptance of sex without use of condom compared to those who practice prep discussion this study revealed that the majority of the study respondents were aware of prep as an hiv biomedical prevention intervention and strategies tool there was statistically significant association of respondents awareness on prep in association to variables such as age marital status and years of sex work about half of the fsws reported they had practiced prep factors affecting the use of prep include lack of prep knowledge presumed side effects of prep lack of time to visit the facility for prep and availability and usage of condom the finding of high proportion prep awareness by the respondents varied with the reports by 22 and 23 who reported prep awareness of 21 and 364 respectively additionally a new most recent study by 24 also reported lower 327 prep awareness among fsws additionally two other independent studies reported similar proportion of willingness to use prep 22 reported 74 and 24 reported acceptability of 802 however similar high proportion prep awareness have been documented 25 among men who have sex with men and female sex workers in nigeria on the contrary 26 reported low knowledge of prep among similar study participants some of the variation between studies could be attributed to several factors such as the selected participants and the types of fsws targeted in those studies regardless those studies largely consistent with existing knowledge about fsws and hiv transmission in developing countries like nigeria further analysis of respondent in association with age showed that prep awareness was significantly higher among fsws in the age range of 25 34 years those who had never been married those who have had ≤5 years in sex work and those who are aware of prep this suggests that younger fsws are more knowledgeable about prep prophylaxis this finding varied with the reports by 27 in east africa who reported association between young age and poor prep knowledge which was also supported another resent study 28 who reported that younger sex workers aged 1924 were more likely not to be knowledgeable about prep data from our study may be because those young age population are actively searching for more knowledge especially in this era of access to information communication technology further it could be because of those young population wanting to prevent hiv so that they can enjoy an hivfree marriage and motherhood hence the condomless sex practice with their boyfriends who they may hope to marry in future the poor awareness of prep among older fsws is worrisome and calls for urgent programmatic revision capacity building for health personnel in oss and key populationfriendly health facilities and intensified public awareness of hiv prophylaxis use among older people regardless more evidence is needed to further understand while those with a shorter duration of sex work being more aware of prep prep acceptance in this study may be adjudged low as only 81 of respondents were willing to use prep the majority of the respondents that were nonwilling to accept and use prep cited the use of herbal medications as the main reason for not accepting prep or recommending prep to colleagues this low prep findings in this study differs significantly with 795 reported by 23 in mombasa kenya and the 846 by 25 in nigeria both kenya and nigerian studies indicated willingness of men who have sex with men and fsws to accept and use prep as an hiv intervention and strategy prevention tool review of the sociodemographic characteristics indicated that none of the five characteristics of the respondents analyzed were associated with attitude towards prep this differs from the report by 29 that reported younger and newer entrants to sex work being less likely to have a good attitude to prep and that by 28 with level of education being significantly associated with prep attitude however respondents with a weekly client load of 011 clients were significantly less associated with an appropriate attitude towards prep as compared to those with 11 clients this may mean that those who see more clients weekly are more willing to use hiv prep use of condoms during sex was significantly less associated with willingness to use prep unlike condom use during sex those who see 07 first time clients per week were significantly more willing to use prep more studies on the relationship between condom use during sex and number of firsttime clients seen by fsws and the willingness to use prep are needed to explain this association analysis on previous experience on the use of prep indicated that of the respondents reported that they had ever used prep this is different from the report of 23 that reported none of their studied participants had used prep lower prep utilization 04 have been reported by 26 the difference in the outcomes could be because the earlier studies 2326 were done when prep was newly introduced compared to the scaleup that had been done before this study none of the sociodemographic variables of the respondents was associated with the practice of preexposure prophylaxis however a respondent seeing 01 boyfriend client per week was significantly associated with the practice of prep engaging in unprotected sex was significantly associated with decreased number of respondents that used prep compared to not engaging the practice of anal sex with a boyfriend client was significantly less associated with the use of prep which means that a respondent that practices anal sex with boyfriend clients was less likely to use prep compared to the one that does not practice anal sex with a boyfriend the practice of anal sex with firsttime clients was significantly associated with an increased number of respondents that used prep compared to not engaging in anal sex with a boyfriend conclusion this study revealed that most of the study respondents were aware of prep for hiv intervention and strategy prevention but very few fwss were willing to accept this biomedical prevention option despite its effectiveness about half of the fsws had practiced prep there was a statistically significant association between respondents awareness on prep in association to variables such as age marital status and years of sex work factors that affect the use of prep include lack of knowledge about it side effects lack of time to go to a facility to get it and condom usage based on these findings there is a need for regular health education programs on hiv prevention for fsws in order to increase their awareness and encourage best preventive practices furthermore there should be more education on coping mechanisms for prep side effects by addressing factors like age marital status and specific aspects of sex work interventions could be designed to increase prep utilization thereby contributing to the reduction of hiv transmission in this vulnerable population limitations of the study a limitation of this research study is that the data were selfreported by study participants this limited the study because participants may or may not have truthfully reported responses to the survey questions and may be biased in the responses they provided participants may have provided answers that they believe to be desired by the researcher to the questions and are expected from them conflict of interest statement the authors have no conflicts of interest to declare all coauthors have seen and agree with the contents of the manuscript and there is no financial interest to report we certify that the submission is original work and is not under review at any other publication

this study investigated the awareness willingness and practice of hiv preexposure prophylaxis prep among female sex workers fsws in uyo akwa ibom state nigeria conducted between june and august 2020 the crosssectional research engaged 344 hivnegative fsws attending services at uyos onestop shop for key populations services through a semistructured questionnaire data were collected on awareness willingness and practice of prep and subsequently analyzed using statistical methods the studys participants had a mean age of 2906±520 years with 686 falling between 2534 years old notably 765 were adequately aware of prep while 81 expressed willingness to use it and 424 had practiced prep factors like age marital status and years engaged in sex work were found to significantly influence awareness of prep participants aged 2534 years those previously married and those with fewer years in sex work exhibited greater prep awareness the frequency of firsttime and boyfriend clients per week impacted willingness and practice of prep with the former positively influencing willingness and the latter negatively affecting practice engaging in unprotected sex was also found to negatively correlate with prep practice these findings highlight that while awareness of prep is relatively high among fsws willingness to use and actual practice of prep remain low the study underscores the importance of tailored health education programs targeting fsws to enhance awareness and encourage adoption of effective hiv preventive measures by addressing factors like age marital status and specific aspects of sex work interventions could be designed to increase prep utilization thereby contributing to the reduction of hiv transmission in this population

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introduction stem cell donation therapy and research are becoming the focus of attention for the scientific community healthcare organizations and patients due to successful treatment outcomes for certain serious illnesses 1 in saudi arabia the treatment by employing stem cells started in the late 80s 2 it was initially started on a limited scale to treat some diseases that included inherited immunodeficiency leukemia and genetic blood diseases 3 although some fatal diseases including blood cancers and some immune system diseases have been treated using stemcell transplantation 4 therapy procedures and outcomes are still evolving in addition the lack of adequate knowledge about stemcell transplantation and therapy outcomes in the various segments of the population 5 has resulted in misperceptions and unrealistic hopes about the contributions and effectiveness of stemcell therapy for various disease conditions 6 5 6 medical professionals involved in stemcell treatment and research often face ethical dilemmas and social pressures due to several myths associated with these treatments the other major challenge in stemcell therapy is obtaining the right match for transplantation retrieval of stem cells and donation of stem cells has several controversies due to various psychosocial 7 religious and ethical aspects associated with it 8 in 2010 the development of the saudi stem cell donor registry and in 2014 the establishment of the national centre for stem cell technology made stem cell donation and 9 transplantation procedures relatively more regularized9 due to limited knowledge of the general population about stem cell donation and treatment outcomes and information about organizations authorized to provide such services patients and families are at risk of being victimized due to existing malpractices in this area the unethical code of conduct will likely have medical social and psychological implications 10 some previous research from saudi arabia conducted during the precovid19 pandemic has explored knowledge about stem cell donation among nurses and dental students 1112 some recent studies focus on assessing the attitudes of medical and health science students toward stemcell transplantation for specific disease conditions 13 a quantitative study reported a moderate level of knowledge and positive attitude toward stem cell transplantation among healthcare providers from the qasim region it recommended the need for informational campaignsprograms on stem cell donation and therapy procedures to enhance the knowledge and to inculcate acceptance towards such therapies 14 in 2020 a qualitative study assessed the knowledge about stem cells and attitudes toward stemcell transplantation and stemcellbased treatments by conducting interviews with research staff medical professionals and science students at king abdulaziz university findings revealed that respondents generally hold positive attitudes towards ethical and best professional practices in stem cell research and treatment however there is a need to implement rigorous measures to protect society from psychological social and economic repercussions 15 in this era when the medical field is advancing at a fast pace and there is easy accessibility to information from multiple channels the levels of knowledge and attitudes of health professionals about advanced and specialized treatments are likely to experience quick shifts 16 therefore descriptive studies are crucial to identify the gaps in knowledge and professional attitudes that can influence ethical practice and patient care this study aimed to assess the perceptions sensitivity and attitudes toward social and ethical aspects of stem cell donation treatment and research among medical professionals in saudi arabia the study has a broad scope as perceptions of medical professionals determine their attitudes and practices limited knowledge and negative attitudes are crucial factors to cause professional negligence and malpractice in healthcare settings in the past few years there has been a tremendous expansion in stemcellbased therapy and research in various regions of the world including middle east countries moreover professionals from other parts of the world deliver health care through telehealth services in addition medical professionals work with international health organizations and stemcell donor agencies due to the focus on a collaborative approach to services and research medical professionals have a central role in maintaining best practices in healthcare and significantly contribute to advancements in medical therapies through ethical clinical research it is therefore essential to assess the knowledge and attitudes of healthcare professionals and pharmacists about health and safety issues in stemcell donation treatment and research because they are providing treatment and care services to clients and are also directly or indirectly involved in research work this study will address the existing gaps in knowledge that will be useful in addressing the ethical and social issues in this specialized area of medical services and research moreover this study will provide insight into establishing and implementing best practices in stemcell transplantation and research this study findings will have significant implications for improving health services and health justice for people seeking stemcellbased therapies materials and methods study design this crosssectional study was conducted in the northern and eastern provinces of saudi arabia data were collected using an electronic survey questionnaire in the first two weeks of december 2022 target population and sample size estimation the target population for this study was medical professionals including clinicians pharmacists and nurses working in healthcare organizations in the northern and eastern regions of saudi arabia the sample size estimation was completed by using raosoft software according to available estimates 17 the number of allied health professionals is around 14000 by choosing the confidence level of 95 5 margin of error and 80 response distribution the estimated sample size was 241 respondents instrument the study questionnaire was developed by reviewing recent literature 6 7 8 9 10 11 12 13 14 15 16 17 18 and questionnaires used in previous studies 12 13 14 15 the first part of the survey collected information about demographic variables these include gender age professional field nationality religious orientation and work exposure in stemcell donation therapy and research the second part of the survey questionnaire comprises 21 questions that assessed basic knowledgeawareness about stem cells with a set of five items sensitivity towards social and ethical issues in stem cell donation therapy and research with a set of eight items acceptance attitudes with a set of four items and rejection attitudes with a set of four items all items on these subscales are rated on a fivepoint likert scale with options of strongly agree4 agree3 neutral2 disagree1 and strongly disagree0 a higher score indicates high levels of knowledge sensitivity acceptance and rejection attitude the english and arabic versions of the survey questionnaire were prepared and pretested for this study pretesting was completed on ten respondents and we completed necessary modifications in the wording and order of presentation of items before conducting the data collection in the main study the content and face validity were assessed by field experts and found to be adequate the internal reliability of the tool was assessed based on data obtained from 260 participants in the main study cronbach alpha coefficient values for all four dimensions and total scale lie between 081087 data collection to recruit participants from tertiary healthcare organizations and research institutes located in these two provinces of saudi arabia we approached the higherlevel management of the organizations involved at some level in stemcell donation therapy or research we explained to them the purpose of the survey and obtained permission and support the organizations that agreed to support data collection distributed the electronic link to the survey questionnaire through their online portals participation in the study was voluntary informed consent was presented at the beginning of the survey questionnaire and anonymity of organizations and participants was maintained during data collection the inclusion criteria for the study were the participant must be either clinician nurse or pharmacist at least two years of professional experience and living in saudi arabia ethical approval and considerations the university of hail ethics committee approved this study after reviewing the methodology and study questionnaires dated 31102022 all study procedures complied with the research guidelines per the declaration of helsinki participation in the study was voluntary informed consent was obtained from all participants before data collection and no personal data or identifying information was collected data analysis was completed on collective data stored in secure files data analysis data were analyzed using spss version 250 software descriptive statistics were used to present the demographic characteristics of respondents other descriptive statistics were reported to describe the levels of knowledge sensitivity and attitudes toward stemcell donation therapy and research the chisquare test was applied to determine the association between categorical variables and ttest and anova were applied to determine the significance of mean differences on knowledge sensitivity and attitudes scores across gender age group professional field nationality religious orientation and work experiences in the area of stemcell donation therapy and research the dataset was checked to meet the assumptions for multiple linear regression the next level of analysis was conducted to determine predictors of knowledge sensitivity acceptance and rejection attitudes of medical professionals towards stem cell donation treatment and research a confidence interval of 95 and a significance level of p≤ 005 was chosen for testing statistical models results background characteristics the demographic profile of the participants is presented in table 1 a total of medical professionals including clinicians pharmacists and nurses completed the survey questionnaires in this sample just over onethird were clinicians around onethird were nurses and slightly below onethird were pharmacists thus there is about an equal representation of professionals from these three disciplines of medicine the male participants were and females over fifty percent were in the age group of 2039 years and the remaining were 4059 years old in addition a large section of respondents was saudi and over ninety percent were muslims the analysis shows that of medical professionals reported a complete lack of awareness about stem cells among which three are pharmacists and one is from nursing findings show that participants have experience in stemcell donation have experience in stemcell therapy and have experience in stemcell research table 2 shows that a significantly higher proportion of clinicians and pharmacists had work experience in stem cell donation and therapy though statistically a higher proportion of medical doctors are involved in stem cell research however there are some participants from the pharmaceutical industry and nursing field who have work experience in stemcell research table 3 presents the mean scores and standard deviation values on scales and items assessing knowledge sensitivity towards social and ethical aspects and acceptance and rejection attitudes towards stemcell donation transplantation and research the average scores on scales demonstrate that healthcare professionals possess moderate levels of knowledge 4 presents the analysis of mean differences in knowledge sensitivity acceptance and rejection attitudes toward stemcell donation transplantation and research as assessed among medical professionals working in saudi arabia findings show that male respondents have higher mean scores on knowledge and acceptance attitude 530 as compared to females in contrast females had significantly higher mean scores on rejection attitude the difference was nonsignificant in the case of sensitivity findings show that older respondents had higher mean scores on knowledge and acceptance attitudes at whereas the difference was nonsignificant on sensitivity and negative attitudes clinicians had higher mean scores on knowledge sensitivity and acceptance attitudes as compared to pharmacists and nurses whereas the differences were nonsignificant on rejection attitudes there were nonsignificant differences across nationalities in knowledge and acceptance attitudes however nonsaudi nationals had higher mean scores on sensitivity and lower mean scores on rejection attitudes nonmuslim participants had higher mean scores on acceptance attitudes and lower mean scores on rejection attitudes about stem cell donation therapy and research however the analysis shows these differences were only significant when data was needed to meet the assumption of equal variance those who had an experience of work in stem cell donation had significantly higher mean scores on knowledge and sensitivity in contrast the differences were nonsignificant in both types of attitudes those who had work experience in stem cell therapy had higher scores on knowledge sensitivity and acceptance attitudes and the difference was nonsignificant in rejection attitudes and the pattern was similar for those who had work experience in stem cell research table 5 shows findings from the multiple regression analysis to determine whether demographic variables and the nature of work experience determine the knowledge of medical professionals about stemcell donation transplant and research in multiple linear regression analysis clinicians and pharmacists likely to have more knowledge as well as work experience in stemcell research significantly predict having higher levels of knowledge related to stemcell donation therapy and research as compared to their reference categories the adjusted rsquare value is 051 illustrating that 51 of the variation in awareness about ethical issues can be explained by variation in the work experience in stemcell donation and research the analysis 6 shows findings from the multiple regression analysis to determine whether demographic variables and the nature of work experience determine medical professionals acceptance and rejection attitudes about stemcell donation transplant and research in multiple linear regression analysis male gender and older age and work experience in stemcell research significantly predicted acceptance attitudes female professionals and saudi nationals are more likely to hold rejection attitudes and respectively those who were not clinicians were also likely to hold rejection attitudes and those who did not have work exposure to stemcell donation likely to hold negative attitudes discussion the current study aims to assess knowledge sensitivity and attitudes toward stemcell donation treatment and research by collecting data from clinicians pharmacists and nurses in saudi arabia because medical professionals limited knowledge negative attitudes and less sensitivity towards social and ethical aspects of stemcell donation treatment and research can impact the quality of healthcare service provision the findings have significant implications for improving healthcare risk management findings illustrate that around four percent of medical professionals in this sample reported a complete lack of awareness on a direct question about awareness of stemcell moreover the respondents had average mean scores on the items and scales which assessed the participants knowledge about diseases currently being treated in reliable ways by using various types of stem cells the potential benefits of stemcell donation and the potential risks of stemcell research moreover participants awareness of the saudi stem cell donor registry and other organizations which collect stem cells from donors in saudi arabia was relatively low findings from our study are comparable with these two studies which also demonstrated that healthcare providers possess moderate levels of knowledge related to stemcellbased therapies and research most of the previous quantitative crosssectional studies from saudi arabia have assessed the knowledge and perceptions about stemcell donation and treatment among medical students 12131920 except two 1415 cumulatively these findings provide conclusive evidence that some gaps exist in healthcare providers knowledge about stemcell donation and treatment possibilities attributed to the several controversies and limited existing evidence about the treatment protocols and effectiveness of these therapies the low mean scores on items assessing awareness about stemcell donor agencies indicate the need to create awareness among medical professionals about saudi stem cell registry and any other organization that collects stem cells from donors in saudi arabia this is also inferred based upon the alignment of our study findings with a prior study12 which found that in a sample of 606 practitioners in dentistry twothirds were not aware of the donor agencies or the procedures followed by these organizations in the collection or supply of stem cells therefore raising awareness about these agencies is essential to prevent malpractice and minimize patient risks this has also been indicated by a previous study from jordan as most physicians lacked the confidence to address patients queries related to stemcell donation and therapies 21 as clinicians are the primary source of information for most patients it is vital to conduct seminars in healthcare settings frequently to create more awareness and share authentic information about these advanced forms of treatment our findings showed that clinicians had significantly better knowledge increased sensitivity and more acceptance towards stemcell donation treatment and research than pharmacists and nurses these differences were nonsignificant in rejection attitudes these findings are interpreted in light of previous literature which also reported that most nurses need more training professional experience and work exposure in this area thus lacking authentic knowledge in this area 1422 nurses and pharmacists are also key in providing service and research advancement in this less conventional and specialized treatment area appropriate attention should be given to training nurses and pharmacists with updated stemcell donation and treatment 533 knowledge these measures are necessary to prevent the spread of myths and false perceptions related to stemcell donation and treatment to enhance healthcare risk management at the institutional level the findings demonstrated that medical professionals largely disapprove of embryonic stemcell research involving fetal destruction understand the requirement of consent and ethical approval for research in this area and support the need to regularize stemcellbased therapy in saudi arabia these findings suggest that medical professionals understand the need to regularize and implement ethical practices in stemcell donation treatment and research in saudi arabia furthermore the pattern of responses on other items shows that they largely disapprove of the notion that the pharmaceutical industry is hindering the progress in stemcell research and do not endorse the idea of applying stemcellbased treatments that have only been tested in laboratory settings on animals or human cells these indicate that medical professionals understand the possible risks associated with violating ethical practices in stemcellbased treatments the findings show that respondents had higher scores on acceptance than rejection attitude a positive indicator of progress in stemcell donation treatment and research in saudi arabia a previous study from saudi arabia 14 which mainly collected data from students teaching staff and healthcare workers working at king abdulaziz university also reported that most of the participants held a positive attitude towards stemcell donation and research however contrary to this studys findings which reported females possessed higher levels of knowledge and positive attitude 14 our study found that male participants had significantly higher scores on these variables our survey findings show that participants had low mean scores on most items that assessed rejection attitudes towards stem cell donation therapy and research except one item which asserts that government must prevent all research on embryonic stem cells from embryos or aborted fetuses these findings are interpretable in the context of local social and cultural influences that might have influenced the general population and professionals views about this issue as most participants are muslims and saudi 23 in multivariate analysis we found that prior work experience in stem cells is the most dominant factor in determining medical professionals knowledge sensitivity and attitudes although it is a positive sign that medical professionals who were or are currently involved in stemcellbased research or treatment are cognizant of the social and ethical issues it also asserts the need for training and workshops for those who did not have such work exposure we also found that young medical professionals have less awareness and acceptable attitudes than older respondents one explanation is that older participants are likely to have relevant work experience associated with better knowledge and acceptance in our study sample around half of the medical professionals had work experience in stemcell research and onequarter had work exposure in the stemcell donation it seems that work exposure has contributed to higher levels of awareness acceptance attitudes and sensitivity towards stemcell donation and research in this study sample our study findings align with a previous study which demonstrated that male professionals knowledge levels were higher compared to female 21 this could be due to limited opportunities and support for the training of female medical staff at various professional forums a qualitative study of healthcare workers from saudi arabia also indicated that most professionals needed more awareness about national and local laws and emerging ethical challenges related to stem cell therapies and research 24 these findings support the need for more educational seminars and workshops additionally specific training in ethical issues related to stemcell donation and treatment is mandatory to minimize the risk of professional negligence due to a lack of knowledge of the negative attitudes of healthcare providers an intervention study from saudi arabia also demonstrated the effectiveness of the educational program in improving the knowledge and attitudes towards umbilical cord stemcell preservation among nurses 25 we found that mean scores on knowledge sensitivity and acceptance attitudes were significantly lower among saudi nationals than nonsaudi medical professionals this finding has significant implications regarding healthcare risk management policy and practice because in the past few years under the framework of saudization an increasing number of saudi nationals are entering the medical workforce 17 therefore training programs at the institutional level should target and ensure enrollment of female staff young professionals saudi nationals and those who still need to gain earlier work experience in stem cell donation and research current study findings have relevance in local regional and global contexts considering that improving healthcare services and health justice for people is a shared concern at the global level moreover in the current era medical professionals are involved in care and research at different levels due to the advanced use of technology in healthcare and research in addition health professionals are collaborating with international agencies in stemcell donation treatment and research due to the focus on a collaborative approach in providing healthcare services and research it is therefore important that both local and international healthcare organizations understand factors associated with the knowledge attitudes and sensitivity of medical professionals about social and ethical aspects of stem cellbased treatment and research furthermore this understanding might be helpful in the adoption of adequate measures to increase general awareness and acceptance attitudes in the target population strengths and limitations the present study has several strengths firstly it focuses on assessing the knowledge and attitudes of medical professionals currently providing services in different roles clinicians nurses and pharmacists are the core component of healthcare services and research teams to develop and implement advanced therapies therefore insights gained from this study have direct implications for improving healthcare risk management and policies given the fast pace of research progress in this field and the popularity of stemcellbased therapies in highincomecountries there is a need for systematic crosssectional studies to assess the current situation in various regions of the world and this study fulfills this requirement by providing the most recent picture of the situation in saudi arabia while interpreting findings some limitations of the present study need to be considered such as an electronic survey form distributed through organizations online portals many medical professionals were automatically excluded as prospective participants who ignored the study invites besides we collected data from various health and research organizations including those involved in stemcell treatment and research respondents from these organizations were overrepresented in this study sample and the elevated score on awareness attitudes and sensitivity is attributable to sampling bias there is a growing debate in scientific communities about social and ethical aspects of stemcell research the social desirability element might impact respondents ratings on these items for instance it is observed that most of the participants disapprove of the perception that the negative competitive environment in the pharmaceutical industry hinders progress in stemcell research due to the tendency to present the positive side of the situation among other limitations the items on the survey related to the knowledge dimension needed to be narrower to assess the specific areas of knowledge related to stemcell donation treatment and research conclusion and recommendations understanding the social and ethical implications of stemcell donation treatment and research are of prime importance to ensure best practices in healthcare and minimize the risk for donors and patients the study findings also revealed that medical professionals endorse the need to regularize stemcellbased therapies in saudi arabia however cognizance and sensitivity about these issues need to be raised for nurses pharmacists females young less experienced and saudi healthcare workers to achieve significant gains in healthcare risk management at the institutional level and community levels including topics such as psychological social and ethical aspects of stemcell therapy in the curriculum for medical and nursing students can achieve this in addition online resources such as journals and books on these topics are provided through institutional subscriptions and access to literary databases moreover seminars and specialized training in hospitals and research centers can effectively dissolve negative attitudes and strengthen acceptance attitudes disclosure the authors report no conflicts of interest in this work

background knowledge sensitivity and acceptance attitudes towards social moral and ethical aspects of stemcell donation and treatment are important factors in preventing professional negligence and improving healthcare risk management and health justice in this specialized area of health services objective to assess knowledge sensitivity acceptance and rejection attitudes towards stemcell transplantation and research and its associated factors among medical professionals in saudi arabia methods a quantitative and crosssectional study was conducted in december 2022 data were collected from 260 medical workers from various regions in saudi arabia ttests anova and multiple linear regression were applied to find variations and associations of gender age profession nationality religious orientation and work experiences of professionals with knowledge sensitivity acceptance and rejection attitude towards stemcell donation therapy and research a confidence interval ci of 95 and a significance level of p≤ 005 was chosen for testing statistical models results a total of n260 medical professionals among which clinicians n9838 pharmacists n7830 and nurses n8432 completed the survey questionnaire findings show that n27 10 participants have work experience in stemcell donation n67 26 in stemcell therapy and n124 48 in stemcell research clinicians and pharmacists in comparison to nurses had better knowledge p 001 and p 005 pharmacists had higher sensitivity p 005 than nurses compared to those who do not have work experience in stemcell research those who had work experience had higher levels of knowledge sensitivity and acceptance attitudes at p 0001 and p 001 acceptance attitudes are considerably higher among male participants than females and similarly higher among older participants than younger participants p 005 compared to nonsaudi nationals saudi nationals scored higher on rejection attitudes p 001 compared to those having work experience in stemcell donation and research those without work experience are more likely to hold rejection attitudes p 001 conclusion findings suggest female professionals saudi nationals and those who do not have prior work experience in stemcell donation therapy or research had low levels of knowledge less sensitivity and less acceptance attitude and are more likely to hold rejection attitude signifying the need to address them to improve healthcare risk management

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introduction in quebec 96 of the population 15 years old and above have a disability of these 746 require assistance to complete at least one activity of daily living only 267 live independently and 367 have an income of less than 15000 a year approximately 1 in 66 children and youth in canada are diagnosed with autism spectrum disorder and they will experience significant social inequities as a result they have a higher prevalence of mental and physical illnesses compared to the general population as well autistic people experience mental issues and daily stress which affect their quality of life caregivers of people with disabilities experience more mental health problems compared to the general population for example the lived experience of parents of autistic children is marked by higher rates of emotional stress and strain as compared to that of parents of typically developing children with about 50 of parents reporting stress in their daily lives people with disabilities and their caregivers are one of the most vulnerable groups in our society little has been compiled on how people with disabilities autistic people and their caregivers are being affected and are facing the pandemic the covid19 pandemic compromised support services and caused drastic changes of circumstances and routines for many autistic people and people with disabilities with potentially serious consequences for their mental health and wellbeing the question arises whether the covid19 outbreak has resulted in an increase in difficulties among this population and their caregivers and in increasing social health inequities within the framework of the international classification of functioning disability and health this translates into identifying barriers and developing facilitators with the goal to enable participation therefore it is important to know the level of support received by these vulnerable populations during the pandemic and to understand the impact that the level of support may have on their stress to address unmet support needs and find effective strategies to better respond to these needs based on what is known we wanted to study the situation in quebec from the perspective of people with disabilities themselves the main goal of this research was to assess the perception of the availability of community support and the support needs of autistic people and people with disabilities at the time of the covid19 pandemic in quebec from their own perspectives and from those of their caregivers community support was defined as availability of adapted healthcare adapted information adapted educational services and community services a second objective was to assess the association between the available support and the perceived stress levels and to assess the role of perceived social support as a potential buffer of this association social support was defined as a mediator between the stressful event and the persons health with several dimensions tangible instrumental or material help informational support for problemsolving emotional support and support for acceptance selfesteem and belonging in this research we were interested in instrumental informational and emotional support because they were the ones most at risk of being cut off during the pandemic methods design and data collection an online 4min survey in french was developed and study data were collected and managed using redcap electronic data capture tools hosted at canchild mcmaster university it was available for 4 weeks in september 2020 resulting in a convenience sample of participants across the province of quebec our recruitment strategy used convenience and snowball sampling by broadcasting the opportunity for participation on social media chu saintejustine online networks and our collaborators network such as autistic persons associations parents associations and fédération québécoise de lautisme outcomes this study focused on available support during the covid19 pandemic for autistic people and people with disabilities in terms of available adapted healthcare available adapted information adapted educational services and community services from the perspective of autistic people or people with disabilities over 18 years of age and caregivers of autistic people or people with disabilities of any age inspired by caron and guay we also asked about perceived social support with two questions and one singleitem stress level perception question we recruited people identified as autistic people or people with disabilities or their caregivers there were no exclusion criteria two autistic people revised the questionnaire to ensure accessibility we asked everybody thinking about the amount of stress in your life would you say that most days are not at all stressful not very stressful a bit stressful quite a bit stressful extremely stressful they were also asked about perceived social support with two questions i have someone who i trust and who i can turn to in case of problems and there are people i can count on in case of emergency for both 6point likert scales were used we chose these two questions because according to the literature it is the availability of social support that is most predictive of its positive effects on reducing the experience of stress in the last section of the questionnaire the following demographic information was collected what area do you live in and what country were you born in finally there was also one open question for everybody do you have any other comments questions or information you would like to share with us no response was mandatory data analysis the data were analyzed using ibm spss statistics software and r 41 descriptive statistics were used to analyze participants perspectives on available supports for autistic people and people with disabilities as well as the perceived social support and perceived life stress by autistic people people with disabilities and their caregivers the chisquare test or the exact fisher test was used for bivariate analyses between participants perspective of available support and perceived life stress we constructed a continuous composite variable the social support level for the two social support questions we considered a rating as follows always6 often5 sometimes4 rarely3 never2 and dont know1 thus a score was associated with each respondent for each question and the sum of the scores of the two questions resulted in the social support level the values could vary from a minimum of 2 to a maximum of 12 next we stratified the variable into two levels level 1 of social support with people whose maximum score was 9 points and who constituted 50 of the sample and level 2 of social support with people with a score above the median of 9 we developed a second set of composite continuous variables called accumulation of nonadapted services or anas using a partial cumulative procedure applied on the set of perception of unavailability of adapted services we gave a value to each response as follows no 2 dont know 0 yes but not enough 1 yes 2 these cumulative variables correspond to the sum of the contributions of each indicator variable thus we originated different combinations of variables we obtained several expressions of an accumulation of nonadapted services ie nonadapted services plus nonadapted information etc for each combination we calculated the respective anas which was the sum of the values of the variables that were part of the combination with the anas obtained we estimated the parameters of the ordinal logistic models we retained just the combinations that had an increasing structure in the chain of combinations finally we only retained the models in which the anas coefficient had p values lower than 010 finally we considered perceived life stress as an ordinal dependent variable with three categories not at all stressful together with a little stressful a bit stressful and quite a bit stressful together with extremely stressful afterwards using ordinal logistic regression we predicted the perceived life stress level by autistic people people with disabilities and their caregivers according to the perception of adapted supports available in the community or in health services for autistic people or people with disabilities at the same time we also examined how life stress levels varied by perception of social support regressions were adjusted for the country of birth and area of residence all results were described according to their confidence interval and p value finally a qualitative thematic analysis of the content of the verbatims of the open question was carried out by two researchers using the nvivo 12 software the study obtained approval from the research ethics board of the saintejustine university health centre project 20213050 online informed consent was obtained from all the participants description of the sample a total of 315 respondents participated in the survey our sample consisted of 55 autistic people or people with disabilities and 279 caregivers nineteen of them were autistic people or people with disabilities and caregivers at the same time and they were analyzed as autistic people or people with disabilities most respondents live in large cities and in nonrural areas 119 and 73 respectively there were 200 participants who were born in canada and 105 who were born outside of canada results no response was mandatory and more than two thirds of the participants answered all questions which is considered acceptable tables 2 and3 show the number of responses for each question for descriptive and bivariate results from caregivers the responses no and dont know were coded together for descriptive and bivariate results for autistic persons or people with disabilities we coded together yes with yes but not enough and no with i dont know expressed needs and perception of available support table 2 shows that 27 autistic people needed healthcare services and 16 of them had telehealth services there were 25 who needed home support and 25 who answered needing delivery services most of them also answered not having adapted services or not knowing their existence like adapted information about the pandemic from community organizations table 3 shows that 141 of caregivers perceived adapted health services as not available and that 142 of caregivers perceived information about the pandemic as not adapted for autistic people or people with disabilities furthermore 185 of caregivers perceived the online education as nonadapted for students with special needs selfreported social support and perceived life stress since the beginning of the pandemic 28 autistic people or people with disabilities and 172 caregivers perceived their days as being quite stressful stressful or extremely stressful on the other hand 8 autistic people or people with disabilities and 66 caregivers reported rarely or never having someone they trust and to whom they can turn for advice if they had problems we performed bivariate analyses of the relation between social support and the perception of the life stress level for the two groups although we found a negative trend it was not statistically significant association of stressful life with availability of adapted services we found a positive trend between autistic respondents or people with disabilities reporting a lack of adapted services such as healthcare or other services at home or adapted information about the covid19 pandemic and their perception of daily stress levels however no association reached statistical significance at p 005 for caregivers we also found a positive trend but not significant between the perception of not having available adapted services during the pandemic for their children and their perception of a stressful life regression and bivariate analyses we estimated ordinal regression models for each group as shown in model 4 of table 5 for autistic people and people with disabilities an increase in one unit in the anas 4 drives a 25 increase in the probability of change from not at all stressfulnot very stressful to a bit stressful with the same model 4 at perceived social support level 2 the odds of being more likely to change from not at all stressfulnot very stressful to a bit stressful decline by 17 table 6 shows the regression models for caregivers for the four models for every unit increase in anas the increased odds of being more likely to change from not at all stressfulnot very stressful to a bit stressful are significant for instance an increase in one unit in the anas 4 drives a 7 increase in the probability of change from not at all stressfulnot very stressful to a bit stressful and at perceived social support level 2 the odds of being more likely to change from not at all stressfulnot very stressful to a bit stressful decline by 46 for both caregivers and autistic people or people with disabilities the four models indicate that the perceived social support component on the stress level is individually significant in reducing the probability of going from a lower stress level to a higher n total 55 the proportions were based on the number of respondents no and dont know were coded together yes and yes but not enough were coded together we asked if yes by whom were these services provided the responses were community organization family clsc other i must pay one we analyzed separately the 26 participants who identified as autistic persons and the results were similar thematic analyses of responses to open question there were many recurring themes during the analysis of the open question two main categories stood out the sense of being abandoned by the system a fact that just got worse with the pandemic and the effects of the covid19 pandemic on daily life many parents of autistic children expressed the feeling of having been abandoned by the system even before the pandemic many expressed the feeling that their needs were not being heard the situation did not get better once the first wave hit they saw many of their already limited services being put on hold they also felt that the services that did remain were not sufficient to meet their needs the services for intellectual disabilities were almost nonexistent before the pandemic during the pandemic we were left to fend for ourselves our child obviously lost a lot of what he had learned there is no support from schools nor from the health system appalling parent of a person with a disability covid19 did not just affect the services it also greatly influenced daily life some autistic persons experienced a lot of disorganization in their routine from lack of preparation to help them follow sanitary measures such as sneezing in the elbow wearing a mask and washing their hands many reported the need to stop working as a consequence i have a lot of difficulty wearing a mask it makes it excessively difficult to think to concentrate to work … at work the mask is also obligatory i have not worked since midmay because of this new rule its disabling not being able to work with a mask autistic person parents and caregivers expressed a lot of exhaustion and the feeling of being overworked we feel alone every day when we are parents of an autistic child as soon as there is an external factor like a pandemic it just adds to the fatigue already accumulated parent of an autistic child nevertheless a few respondents pointed out some positive outcomes such as the normalization of autistic traits like wanting to stay home and being socially distant this resulted in some experiencing less stress than before the pandemic isolation has been for our totally asperger family the best time of our lives returning to workschool is very stressful autistic person and parent of an autistic person discussion our study shows that during the covid19 pandemic in the province of quebec from the perspective of autistic people or people with other disabilities and their caregivers the community support defined as availability of adapted healthcare adapted information adapted educational services and community services was not available was not known or was not sufficiently adapted to their needs endorsing our quantitative findings the qualitative analysis of the open question answers shows the sense of abandonment and distress in which this vulnerable population finds itself feelings that have been heightened by the pandemic this situation increases the perceived stress level of this population in addition the accumulation of nonadapted healthcare no home support services and no telehealthcare increases the impact of the pandemic on the stress level of autistic people and people with disabilities as well other than no adapted healthcare and no home support no adapted educational services and no assistance for teleeducation increase the impact for stress level in caregivers nevertheless perceived social supports can play a mediating role in attenuating the effects of the absence of adapted services on the perceived stress level of these vulnerable populations even more stressful lives during the pandemic about 50 of caregivers of children with disabilities have some stress in their daily lives in nonpandemic time in canada in 2019 21 of canadian people over 12 years old perceived most days as quite a bit or extremely stressful in 2020 during the pandemic 28 of canadians reported high stress levels in our study 17 autistic people or with disabilities and 99 caregivers of autistic people and people with disabilities perceived their days as being quite stressful or extremely stressful this is a significant increase of their stress levels during this pandemic being twice that of the general population in nonpandemic time widening an already existing lack of services but also promising avenues autistic people and people with disabilities are a population with difficulties to access services in general while the direct impact of infection with sarscov2 is major such as a larger case fatality rate and higher morbidity in autistic children this group also suffers more from the impact of noninclusive covid19 pandemic mitigation measures as a result as was revealed by kent et al outreach services that provide food and medication may have been disrupted increasing the risk of food insecurity or the exacerbation of chronic problems and the disruption of support for daily living nevertheless according to our data the absence of telehealthcare contributes to the increase of the stress level in autistic persons and persons with disabilities so as was already pointed out by other authors it appears that telehealthcare could be a particularly promising strategy to increase access to services for this population for caregivers what increased their stress levels other than the absence of adapted health services and home support was a lack of adapted educational services and a lack of educational assistance for teleeducation the impact of the lockdown on the development of children and adolescents with disabilities must be studied but also the opportunities that teleeducation could have for autistic students and students with other disabilities what are the opportunities to protect this population in this crisis around 12 and 15 of the quebec population aged 12 and over has a low level of emotional and informational social support respectively even though they were not measured with the same indicator our study shows that 8 autistic people or people with disabilities and 66 caregivers reported to rarely or never have someone to trust and to turn to for advice if they have problems social support is a wellknown protective factor of mental health and it could be a buffer between nonavailability of adapted services and perceived stress levels the unmet need for social support of parents of autistic children is acknowledged in nonpandemic times the social support needs of these populations are not met during nonpandemic times nor during a pandemic when it is even more necessary to do so other researchers studying people with disabilities report similar data related to stress levels the unavailability of adapted services and the need of social support for this vulnerable population therefore beyond expanding remote services we need to propose populationbased measures to provide this population with social support some autistic people or people with disabilities show lower perceived stress levels than other groups it could be because some people find positive outcomes during the pandemic but further research is needed limitations as this is a convenience sample the results cannot be extrapolated to the general population we did not ask about educational level or other economic status proxies and our cohort is probably not the most vulnerable of the vulnerable who might have shown even more severe impacts we had about one third of nonresponses and we did not analyze the differences between the people who answered or not some questions other than perceived stress levels we did not use validated scales we did not use a validated scale for measuring social support instead we used two questions inspired from short scales to look for the available instrumental support however this study sample mainly consists of autistic people and their caregivers populations that are hard to reach conclusion disability as conceptualized in the icf refers to the interaction between individuals with a health condition and personal and environmental factors t h e s e environmental barriers may hinder their full and effective participation in society on an equal basis with others autistic people people with disabilities and their caregivers were left unsupported during the covid19 pandemic and they report significant levels of stress within the concept of the icf environmental factors can also act as facilitators for participation covid19 pandemic mitigation strategies must be inclusive to avoid widening existing disparities targeted measures are needed to improve adapted supports and to protect them from discrimination our study adds that other than social support adapted healthcare home support services and telehealthcare could reduce the impact of the pandemic on the stress level of autistic people and with disabilities and that adapted educational services and necessary equipment for online education for people without resources could reduce the impact on the stress level in caregivers these findings should be further explored in order to find interventions that better meet the needs of this population finally it is necessary to raise awareness and show the reality of this population and the need to prioritize them to develop disabilityinclusive public health responses and emergency preparedness and to train health professionals about this reality contributions to knowledge what does this study add to existing knowledge from the perspective of autistic people or people with other disabilities and their caregivers the community support and the services during the covid19 pandemic were not available or were not sufficiently adapted to their needs about 40 of autistic people or people with disabilities and 44 of their caregivers perceived their days as being quite stressful or extremely stressful this is double the rate of that of the general population in nonpandemic time public health measures of containment and mitigation need to consider the needs of people with disabilities what are the key implications for public health interventions practice or policy the social support needs of these populations are not met during nonpandemic times nor during a pandemic when it is even more necessary social support could be a buffer between nonavailability of adapted services and perceived stress levels for autistic persons or people with disabilities the absence of adapted healthcare home support services and telehealthcare significantly increased their perceived life stress for caregivers the absence of adapted health services and home support a lack of necessary equipment for online education for people without resources and a lack of adapted educational services significantly increased their perceived life stress targeted public health measures are needed to improve adapted supports and to protect this vulnerable population from discrimination data availability dataverse udem valderrama alena 2021 données de réplication pour personreported perspectives on support availability for people with disabilities during the covid19 pandemic in quebec scholars portal dataverse version provisoire code availability token388d7b8458b2430593de157baa6f8dc8 table 5 determinants for stress level increase for autistic people or with disabilities by best ordinal logistic regression models dependent variable 3 categories of stress level 1 172

objectives to identify the perception of the availability of community support and the support needs of autistic people and people with disabilities from their own perspectives and from those of their caregivers at the time of the covid19 pandemic in quebec to assess the association between the available support and the perceived stress levels to evaluate the role of perceived social support as a potential buffer of this association methods a total of 315 respondents participated in a 4min online survey across the province of quebec by snowball sampling community support was defined as availability of adapted healthcare adapted information adapted educational services and community servicesthe community support and services during the covid19 pandemic were not available or were not sufficiently adapted to their needs about 40 of autistic people or people with disabilities and 44 of their caregivers perceived their days as being quite stressful or extremely stressful this is twice the rate of that of the general population in nonpandemic time nevertheless social supports can play a mediating role in attenuating the effects of the absence of adapted services on the stress level of this vulnerable population conclusion the nonavailability of adapted services was related to an increase in the stress level in this population our study adds that other than social support adapted healthcaretelehealthcare and inhome support services could reduce the impact of the pandemic on the stress level of autistic people and people with disabilities adapted educational services and necessary equipment for online education for people without resources could reduce the impact on the stress level in caregivers people with disabilities and their caregivers are one of the most vulnerable groups in our society public health measures of containment and mitigation need to consider more their specific needs

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introduction red cultural resources as a material entity with historical significance contemporary value and educational function formed by the chinese communist partys leadership in promoting the integration of marxist basic principles with chinas reality and traditional chinese culture during the revolutionary construction reform and the new era of socialism with chinese characteristics represents an important manifestation of socialist core values higher education institutions bear the important mission of moral education and are entrusted with the sacred duty of promoting red culture and carrying forward the red legacy in the era of big data higher education institutions red cultural education faces new challenges and tasks it requires the utilization of big data technology and platforms to innovate the content forms and methods of red cultural education enhancing its relevance impact and effectiveness this article aims to explore the conceptual definition value connotation current status analysis problem diagnosis and policy recommendations for red cultural education in higher education institutions in the era of big data it intends to provide theoretical support and practical reference for red cultural education in higher education institutions the concept and value of red cultural education in higher education institutions in the era of big data red culture education refers to the activities of ideological and political education and spiritual civilization construction for different groups through various educational channels with the revolutionary history and socialist construction achievements led by the cpc as the main content the marxist education concept as the guidance and the goal of cultivating the social red culture atmosphere and encouraging the masses to inherit the red gene red culture education is an ideal moral education model that can enhance the patriotic consciousness and political quality of the people stimulate a sense of historical responsibility struggle spirit and innovation consciousness promote the cohesion of socialist core values and establish firm ideals and beliefs red culture serves as a valuable resource for the teaching of ideological and political theory courses in higher education institutions integrating red culture into these courses is a practical requirement for fulfilling the fundamental mission of moral education and is a significant approach to creating distinctive and exemplary ideological and political courses 1 as the vanguard of red cultural education issn 26165783 vol6 issue 215359 doi 1025236ajhss2023062109 published by francis academic press uk 54higher education institutions through curriculum design textbook development and other teaching methods translate the spiritual essence of red culture into a scientific educational approach higher education institutions also play a vital role in innovating and advancing red culture leveraging their academic advantages and innovative capabilities they can delve deep into the exploration and theoretical interpretation of red culture continually infusing it with new contemporary significance that aligns with the primary tasks of the new era additionally higher education institutions can serve as crucial platforms for promoting red culture fostering collaboration between universities enterprises museums and research institutions to organize various commemorative and educational activities these initiatives inspire young talents in higher education to consciously inherit the red genetic code carry forward the red legacy and shoulder the responsibility of national rejuvenation with the development of information technologies such as the internet the internet of things and cloud computing the volume of data has experienced explosive growth marking the advent of the era of big data diverse data types and widespread data analysis and application are key characteristics of the big data era leveraging big data technology data from various aspects of social production and daily life are collected stored and processed this empowers various industries with precise data processing and utilization capabilities that surpass those of traditional information societies the advent of big data technologies tools and methodologies has significantly propelled societal development garnering high attention from the party and the nation since the 5th plenary session of the 18th central committee of the communist party of china the party and the nation have implemented a national big data strategy driving the widespread application of big data in our country the big data era provides a favorable opportunity for innovating the paradigm of red culture dissemination and education higher education institutions as crucial platforms for research innovation and ideological education have become important settings for the application of big data technologies and methodologies the material form of red cultural resources is transitioning from physical to digital leveraging higher education institutions as vital platforms the convergence of big data and red culture demonstrates remarkable compatibility and offers immense practical value in the big data era the material form of red cultural resources is shifting from the physical to the digital and their spiritual essence is evolving from the typical to the comprehensive showcasing their significant role in governance and nurturing individuals 2 seizing the development opportunities of the new era actively utilizing big data technology thinking and methodologies to drive the transformation of red cultural education continuously enhancing the effectiveness of red cultural education and achieving its steadfast innovation and development is imperative the value of big data empowerment in higher educations red cultural education can be realized in the following aspects firstly empowering red culture education in universities with big data can help enhance national awareness and consolidate ideological positions in the virtual field the first problem faced in the current construction of national ideological security is to hold onto the battlefield of online information dissemination and ensure the quality of cultural dissemination red culture as an advanced culture with marxism as its core value has always held high the clear banner of criticizing capitalism spread red culture effectively analyze erroneous trends such as money worship and value nihilism in the online space guide the healthy and positive atmosphere of online platforms achieve the promotion of turbidity and purity in the online space make red culture a positive energy and create a clean and upright online cultural environment 3 big data technology and thinking are conducive to the innovative practice of red culture education which can change the oneway preaching mode of traditional education enhance the attractiveness of red culture in the vast information flow achieve more effective dissemination effects and better help red culture education cultivate national spirits and enhance national identity red culture education in universities can use big data technology to collect organize and analyze red culture resources innovate the content and methods of displaying red culture better showcase the excellent qualities of the older generation of revolutionaries and stimulate students sense of national pride patriotism and passion for struggle at the same time red culture can play a positive role in uniting the ethnic masses the red culture created by the chinese peoples unity and unity in the great practice of striving for national independence national prosperity and peoples happiness is the spiritual crystallization of the chinese nations awakening in danger and struggle in difficulties over the past century the cpc has forged the most vivid cultural memory of the chinese nation condensed into the spirit of unity diligence courage and selfimprovement and is an important part of the red culture the online dissemination of red culture has enhanced and consolidated the identification of the new generation of young people with chinese national culture awakened the emotional memory and national cohesion of the chinese nation and played a strong supporting role in the great rejuvenation of the chinese nation issn 26165783 vol6 issue 215359 doi 1025236ajhss2023062109 published by francis academic press uk 55secondly big data empowers red cultural education in colleges and universities to help promote and inherit red spiritual character on one hand digital technology has broken the temporal and spatial limitations of inheritance education promoting the transformation from traditional didactic and linear teaching methods to experiential and immersive education this technological shift provides the conditions for a comprehensive and lifelong inheritance education model learners can shape emotional identification and shared values through immersive experiences by developing red culture digital creative products such as audiovisual and gaming content young students can receive education while being entertained and practice while learning this nurtures their steadfast ideal beliefs and lofty moral character leveraging the interactive and emotionally impactful nature of converged media it encourages the production and dissemination of red cultural products aligned with the spirit of the times and contemporary issues through multimedia outlets this enables the seamless integration of red culture into the lives of young students making it more relevant to their everyday experiences it allows them to intuitively grasp the essence of red culture transforming red cultural education from a oneway transmission to a process of interactive identification 4 which fosters a conducive environment for red culture in society on the other hand it promotes the digital storage and dissemination of red culture protecting and inheriting the red cultural heritage through technological innovation mechanisms like collaborations between institutions and museums a digital repository for red culture resources is established this includes the systematic standardized and dynamic uploading and management of red documents images audiovisual materials artifacts and more this ensures the effective preservation and wide dissemination of red cultural resources additionally digital storage enhances and optimizes the channels for red cultural education in higher education institutions by creating and utilizing digital platforms for sharing red culture such as online memorial halls revolutionary sites museums etc a combined approach is formed bridging the online and offline worlds and enhancing the complementarity between oncampus and offcampus resources this results in a diverse multidimensional red cultural education network thirdly big data empowering red culture education in colleges and universities can help resolve the contradiction between education supply and demand and improve the quality and efficiency of red culture education big data tools can effectively improve the accuracy of red culture grasp the laws of red culture education and improve the scientific planning and pertinence of red culture education work on the one hand we should optimize the supply of red cultural resources promote adjustment and optimization of the supply side and enhance the timeliness and effectiveness of communication digitization not only broadens the preservation paths of red cultural resources and improves resource mining and collection capabilities but also promotes targeted innovation of red cultural education content big datarelated technologies can effectively handle the diachronic and synchronic coordination of heritage education thus improving the relevance of the times and vivid personalization of red cultural education content by constructing and using the big data model of red culture education we can accurately analyze and predict the needs interests behaviors etc of young students focused communication uses individual needs as a breakthrough which can effectively improve the penetration of communication to break down barriers and accurately grasp the demand side psychology to achieve personalized and intelligent dissemination of red cultural education on the other hand the evaluation feedback mechanism of red cultural education is optimized through big data tools and methods the application of big data in education effectively captures the changing patterns of students many learning behaviors and forms a digital portrait of their studies thereby promoting the reconciliation of the contradiction between red culture education and the students establish an instant digital visual evaluation and feedback mechanism for red culture education practices to provide educators with a more reliable realistic basis for their educational behaviors and decisions recommendation algorithms and artificial intelligence technology help colleges and universities explore the learning preferences of learners capture changes in thinking emotional cognition and other patterns and help improve the scientificity pertinence and planning of red culture education work the system construction of red cultural education in higher education institutions in the era of big data in the era of big data the construction of the system for red cultural education in higher education institutions involves establishing an integrated educational model that centers on universities leverages red cultural resources utilizes big data technology and aims at fostering moral character while inheriting the red genetic code this system is designed to effectively enhance the patriotism and emotional connection to the the red cultural education system in higher education institutions possesses several distinctive characteristics first and foremost it has a firm value orientation the value pursuit of red cultural education in higher education institutions embodies the goals of the party and the nation in ideological and ideological education from the perspective of students the red cultural education system in higher education institutions should cultivate students to inherit revolutionary character and nurture their love for the party and the country from the perspective of the institutions themselves the red cultural education system should promote the red history and revolutionary traditions of the university and its region enhancing the red cultural atmosphere and spiritual civilization at the national level the red cultural education system in higher education institutions should widely disseminate advanced models of the era inspiring the people of the new era especially young intellectuals to embark on the new journey of building a socialist modernized and strong nation secondly it is characterized by digitization modern digital information technology has profoundly transformed cultural communication methods and educational formats the red cultural education system in higher education institutions has achieved digitization of the material carriers of red cultural resources expanded educational and dissemination forms and greatly improved the efficiency of communication thirdly it possesses purification and optimization capabilities through evaluation feedback and learning improvement mechanisms the various units of the red cultural education system in higher education institutions can continuously obtain dynamic feedback on their educational and teaching or product manufacturing activities this enables them to make immediate improvements in their educational and service capabilities lastly it is characterized by collaboration and inclusiveness the red cultural education system in higher education institutions is not a closed system but one that can involve social units public organizations and individuals in accordance with certain rules and norms through the establishment of network platforms and other means it facilitates resource sharing and collaborative governance among multiple participants continuously improving its own teaching methods and enhancing the quality of education while driving the continuous advancement of red cultural education in higher education institutions it also engages in twoway interactions with other participating nodes in society providing them with feedback support and assistance in the era of big data the key components of the red cultural education system in higher education institutions consist of toplevel design digital platforms universities students social units and organizations firstly there are closely related policies and regulations governing the development and operation of red cultural education in higher education institutions these policies and regulations serve as the toplevel design guiding the digital development of red cultural education in universities and regulating its operation related planning guidelines task assignments and inspection and supervision require legal support from relevant government departments secondly there are digital resources and educational platforms consisting of a unified standard red cultural digital resource library and a red cultural digital dissemination platform these components are responsible for collecting organizing processing storing and presenting red cultural resources especially their material carriers they also create digital windows for interactive communication and wide dissemination with the external worldnext there are universities including the university party committee propaganda department relevant colleges and red cultural education bases which play a crucial role in providing red cultural promotion and education universities are responsible for conducting diverse multiform and multilevel red cultural education activities developing red cultural teaching materials that align with the characteristics of the era and student needs offering specialized red cultural courses and organizing a wide range of colorful red cultural practice activitiesfurthermore there are students who are not only recipients of red cultural education but also active participants and disseminators of red cultural education in the era of big data they engage in a combination of online and offline red cultural education activities through platforms online classrooms online communities etc guiding them to understand identify with and practice red cultural values through their active involvementlastly there issn 26165783 vol6 issue 215359 doi 1025236ajhss2023062109 published by francis academic press uk 57are social units and organizations including memorials research institutes enterprises nongovernmental organizations volunteer associations etc that provide red cultural education projects these entities are important participants in the construction of digital red cultural education facilities resource development product creation and promotional activities in the context of big data they are contributors to the construction of the red cultural education system in higher education institutions in conclusion the red cultural education system in higher education institutions in the era of big data should be an open structure guided by policies led by universities and characterized by a clear value orientation the system is centered around several universities with control and influence radiating to the surrounding areas these universities are interconnected through a network maintaining close ties each unit enhances its capacity to provide corresponding services for red cultural education through collaborative governance simultaneously with the wideranging influence of the big data network the number of participants continues to increase and the boundaries of the system expand gaining new functions and capabilities it possesses the ability for selfupgrade and evolution risk governance in red cultural education in higher education institutions in the era of big data in the era of big data red cultural education in colleges and universities is facing new opportunities and challenges big data technology provides rich resources convenient platforms and effective means for red culture education in colleges and universities while improving the coverage participation and influence of red culture education in colleges and universities it also brings some risks and hidden dangers such as information security issues such as personal privacy online public opinion and values that may have a negative impact on the development of red culture education in colleges and universities in order to lead and regulate the upright and innovative development of red culture education in colleges and universities in the era of big data we should actively respond to risks and challenges and further promote the digital transformation of the red culture education system 5 the digitalization of red culture education is uneven and the risks to the cultural environment to tackle these challenges it is imperative to accelerate the construction of a unified digital platform for red cultural education in the era of big data ideological struggles have expanded from the physical realm to the virtual domain in the worlds digital environment dominated by global capitalism developed western countries are striving for digital colonization of the third world the information domain has become a significant battleground where china and the west engage in ideological struggles affecting the process of information dissemination perception and acceptance thereby posing environmental risks to digital red cultural education constructing a unified standardized digital platform for red cultural education is the ideal choice to enhance the effectiveness of digital red cultural education and address these cultural environmental risks firstly this should be an overall planning effort led by relevant authorities involving the structural collection and integration of red cultural resources nationwide using national unified big data standards a public digital repository for red cultural resources should be established offering diverse options for safeguarding various forms of red cultural resources leveraging big data technology data collection categorization and integration of red cultural relics from different regions should be conducted to create a comprehensive contentrich and diverse digital resource library for red cultural education emphasis should be placed on the classification and standardization of red cultural resources while developing a unified metadata standard and retrieval system to enable rapid retrieval and sharing of red cultural resources furthermore innovation and development of red cultural resources should be prioritized utilizing technologies such as artificial intelligence digital modeling and augmented reality among others to transform these resources into red cultural products encompassing audiovisual materials models games and more secondly establishing a digital propaganda platform for red cultural education is vital big data technology should be fully exploited to build a multilevel multichannel and multidimensional digital propaganda platform that ensures extensive coverage and deep penetration of red cultural education this platform should prioritize interactivity and experiential elements by employing techniques like media integration online live streaming virtual interaction and more to enhance user participation and immersion personalization and precision of the red cultural propagation platform issn 26165783 vol6 issue 215359 doi 1025236ajhss2023062109 published by francis academic press uk 58should also be emphasized big data analysis recommendation systems and similar technologies should be employed to provide customized and intelligent red cultural products based on user characteristics behaviors and preferences making red cultural education more appealing in summary leveraging resource repositories and propagation platforms is essential to enhance the effectiveness of digital red cultural dissemination by employing digital dissemination methods static exhibitions can be transformed into dynamic experiences this approach allows for the full exploration of the unique value of red objects historical sites and stories revitalizing red culture in the modern era while catering to the personalized aesthetic preferences of young students the issue of obsolete discourse in red culture education trendy internet discourse in the big data era has weakened the discursive effectiveness of red culture discourse mechanisms need to be constantly updated to adapt to the fashionable and fast dissemination of discourse in terms of discourse content the discourse content of red culture education in colleges and universities should conform to the characteristics of the times and the needs of students it must not only adhere to the core values and spirit of red culture but also be combined with the current development status of contemporary china and the goal orientation of the new era and new journey at the same time the discourse content of red culture education in colleges and universities should focus on diversity on the premise of ensuring the political nature and correctness of the educational content multiple perspectives can be respected and avoid simply emphasizing unity in addition the discourse content of red culture education in colleges and universities should focus on innovation and vitality use big data technology to collect analyze mine and display new materials and stories of red culture and avoid reusing old materials in terms of discourse form the discourse form of red culture education in colleges and universities should adapt to the diversity advantage of big data and improve the attraction and attention of red culture education in colleges and universities it can learn to absorb the diverse expression forms of interactive spaces such as social platforms and online communities learn and integrate discourse forms in different media spaces and fields and form a discourse system for red cultural education in colleges and universities in the big data era but at the same time the discourse form of red culture education in colleges and universities should focus on moderation and standardization and must adhere to the revolutionary and simplicity of red culture discourse to avoid falling into the trap of being flashy and entertaining lack of professional education analysis technology and lagging evaluation system the lack of scientific data analysis tools for red cultural education makes it difficult to carry out dynamic and precise educational data analysis for the red cultural education process hindering effective feedback and supervision of red cultural education to enhance the effectiveness of digital red cultural education it is imperative to establish scientific educational data analysis tools and build an uptodate professional feedback and supervision system on the one hand with the help of big data and artificial intelligence analysis tools we build a red culture education evaluation analysis and prediction mechanism to dynamically control the needs of digital red culture education crawlers can be used to collect information generated by young student groups when browsing and studying and accurately push relevant red cultural information use data analysis tools to analyze the learning behavior habits psychological cognition and emotional changes of young students to build an educational prediction model and dynamically grasp their cognitive emotional and behavioral change trends thereby achieving accurate judgments on learning trajectories and providing a basis for improving education and teaching paradigms provide a reference use the focus communication method and combine the analysis of the impact and effectiveness of big data on students of different ages and disciplines to improve the educational communication plan in a timely manner and improve the efficiency of red culture acceptance on the other hand build a digital evaluation system the digital evaluation system is a feedback channel for red culture education and a supervision mechanism for red culture education through technical means such as data collection data analysis and data mining quantitative and qualitative evaluations of the quantity quality and structure of red cultural resources are conducted to provide a basis for the protection development and utilization of red cultural resources through data tracking data monitoring data statistics and other technical means realtime and dynamic evaluation of the coverage influence satisfaction and other issn 26165783 vol6 issue 215359 doi 1025236ajhss2023062109 published by francis academic press uk 59aspects of red cultural communication can be carried out to provide a reference for the optimization and innovation of red cultural communication in short it is necessary to make full use of big data technology to build a scientific reasonable comprehensive objective dynamic and flexible red culture prediction model and digital evaluation system to provide effective support for the quality improvement and effect optimization of red culture education conclusions to sum up promoting the digital construction of red culture education in colleges and universities is an inevitable trend in the era of big data big data technology and thinking are of great value in improving the dissemination attractiveness of red culture the pertinence of education and resolving educational conflicts at the same time big data also brings a series of risk challenges which may affect the quality and efficiency of the digital construction of red cultural education in the new era in order to further promote the digital development of red culture education in colleges and universities we should adapt to the requirements of the times make full use of the advantages of big data technology and innovate the content and form of red culture education at the same time we will improve the theoretical construction of red culture education in colleges and universities prevent and continuously crack down on the disadvantages of big data technology and thus promote the creative transformation and innovative development of red culture digital construction

integrating red cultural elements into the ideological education of young students is an effective approach for higher education institutions to inherit their red genes the higher education institutions red cultural education system empowered by big data is a multinodal structure comprising universities as the core digital platforms students social units and organizations this system aims to enhance patriotism and promote the inheritance of red spirit and character values however red cultural education in higher education faces challenges in terms of cultural environment risks lagging discourse and institutional development therefore there is a pressing need to accelerate the establishment of a unified red cultural digital education platform continuously update discourse mechanisms develop scientific education data analysis tools construct a progressive professional feedback and supervision system and enhance the digital effectiveness of red cultural education

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background the family physician has a key role in detecting and caring for abused children or those at risk of being abused a suspected case of abuse is always difficult to deal with and some physicians will be unsure of how to act 1 france has well codified systems for dealing with suspected or potential child abuse 2 in france if a fp suspects abuse he must do everything possible to protect the child it may report to the district prosecutor in writing or by phone with subsequent written confirmation the district prosecutor begins a criminal investigation and if necessary also contacts the county social services if a fp identified risks of abuse he can contact the county child abuse prevention office this office starts to evaluate the childs situation if necessary the office she sends the file to the district prosecutor with a view to legal proceedings however only 25 of reports come from the medical profession 34 most reports are made by social services schools and hospitals several studies have sought to identify the difficulties faced by fps and that might explain this underreporting fear of an incorrect diagnosis 56 the possible impact of a report on the fps relationship with the family open access correspondence 1 medical school university of picardyjules verne 3 rue des louvels 80000 amiens france full list of author information is available at the end of the article 6 fear of not spending enough time with other patients and lastly financial repercussions 5 6 7 in study by jones et al 8 83 of the physicians explained that they had failed to report an incident because they knew the parents well other research has found that physicians are less inclined to make a report because they feel that this action will not benefit the child 7 8 9 and may even aggravate the situation 610 physicians also mention a lack of confidence 5611 or a previous negative experience with social services or the judicial system 8101213 they are also afraid of the penal repercussions for fp andor parents and considered that making and following up a report is very timeconsuming 11 prevent child abuse and improve screening should help overcome these obstacles however for this type of approach to be effective fps must be aware of the risk factors for child abuse certain researchers have insisted on the need for physicians to learn to recognize these risk factors and thus handle difficult situations more easily 14 risk factors for child abuse are those likely to weaken the childs relationship with her parents some are well established and others are still subject to debate the present studys primary objective was to estimate fps level of knowledge of the risk factors for child abuse the studys secondary objectives were to estimate fps use of this knowledge to identify suspected or potential abuse in their practices identify obstacles to dealing effectively with suspected child abuse gauge the fps feelings about their role in managing child abuse determine the type and level of any specific training received and estimate the fps stated requirements for training methods the study was based on 50 interviews with fps in private practice in the somme county we used a heteroadministered questionnaire with open and likert scale questions questions during interview the interviews were performed by one interviewer between july 2011 and may 2012 the study population the study population was drawn from the list of the fps in private practice in the somme on july 1st 2011 according to the picardy association of private practice physicians a total of 577 fps were included in the study selection database we arbitrarily set a target sample size of 50 fps on the basis of a participation rate of 25 observed in similar methodological studies 200 fps were selected at random from the database by using hazard ® software the selected fps were contacted sequentially by telephone until 50 had agreed to participate in the study data collection each individual interview in the fps office was based on a set of 30 closed or open questions and lasted for between 15 and 30 min the first part of the interview focused on the fps sociodemographic characteristics and the second part looked at how the fp would deal with suspected child abuse and probed their knowledge of the risk factors the third part questioned the fp about their perceived role in detecting and managing suspected child abuse and their opinion of the other stakeholders in the area of child abuse the fourth and last part of the interview focused on the fps past training and perceived training needs the interviews were conducted in french and were transcribed and analysed by native french speakers this study was approved by the committee of primary care of the university fp were informed and all participants provided their informed consent analysis a descriptive analysis of these data was performed using spss software quantitative variables were expressed as the mean ± standard deviation and qualitative variables were expressed as the frequency and percentage in a second step a bivariate analysis of the data was performed by using the chi squared test or the fishers exact test the threshold for statistical significance was set to p 005 a multivariate analysis could not be validly applied because of the small sample size in a third step answers to openended questions were analyzed with a qualitative approach answers related to a common concept were then gathered together open responses were analyzed qualitatively in order to identify the concepts developed the transcripts were entered into tropes ® for content analysis and then coded according to the session headings after content analysis the discussions were recoded according to the themes that had emerged lastly the answers were grouped into categories in order to summarize the opinions results disposition of the study group to achieve the target of 50 physicians we called 173 fps so the response rate was 289 the median age was 52 and 38 of the fps were men all fp are born and graduates in france the fps mainly practiced alone in semirural areas the others fps practiced in rural areas or urban areas perception of the risk factors by the fps ninety percent of the fps considered that there are risk factors for child abuse whereas 3 considered that there are none at all all the results are summarized in table 1 some doctors talked about their desire for screening tools i will use it to simplify the screening i like what we can quantify a scale is reassuring official or just to have this tool available is relevant if we have the tool we think more about screening thus increasing our experience in this field and we are more vigilant others are more reserved its not a scale that will tell me if a child is being abused the physicians own experience eightytwo percent of the fps had already suspected a case of child abuse and had identified risk factors beforehand in more than half of these instances of these fps 31 stated that their diagnosis had been strengthened by the presence of risk factors in most cases the childs consultation had been followed by hospitalization ten of the fps had filed an administrative report and 12 had contacted the state prosecutor some of the fps preferred to ask the social services for advice to discuss the case with a colleague or investigate matters further themselves in four cases the report was not followed by legal proceedings the child abuse was confirmed in 61 of cases 64 in the presence of risk factors and 50 in the absence only nine fps had never encountered a case of suspected or potential child abuse fiftysix percent considered that the presence of risk factors would not strengthening their diagnosis more than half declare to have no barriers in the support of a case of child abuse difficulties encountered in cases of suspected child abuse the most frequently mentioned problem was the difficulty in establishing a diagnosis of child abuse almost all the fps stated that protecting the child was the major driver for their actions diagnostic certainty and being able to count on help from third parties were also motivating factors the impact of a procedure for the child and his family are a hindrance that reporting is done wrongly or rightly i may explode the family im afraid of losing sight of the child the risk is that the report due to bringing more harm to the child that if i did not report many doctors criticize relations with social services seeing them as being unresponsive holding that the monitoring of the child they propose is not always consistent they show considerable inertia workers social are useless social services either they panic for nothing or they are missing out on real life situations the physicians feelings about the role in caring for potential victims of child abuse most of the fps stated that they felt personally involved in caring for children at risk of child abuse however once child abuse had been identified less than about ten of them refer the child and her family even report many of the fps did not feel that they were sufficiently involved in the process by the other stakeholders in the field of child abuse some of the surveyed fps deplored the lack of information about the consequences of reporting suspected child abuse and sometimes went as far as criticizing the action of the social services some doctors emphasize their personal and professional conscience i will act so as not to be angry with me all my life if i close my eyes to a situation of child abuse past and future training only 15 of the fps had received training on detecting and managing child abuse and over half of these had found it useful of those who had not received any training 35 wished to receive training in the future the remainder considered that they did not need any additional training the fps stated that the training course should be compact practicebased fpled and uptodate and should be delivered in a universitylevel institution more than half of the fps suggested that a 247 medical support line would be useful we did not observe significant differences between fps having received specific training and those not having specific training in terms of knowledge of risk factors for child abuse however there was a statistically significant difference between trained and untrained fps in terms of their level of knowledge of the reporting procedures discussion knowledge of risk factors and perception of the value of these factors in clinical practice fortyfive of the 50 fps in our study considered that there are a number of risk factors for child abuse the fps were not greatly aware of the key role of prematurity and psychological and emotional factors they considered that disadvantaged socioeconomic status was more important it is probably more difficult for the practitioners to detect the child abuse in the favored environments especially as they belong to them the french social action observatory has emphasized that psychological and emotional factors are more important that low socioeconomic status in the risk of child abuse 15 this was confirmed by tursz et al s study in which most of the mothers having shaken their child had an higher socioeconomic status 16 according to the literature there are many risk factors for child abuse however low educational level and disadvantaged socioeconomic status are subject to debate 15 16 17 18 19 according to flaherty et al the level of suspicion of child abuse should be higher when the practitioner identifies the presence of a risk factor 20 difficulties encountered in cases of suspected child abuse the main difficulty evoked by the fps of our study was the fear of making an incorrect diagnosis in the literature the fear of making a mistake is also the main obstacle to reporting 5713 roles in reporting child abuse even in clear cases of abuse physicians fear that breaking up the family unit will have even more harmful consequences for the child this aspect is also related to the widely reported feeling that judicial and social services are not sufficiently active or do not offer adequate solutions 58 13 21 some fps report a negative experience with social services or judicial for the child or for themselves which does not encourage them to report or to screen this difficulty is compounded by the fact that 46 of the fps having suspected child abuse had little or no knowledge of the reporting procedures poor understanding reporting procedures was also cited as a possible obstacle by nine fps who had not been confronted with a suspected case of child abuse 9 training now and in the future training is one possible solution however although this is a legal obligation in france few fps stated that they had received specific training an important aspect in line with the literature is the fact that most professionals did not attend training on the thematic of violence against children and adolescents other authors highlight the scarce knowledge about the issue as one of the main factors affecting the identification and reporting of maltreatment 2223 an other study undertaken with professionals of primary health care in northern ireland found that many workers failed to report for not knowing how to proceed in cases of abuse 6 there was a significant difference between fps having received training and those who had not the former were more likely to state that that did not understanding the reporting procedure this may be because training increases the physicians awareness of the complexity of the situation without helping himher in practical terms fps do not have a particular focus one can hypothesize that fps do not have a particular focus child abuse during their medical training because they are rarely confronted with this problem in practice even though training on detecting and managing child abuse is a part of the french national curriculum for sixthyear medical students it is not a greatly studied topic other tools mentioned by the fps included a national hotline for physicians a french national hotline for reports of suspected abuse already exists and county child protection units often offer similar services however these hotlines are not specifically targeted at and staffed by physicians 12 study limitations recruitment bias was a potential limitation since participation was voluntary practitioners who were more interested in and comfortable with the subject were probably more like to agree to participate a third potential source of bias related to the vocabulary used in the study before starting the interview we did not remind the fp of the main definitions in this field implications for clinical practice and research overall our findings are in agreement with the literature data on risk factors for child abuse nevertheless they did not know much about the predominant role of prematurity and psychologicalemotional factors in the genesis of child abuse insisting on this point in specific trainings for fps might increase the detection of suspected child abuse with regards to the current legal obligation it would be advisable to extend this training to all fps and to make it very practically focused and rich in case studies in contrast to several larger studies performed outside france our survey of the obstacles to reporting did not highlight a particular interest in this type of training 7102024 one of the major obstacles mentioned by the fps in our study related to the impact of the report on the child and its family if child abuse was confirmed we did not assess the fps knowledge of the various types of support available to the child and its family following a report it may be of value to provide fps with more information about these measures and to show that the overall outcome of support is beneficial for the families 7 similarly changing the fps view of the social and judicial services appears to be essential if practitioners are to improve their detection and management of suspected child abuse a canadian survey of pediatricians suggested informing them more precisely about the roles of the social services and their own difficulties when faced with an atrisk child 25 it may be essential to increase the feedbacks of the social and judicial services and of the system to the fp giving the feeling to the latest to belong to a multidisciplinary team and that their action is not useless 7810 along with a welldesigned training program the surveyed fps suggested that a support hotline would be of great value working as part of a network with specialist hospital units may be a source of support for primary care physicians 24 conclusions there are many obstacles in fps to perform their role in protecting children from abuse it is important to offer the fp support so that the physician does not have to deal with these challenging situations alone funding competing interests the authors declare that they have no competing interests additional files additional file 1 courses of action in a suspected case of actual or potential child abuse in france additional file 2 risk factors for child abuse reported in the literature additional file 3 questionnaire

background family physicians fps have a central role in the detection and management of child abuse according to the literature only 25 of initial reports of child abuse come from the medical professionthe objective of this study was to assess levels of knowledge of risk factors for child abuse by family physicians fps and the attention that the physicians pay to these risk factors we conducted a mixedmethod survey based on semistructured interviews 50 fps practicing in the somme county northern france were interviewed with closed and open questions the fps level of knowledge of risk factors for child abuse and obstacles in the detection of child abuse were assessedthe fps level of knowledge of risk factors for child abuse was similar to that reported in the literature however fps knew little about the significant role of prematurity likewise the fps training did not seem to influence their knowledge of risk factors fear of an incorrect diagnosis was the main obstacle to reporting a suspected case the fps considered that they were often alone in dealing with a difficult situation and considered that the judicial system and the social services were not sufficiently active conclusions few fps had actually received specific training in the detection and management of child abuse but many stated their need for this type of training fps encounter many obstacles in the detection of child abuse which sometimes make the fp reluctant to report a suspected or potential case medical education need to be improved in this field

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introduction historically the discovery of gold and other minerals in south africa led to a booming mining industry that continues to make a significant contribution to the countrys gross domestic product at the same time however the mining industry has sustained racialized capitalismie the broader global phenomenon of economic disenfranchisement of black people which has its roots in colonial systems that provide economic opportunities for white people while depriving these to other groups 1 the south african mining industry grew its profits from the cheap labour provided by thousands of black men who were recruited from the homelands and neighboring countries during apartheid 2 previous research has described health vulnerabilities among black south african men generally as well as among black south african men working in the mining industry building on social and anthropological research by hunter 34 and others 5 6 7 8 this paper centers the analysis on intersections between notions of masculinity work and economic and familial responsibilities among black south african mine workers and explores implications of these intersections for health wellness and gendertransformative interventions scholarly work on men and masculinities has increasingly demonstrated that gender identities are intertwined with racial and socioeconomic politics that have resulted in the socioeconomic marginalization of black men and women 910 such theorization about marginalized masculinities is often juxtaposed against connells theory of masculinities 11 connell recognizes patriarchal privilege as an organizing principle that confers men with genderbased advantages relative to women but also contends that in any context there are multiple constructions of masculinitieseach of which might uniquely hold unequal relationships to control over women unequal access to resources and opportunities and afforded unequal regard by other men hegemonic masculinity is both a highly popular and contested concept in the scholarship of men and masculinities 12 particularly in the global south 13 the contestation has centered around the position of black men in society and the role of power as the main defining property of hegemony given black mens disenfranchised material conditions both globally and in south africa specifically the concept is highly problematic for understanding the lives of black men 14 for example ratele 14 calls for a view of hegemonic masculinities among black men as hegemony in marginality giving rise to a recognition that black masculinities are constructed within contexts of patriarchal privileges that are tied to maleness yet also shaped profoundly by raceand economicbased marginalization some scholars have argued about masculinity in crisis which involves recognition of the structural conditions that destabilize assumptions of hegemonic masculinity and contribute to mens failure to fulfill masculine ideals 361516 across many cultures men are ascribed the roles of head of households protectors and providers 1718 the current south african social and economic conditions characterized by high levels of unemployment or precarious job opportunities make it difficult for many men particularly black men to achieve local forms of hegemonic masculinity including securing jobs marrying fathering children and establishing their own households 19 they often cannot afford to pay ilobolo and inhlawulo 152021 or build their own umuzi or motse 19 the lack of resources makes it difficult for many black men to establish families or establish themselves and take on the role of legitimate fathers particularly when they father children outside the institution of legalized marriage 22 furthermore many men are unable to fulfill their traditional roles as providers and breadwinners to support their families hunter 3 describes these men as men without amandla mining remains a very significant economic activity in south africaboth for the national economy as well as for mineworkers and the families that they support poor black african men from rural areas of south africa continue to disproportionately provide workforce for the mining sector 23 in addition to being historical sites for the economic exploitation of black mens labor mining locations are also settings for workers increased vulnerability to occupational and socialrelated health risks such as respiratory illness 2425 infectious diseases including hiv 26 27 28 29 violence 230 and mental health problems 3132 mining locations are also potent sites for social unrest and active protest among workers for example in august 2012 a mass protest of about 3000 mineworkers broke out in the platinum mines in marikana northwest province this was arguably the longest strike in the mining sector since the advent of south africas democracy in 1994 lasting over 18 weeks 33 amongst other demands the mineworkers were seeking better living and working conditions and a livable wage of r12000 per month on 16 august 2012 south african police opened fire on striking miners using automatic weapons killing thirtyfour 34 mining sites provide a compelling backdrop to examine the intersections of marginalized masculinities occupational setting and health vulnerability of black south african male workers the specific aim of this qualitative study was to explore male mineworkers insights on the ascribed provider role and how it reflects the construction of masculinity and relates to health consequences in the specific context of minework in marikana northwest province south africa material and methods study design this was an explorative qualitative study using indepth interviews we adopted this study design because we were interested in gathering narrative insights into the lived experiences of black african male mineworkers with regards to the provider role and how it is linked to the construction of masculinity in this setting study area participants lived in nkaneng and wonderkop settlements located outside the premises of the lonmin mines in marikana northwest province south africa while these two communities were mainly comprised of informal houses there were several houses built of cement blocks present in both settlements these communities provide residence primarily to men who are either working or seeking employment in the platinum mines mineworkers in this setting have the option of residing in companyprovided single sex housing or family units alternatively they can receive a housing allowance and seek accommodation outside of the mine premises empirical evidence from south africa shows that informal settlements are characterized by poverty poor infrastructure and hygiene high unemployment rate with studies suggesting a strong association between these conditions and a range of serious public health problems including interpersonal violence 3536 and hiv and aids 3738 the majority of participants resided in nkaneng next to the koppiethe specific site of police violence during the 2012 strike 39 many participants lived in small shacks or rented back rooms with no access to basic services such as running water electricity and hygienic drainage systems the streets were not tarred these issues were raised during the strikeespecially the lack of decent houses for mine workers 39 but little has changed materially since study participants table 1 provides descriptive sample characteristics most men in our sample were either currently working seeking employment or were recently employed on the mines at the time of the study mens ages ranged between 28 and 63 years in terms of formal education levels of completed education ranged from grade four to grade 12 none of the men interviewed had a tertiary education most were married with the majority married traditionally which is legally recognized in south africa under the customary marriages act 1998 amongst those married almost all reported that their wives and children were permanently residing in their rural homes in other provinces in terms of ethnicity most participants identified themselves as xhosas one as a pondo another as a mpondomise one a sotho and three as tswanas all men reported to have had at least one biological child data collection the data came from 13 indepth interviews conducted over two phases of data collection the first phase of data collection was done in nkaneng in 2016 where nine idis were conducted this was followed by a preliminary data analysis which enabled us to identify new directions and emerging patterns in the data to pursue in subsequent interviews 4041 we then revised our interview guide and conducted a further four idis in wonderkop in june 2017 for the first phase of data collection a purposive sampling technique 4042 was used to select nine men who resided in nkaneng and had been living there for a period of five or more uninterrupted yearsa time period which overlapped with the occurrence of the 2012 mineworkers strike the first author spent approximately 3 months visiting homes in nkaneng and inviting men who met the study criteria to participate in the study the marikana mineworkers strike was a very painful and traumatic experience which left a legacy of hurt anger and mistrust amongst people see 39 therefore concerned with their safety four men expressed discomfort with the research focus and declined the invitation to be interviewed for the second phase of data collection we used a theoretical sampling technique 4041 to identify four men who were receiving professional counselling to deal with the effects of the 2012 mineworkers strike recruitment was facilitated by lay counselors working with mineworkers in marikana who provided referrals to the study almost all participants had actively participated in the strike in the interviews participants were asked to share their views on what they think the roles of men are within families what challenges they had personally experienced in fulfilling expectations associated with their role as men in their families what working in the mines mean for them as a man what are the most important things to them as a man what they need to achieve as a man for them to view themselves as a successful man how much would they say they have achieved as a man what kind of a man one needs to be to fit well among other men in the mines what kind of men are not popular or considered weak men in the mines next men were asked about the 2012 mineworkers strike their views involvement and experiences of the strike the idis allowed the intricacies and contradictions of real lives and personal stories to emerge without men feeling obliged to represent themselves in a social desirable manner as they would likely do when in a group 43 idis lasted approximately 1 hour ranging from 30 minutes to 15 hours all idis were digitallyrecorded and conducted by the first author using a mixture of isixhosa isizulu and bit of setswanaand the participants could express themselves through one or a mix of these languages digitally recorded idis were transcribed verbatim and translated into english by a professional translation and transcription company upon completion of the transcription recordings were checked to ensure transcription accuracy data processing and analysis we analysed data inductively employing a thematic analysis approach 4044 all authors were involved in various stages of data analysis we first read and reread the transcripts individually to familiarize ourselves with the content of the transcripts next we established some general codes which somewhat resembled the questions in the interview guide further to this text which seemed to fit together was grouped under a specific code 40 next we examined the data and found numerous open codes open codes which were deemed to be similar were clustered together under clearly defined themes thereafter we explored the associations between the themes and interpreted what we saw emerging last we compared our findings with those of similar published studies 4041 ethical considerations this study was approved by the south african medical research council human research ethics committee before conducting the idis the first author reviewed the participant information and consent form with the participants the discussion included the rights of participants in the study and risks and benefits of participating in the study written informed consent was obtained from all participants we have replaced the names of study participants and two locations in which the study was conducted with pseudonyms to protect the identity of the participants participants were reimbursed with r150 for their time results five main themes emerged during data analysis first participants narratives depicted the dynamic construction of masculinities as mineworkers straddled both the temporary space of work and the real rural home space second economic provision was characterized as an inescapable demand on poor black male mineworkers imposed by society but internalized as an intrinsic part of their manhood third despite economic hardships and instability participants consistently endorsed the fundamental societal expectation for men to provide for their children although men conceded that attempting to achieve the provider role was painful they did not contest this demand on them fourth narrative accounts revealed impacts of the intersection between masculinity and minework on psychological and physical health last we show that the mens efforts to provide economically for their children and family continued despite their concessions that they had limited chances of succeeding with this realization some men sought to create alternatives to ensure the future survival of their families the land that we live in here is not ours constructions of masculinity straddling spaces men interviewed spoke of the responsibility of straddling the rural home and work spaces and negotiating the masculinityrelated expectations that were specific to each space the mining context where the men worked and resided was viewed as a temporary space for the purpose of generating income and subsequently transferring income to the real home space to provide for their families this is illustrated in vusumzis narrative below here in marikana it is just a place of work where i am supposed to do something is at rural home i am working here so that they will not suffer back at home a similar sentiment was shared by liwa i do have another house back at rural home i do not want to lie but i am here for work purposes i am here because i thought about the future of my wife kids and myself so i am not here forever i came here for work purposes the land that we live in here is not ours however we stay because we want to support our families in the real home space ideal masculinity was defined by establishing a family being a provider and having certain possessions like livestock 45 all of which bestowed upon men a desirable masculine identity and respectable social standing among other men in the home community wisemans quote below clearly summarizes this notion of a desirable masculine identity for you to be an honored man you must be married a man that is married is always followed by children then when the children are there they will call you father which means they are scared of you and you also need to set an example and all that makes you as a man feel honored you become an example to them children and they can easily say there is our father and not call you by other names you must also have livestock in your yard like chickens cows sheep you name them so people can see this is a home belonging to a man having livestock also puts you in a position to say something in meetings amongst other man because you are also a man now your voice must be heard and you should appear to be a man working towards something that can be noticed in his interview morena explained that a man who fails to achieve certain masculinity milestones in the rural home space will not be recognized as a man by other members of the community morena when you are a man you are supposed to get married build your own house and have your own family interviewer if you have not done that how does the community perceive you morena ey you are not recognized you know they do not consider you as a man they undermine you as reflected in the extracts above the mens definition of manhood in the rural home space emphasize leadership being accomplished establishing and providing for a familyaspects of masculinity that have been associated with traditional patriarchy 4647 in the temporary space of work in which men were deprived of external symbols corresponding to ideal masculinity that are present in the real home context participants described a reconfigured masculinity this reconfigured masculinity was constructed through the demonstration of monetary prowess and behavioral performances strikingly akin to the concept of hypermasculinity 48 for example in these temporary work spaces men displayed their reconfigured masculinity by spending money publicly having sexual relationships with multiple women drinking alcohol and similar performative gestures that gained admiration and recognition by women and other men in mining environments some men like nice times they forget where they are coming from and where they are going they groove they call it groove participants described that transactional sexual relationships in marikana were common and typically were initiated based on men buying alcohol for women whom they met at bars taverns while these relationships often involved onceoff sex and money exchange some of these women took on the temporary role of homemakers the men in turn contributed to the material needs of these temporary partners and sometimes to the needs of her family interviews revealed that some of these relationships developed into longerterm relationships hence they were perceived and served as pseudo marriages and provided men an avenue to enact a provider role status in the temporary work space if she nonmarital sexual partner is here she will want to stay behind and sleep and when you return from work she has washed all the dishes your clothes and cleaned the house too a lot of men are staying with them nonmarital sexual partner now like a wife and she cooks for him does everything a lot of men do that they stay with women in their houses its like she is his wife men do that here a lot of men the interviews suggested a contestation between the ideal masculinity which was hegemonic in the rural home space and the hypermasculinity in the temporary space of work disapproval was directed toward men who engaged in transactional relationships that benefited masculinity in the temporary space at the expense of providing financially for the mans family in their rural homes these types of hypermasculinity performances were deemed reckless and violations of the very reason for mineworkie prioritization of family provision we men view him as a stupid man theres a lot of men here that are like that they finish their money here and dont send anything home we see their wives coming here to collect the money in his interview lethabo expressed skepticism about sexual interactions and relationships between men and women that occur in the temporary work spaceintimating that these exchanges in the temporary work space are centered on physical and monetary exchange rather than emotion and partnership in his own words woman are no longer in love with a man they sell sex if you ask for love they do not do that but you can get that by luck but these days no they are many and they want you to buy you give her money and she gives you her thing sex and thats the end then you go in separate ways they are not up to this thing of loving each other staying together you can get one but they are no more most of the men who were critical of their peers who spent money on women and in bars taverns spoke proudly about taking on chores like cleaning their own roomshouses washing their own clothes and cooking for themselvesactivities that are traditionally aligned with the role of homemaker and ordinarily a womans role in patriarchal contexts these men spoke of their engagement in domestic chores with great comfort and at times pride particularly when they compared themselves to men who opted for temporary female partners to do these domestic chores for them this is best illustrated in vusumzis account below not that i would meet someone and say come and cook for me even when i was in durban i had no problem with cooking when i was working in the firms we are at the mines here so most men cook for themselves while these men took on the domestic chores in the temporary space of work it is difficult to conclude that they were intentionally challenging norms of patriarchy and ideal masculinity which is hegemonic in many black communities in south africa 1349 men viewed this as a temporary measure and roles from which they disengaged when their wives visited the work space or when they returned to their rural home space providing is an inescapable demand most of the men interviewed were committed to fulfilling the provider role however they also expressed views about the burdens associated with the role for example luzukos quote below acknowledges the taxing demands of the provider role im the man everyone is looking up to and depending on so even if i complain i cant complain much because there is no one else to take these responsibilities the burden to provide appeared to have been particularly acute amongst men who were unemployed as they were still expected to devise means to provide for their families in the rural areas buhlebezwes extract below evidences this a man must provide support at home yes money is expected from a man so everything stops now if you are not working nothing is progressing you see but because i had worked before and had cattle when it is very difficult i would say no lets sell a cow because i dont have money narratives also revealed that the expectation for men to provide for their nonmarital sexual partners also existed in the temporary space of work when oupa was asked how people in marikana perceive a man who is not working he posited ey you are nothing no you are nothing even the woman you are staying with who looks after you here in marikana if you man are not working you cannot take care of her you should at least look for jobs you see this thing is hard ey this thing is painful when asked what a man in marikana should do to demonstrate that he is a man in his house oupa a retired mineworker who said he was struggling to provide for his family contended that he must work you see and respect his job and know how to get successful without working theres nothing he can do yes never without working participant narratives emphasized the mans core responsibility to devise a means for financially supporting his family however it was clear in the mens narratives that this role expectation carried strong emotions and feelings when a man is unable to fufill these expectations luzuko described how he felt in instances when he was unable to provide for his familys needs you feel very sad if cant provide its not a good thing to fail you tell them family you will send money next week but the child is sick now fulfilling the masculine expectation of the provider was both a source of pressure and also a measure of selfworth and manhood as seen in wisemans account below it made me feel bad especially when i got a call from home asking for money i did not have because now back home they know i got paid and i havent given them anything because i dont have i had to provide for the needs of my other lady nonmarital sexual partner here her rent and my needs now i get reports that my children need this and that it makes my heart ache very much being a provider was particularly overwhelming for men who provided for their immediate and extended families in the rural home space as well as for their nonmarital sexual partner in the temporary work space this burden reflects the common notion that in a traditional black african family expectations of being an economic provider often extend beyond ones immediate family indeed participants noted that a man who earns an income or is employed is expected to support the entire family system many participants consequently felt that their salaries as mineworkers were not enough to support their families luzuko and oupas narratives to follow are illustrative its painful to know that you are the only one working and the whole family depends on me and the money we get here doesnt even get to r10 00000 only when we work overtime then we get a little more than that i rent here and the kids are at school in the rural home space and i must send money for food and clothes no it pay was a cent that time i was not getting enough money per day i was paid r700 i worked as an electrician in the mine i was paid r700 per day not per hour but per day no it was very small and was not even funny because it was me and my children depending on it fatherhood centered on provision although most participants were married and had children and hence had attained important features of the ideal masculinity in black african communities 50 they saw their families infrequently due to migration to work at the mines consequently most mens experiences of fatherhood focused predominantly on economic provision while the mens sense of fatherhood chiefly centered on providing their jobs were precarious they were poorly paid and some were unemployed making it difficult to fulfill the provider role participants oupa and buhlebezwe elaborate on this experience you see these boys they are my children theres an older one his name is bongani they sons have children also the two of them another is my grandchild and ndaba he has a daughter who is here i buy them pampers disposable diapers and i am still feeding them because they are not working there are no jobs it pains me a lot you see when a child says father i have a shortage with something at school or its something like rent and i would realize that its not month end yet and concede that there is nothing i can do and just tell her please persevere or at least i would talk to someone who is at the rural home and say hey man can you lend me r2000 we will talk about what i will give you at home so i get by through making plans when a child is asking for a big amount of money i quickly call someone so when that person gives me the money i would sell him something at home that is the kind of life i am living if i did not have a livestock it would have been very difficult men who were unable to meet the responsibility of providing for their children attracted criticism from peers who would remind them of the primary reason for minework to earn an income to provide for ones family luzuko elucidated how one male colleague was rebuked for neglecting his family in the rural home they colleagues at the mine sat down with him a man who does not send money home and reminded him what he is here to do and is not supposed to spend money like that they told him man we are sent here we are not here to play dont forget we are not here to work for ourselves we are working for our families fulfilment of the provider role was highly scrutinized and socially policed by peer mineworkers rhetoric around being a real man centered around how men spent their money with providing for families and children being one of the main duties to fulfill indeed participants noted how they can observe whether their peers adequately fulfilled the provider role expectation based on their childrens appearance you see sir when youre working there must be a difference between you and the person not working you can buy groceries and send money home but if you are not working you cant do that but some men dont send money home and now their kids suffer they walk bare feet to school and at home there is no food but the man is working that is not right impact of work on mens health against the backdrop of masculine role expectations predicated on economic provision for ones children and family participants pointed out the daily dangers they face in their jobs and the constant threat minework posed to their lives men like sinovuyo highlighted negative health impacts of minework working in the mines most of the time it is nice and at the same time not nice in this way most of the time here we use explosives and they are affecting us health wise so it is not nice in that way even in the hospitals that we have here you would see that people are not alright although they will say it is other diseases and you will find that it is because of these explosives most of the time because some people have a weak immune system tb is highest here in the mines because of the things we are working with it is not nice in that way because you end up seeing that your life will be shortened because of your working conditions sinovuyos assertion regarding the dangers inherent in minework was corroborated by men like vusumzi and ntsizwa who emphasized the difficult conditions they work under and risks associated with their work in their own words the conditions that we work under are very difficult for example you may come here next week to ask for vusumzi and they would tell you that he has passed away the mine collapsed on him we just survive through gods protection otherwise when you go to work you dont know if you will be coming back or not because the rocks can fall on us whenever they feel like these accounts demonstrate participants concerns that minework threatens their ability to work in the future and even more so their fears that workrelated impairment or death could leave their children without a provider as such the health hazards associated with minework undermined the provider status and notions of ideal masculinity conferred by this work and further introduced anxieties about both shortterm and longterm financial security for the men interviewed he must not end up like me and work in the mines creating alternatives the majority of participants felt that opportunities for work outside of the mines were limited as it was increasingly getting difficult for men like us to secure jobs in the country most participants sought work at the mines at a young age because their own fathers had struggled with providing for the family intensified by the masculine role expectation to provide participants described having to terminate their education and relocate to the mines in order to supplement or take over their fathers provision for the family this dynamic is explained in boitumelo and morenas narratives below he was not working it was very hard to continue with schooling that is why we ended only in standard 7 grade 5 and did not continue with schooling it was very difficult growing up we were hustling for small jobs while growing up until today ey it was hard because i was supporting my siblings my two brothers and i dont have parents my mother passed away in 1983 eh so i had to drop out of school and go work so that i can support my brothers and push them to go to school that is what made me to continue working in the mines now if i wasnt retired because of sickness id still be working now most men in our study described a sense of entrapment to work in the mines due largely to their low levels of education participants like vuyani bemoaned the cycle between education limited opportunities outside of minework and implications for their health and further opportunities vuyani explained mines are not a good working environment unfortunately because of my level of education this is the only place with my bread and butter if you worked a long time in mines once you retire you do not live for long we just work because we are in need men like morena shared accounts of retiring early at the mines because of ill health he posited i was sick in 2013 yes i retired from work by medical board eh after the strike you see the 2012 strike it started while i was still working it took six months so after six months it was january 2013 i got sick you see i was suffering from tb and i found that the mine is releasing me i was given a medical board so even now i am not working eish i am hardly surviving in light of the emotional and economic struggles associated with fulfilling the provider role through minework participants imagined better opportunities and career paths for their children they perceived education as a means to access better opportunities for employability and financial stability participants like vusumzi and luzuko thus encouraged their children to complete higher levels of education in order to enhance their employment prospects they explained i am also giving him son a bright future so that he will not end up like me and work in the mines yes he must not end up like me and work in the mines i would love to send my children to tertiary schooling and they become lawyers i would like to be that father that has children that are lawyers my father didnt have children that were lawyers because we didnt finish school while all participants had internalized the provider role and did not contest this responsibility many conceded that meeting the financial needs of their families is unattainable and their ability to provide for them is threatened by the precariousness of minework and job scarcity in south africa men like buhlebezwe were thus open to the possibility of women becoming providers and breadwinners in families in the future he posited im telling myself that perhaps when the one daughter who is a girl who is at university can finish it would not be the same she can be able to contribute even with a r1000 as we are not yet at the stage of getting a pension we are still young so whatever cent she would give us it would make a difference this example of readiness for women to become family providers and breadwinners suggests a window of opportunity for engaging men in gendertransformative work statements such as this reveal the capacity for these men to critically reflect on the impacts of provider role expectations on their health and consider alternative lives for their children discussion in this paper we demonstrate how migration and minework informs the construction and performance of idealized masculinities in both the rural home space and the temporary space of work and how these masculinities contest each other in the temporary space of work moreover we present findings showing how poor black african men who migrate for work from the rural areas to the mines in big cities must straddle these two spaces which prioritize distinct constructions and expectations about masculinity there are implications emanating from this tension in the construction of masculinity for poor black african men first they must use their meagre salaries to support themselves in the temporary space of work while also providing materially for their families and children who have remained in the rural home space second while away from their families in the rural home space some men constructed and performed hypermasculinity aligning with expectations and opportunities in the temporary space of work men and masculinity studies have shown that this masculinity is performed through engagement in risky practices including having multiple sexual partners harmful use of alcohol and illicit drugs 4851 consistent with our findings studies in resourcepoor communities in south africa and elsewhere suggest the performance of hypermasculinity and other exaggerated masculinities oftentimes leads to the detriment of the men who ascribe to role expectations 14 49 50 51 in this study we have shown that while minework enabled access to the ideal masculinities in both the temporary space of work and the rural home space for most men it did not enable a sustained ability for them to meaningfully provide for their families in our sample men who had recently retired or been retrenched from the mines reported struggling financially and failing to provide for themselves and their families thus soon after leaving the mines men and their families entered further into poverty as gibbs et al 52 argue livelihoods challenges for poor black men in south africa are embedded in a complex intersection of economic political and social marginalization that they have experienced over many years and even intergenerationally with histories of migration and distant fatherhood first emerging on their grandfathers continuing through to them targeted research is needed to establish the longlasting implications of migration and mine work for poor black men in south africa we have also shown that in the temporary space of work men reconfigured their masculinity and constructed one which was predicated on public demonstrations of possessing money which often manifested as frequent patronizing of bars and buying and drinking large amounts of alcohol often men also purchased alcohol for women in the bars which in turn facilitated transactional sexual relationships the mens practices of reckless spending of money in bars engaging in harmful consumption of alcohol and transactional sexual relationships are consistent with the hypermasculinity that is hegemonic in resourcepoor communities 5354 while our findings support this literature our analysis further revealed that some men questioned the hypermasculinity that circulated in the temporary space of work these mens opposition to the hypermasculine positionwhich is predicated on economic provision sexual conquest and transactional sexopens a window for engaging these men in gendertransformative and hiv prevention work and assisting them to reflect on other positive forms of masculinity 54 we have presented findings showing that men in our study internalized societal expectations to be providers for their families and elevated the provider role to a key characteristic of idealized masculinities in both the rural home space and the temporary space of work 53 notably endorsement and internalization of this belief persisted among this sample of men who expressed frustrations anxiety and feelings of burden linked to the provider role published literature suggests that in many contexts in africa men are expected to provide economically for their families 655 izugbara has argued that expectations that black african men should be providers for their families prevail even in times of hardship in his study poor men in two kenyan slums vehemently argued that a man cannot call himself a man if he fails to put food on his familys table 6 yet in the current economic climate in south africa which is characterized by high unemployment rates 56 many black african men struggle to fulfill the provider role within their families 5758 in line with this khunou contends that the current high rates of unemployment in south africa suggest that the idea of men as sole providers is not sustainable we concur with khunou and further argue that there is a need for labour reforms to address employment conditions of lowpaid mineworkers to enable them to strengthen their livelihoods and secure better futures for their families our findings show that as most men in our sample had migrated to the mines for work their experiences of fatherhood mainly focused on economic provision with little involvement in nurturing and providing emotional care for their children while literature on fatherhood in south africa is increasingly showing that fatherhood is seen by some men as going beyond material provision to include nurturing and provision of emotional care to children 2059 our findings conversely show that fatherhood among migrant mineworkers continues to be tied to material provision this finding can be explained by literature which suggests that this way of fatherhood emanates from both historical and current reality of many poor black african men who have to travel long distances to work or seek employment in the mines and only visit their rural homes and children infrequently 2 we have presented a finding demonstrating that men in our sample were lowpaid mineworkers with precarious jobs while others were unemployed and how this made it difficult for these men to fulfill the provider role literature from south africa suggests that the societal expectation for poor black african men to meet the demands of being a provider has implications for the degree of pressure they may perceive or experience towards being unable to fulfill the provider role 3 poor black mens inability to fulfill the provider role has been shown to have serious ramifications for their masculinity 205758 and psychological health 58 in light of this thomas and krampe 60 underscore the need for gendertransformative interventions to support black african men to shift their thinking about their roles as menfrom one which amplifies the provider role to one that accentuates the importance of spending time with family and children being available emotionally for their children and being a role model to them in this paper we have demonstrated that some men perceived minework as dangerous and a threat to their lives yet they felt trapped to continue working or seeking work in the mines as they had limited opportunities to secure jobs in other sectors because of their low levels of education prior qualitative research in resourcepoor african communities has shown that poor black african men aspire for improved livelihoods enhanced social conditions and economic opportunities that would enable them to break the cycle of poverty for their children and families 6 indeed some men in our sample reimagined different lives for their children these men envisioned a disparate future and career paths for their childrenwishing to break the cycle of intergenerational migration for work to the mines this finding suggests that within these men there were tensions in relation to performance of masculinities furthermore there were tensions in relation to how these men felt compelled to be distant fathers separated from their families 15 and their appreciation and conviction that this arrangement was a prerequisite so that they can reimagine a better future for their children however based on this analysis we contend that in trying to economically craft a better future for their children these men were exposing themselves and their families to immediate hardships limitations in this qualitative study we interviewed men who were purposively selected because they had spent five or more years living uninterruptedly in marikana and working or seeking work in the mines thus our findings are not generalizable yet we hope the insights we have collected are of interest to other similar african contexts there is a possibility that some men may have felt obliged to respond in a particular manner including feeling the necessity to describe themselves as real man with traditional values or to represent themselves in a socially desirable manner with regards to their struggles for work and inability to provide for their families conclusions we have shown that migration and minework allowed men to attain the dominant forms of masculinities that were salient in both the temporary space or work and the rural home space yet we also demonstrated that migration and minework in this setting failed to provide poor black african men with the ability to provide for their families in the longterm based on these findings we argue that the provider role expectation placed heavy psychological and familial burdens on men by conferring ongoing pressures and anxiety to provide for their families and children even within the current reality of job scarcity in south africa and paltry salaries associated with minework the mens critical appraisals of their own and their peers masculine performances as well as their reimagining different lives for their children both male and female indicate an openness to disrupt their current constructions of masculinity this finding suggests an opportunity for gendertransformative and parenting interventions which seek to transform notions of masculinity that essentialize providing instead of emotional involvement with families and nurturing of children all relevant data are within the manuscript and its supporting information files supporting information s1 file s1 data

in this paper we examine mens insights on how migration and minework affect their perceptions and performances of masculinity in the settings of minework and in their real home communities and explore the potential consequences of masculinity constructions for their own and their familys health this study used qualitative methodology findings are based on 13 indepth interviews conducted over two phases of data collection with adult men who were either working or seeking work in the mines in northwest province south africa data suggest that for these men migration to and working in the mines meant they must straddle the temporal space of work and the rural home space for these men the role of provider was an inescapable demand and resulting from migration for work their experience of fatherhood was solely centred on material provision with little or no emotional involvement with their children findings further illustrate the impact of minework on mens health and livelihoodsresulting in some men reimagining and seeking to create alternative career paths for their children there is pressing need for labour reforms on the employment conditions of lowpaid mine workers to enable them to reinforce their livelihoods and secure better futures for their families gendertransformative interventions which aim to transform ideas of masculinity that emphasize providing rather than emotional involvement with children are also needed

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introduction the desire to be physically attractive and to be regarded as having beauty of form and face is a common preference for humans 1 to cultivate that desire it is necessary for people to exert a certain level of effort through tasks and activities to become beautiful while beauty is a subjective concept beauty ideals are socially constructed and largely determined by social norms culture and social interaction 2 in the contemporary world the beauty pageant reinforces this hegemonic social construction of beauty a modernday beauty pageant replicates a ritual form that introduces young women to their community state or nation transforming them into a special class through the principle of competition 3 at present beauty pageants have gone beyond judging the physical attractiveness of a woman as they have started selecting winners who have affective qualities such as confidence intellect and communication skills 4 in order to represent a brand an organisation or a nation in recent decades more young women have desired not only to be beautiful but to participate and win in beauty pageants that is modernday beauty pageants are a common place of work especially in the lowincome global south while only a few women who work as beauty pageant contestants are said to represent these socially constructed standards of beauty some women tend to spend more time energy money and emotional resources in the endless effort to alter their natural body and look to adhere to these socially constructed beauty ideals 56 in order to participate in a beauty pageant big or small a pageant contestant has to perform and experience certain occupations occupation is commonly understood as everything we do in life including actions tasks activities thinking and being that restore or maintain good health and promote a state of wellbeing 7 given these purposes and functions beauty pageantry is under the category of occupation referred as work which is defined in occupational therapy as labor or exertion related to the development production delivery or management of objects or services resulting in financial or nonfinancial benefits including social connectedness contributions to society structure and routine to daily life 8 p33 beauty pageantry is considered a form of work because it facilitates economic mobility 4 and ensures effective career progression 9 for those who engage in the competitions catriona gray miss universe 2018 winner was criticised by fans about her body while preparing for the miss universe 2018 pageant this led her to respond by saying yes i am preparing for miss universe but first and foremost i am miss universe philippines 2018 and that in itself comes with duties and responsibilities… i post beautiful scenes of travel cause i love to share that with you all but behind that what you all dont see is me working 10 her response is a clear indication that preparing joining and winning a beauty pageant is indeed a form of work that can become a career or even a profession while the assumption about occupation underpins a positive meaning it is commonly reserved for the privileged few 11 p 34 and can potentially silence the meaning of occupations for those in the majority world where occupation does not necessarily contribute positively to health wellbeing and justice 1213 in the context of beauty pageants some of the contestants go beyond doing what is good for their health and wellbeing just to have a chance of clinching that coveted title beauty queen that is there are instances where contestants engage in doings that are considered perceived or experienced to be healthcompromising risky dishonest illicit and socially or personally undesirable traditionally the profession of occupational therapy has focused on the positive impact of occupation in peoples lives as a challenge to this twinley introduced her concept of the dark side of occupation as a prompt to consider occupations that have been hidden or not been implicit 14 p2 within the literature regarding everyday occupations including work this includes the assertion that work work places and work practices are not always conducive to the health safety and wellbeing of workers themselves 15 through the conceptual lens of the dark side of occupation 1617 we would like to contribute to the ongoing discourse about occupations that challenge pervasive beliefs and dominant social order in doing so we do not intend to further problematise the binary conceptualisations of occupation rather we assume the role of occupational scientistswho study and consider people as occupational beingsto critically examine and expose misrepresented occupations being cognisant of the diverse occupations participated by a plurality of human groups including beauty pageant contestants this commentary aims to explore the dark side of occupations enveloping the unique context of beauty pageants inspired to shed light on certain occupations that have been until now hidden or unseen following the conceptualisations of twinley and hocking 18 the article begins by defining the modernday beauty pageant followed by discussing beauty pageants from different known perspectives outlining the hidden occupations in the context of beauty pageants and ends by suggesting the conceptual lens of the dark side of occupation provides a relevant focus from which to explore beauty pageants from an occupational science perspective modernday beauty pageants historically especially in the twentieth century pageants were not really about celebrating physical beauty but by bringing communities together through theatrical performances that fabricate the local past and its folk traditions 19 the first known beauty pageant was held in scotland in the year 1839 it was organized by archibald montgomerie 13th earl of eglinton to reenact a medieval joust and in the pageant georgina seymour duchess of somerset was proclaimed the queen of beautyshe was the first known beauty queen in history 20 in this paper we look at modernday beauty pageant as work in the field of performing arts where diverse occupations are at play purposes of modernday beauty pageants may differ but they have one thing in commonthe winner is almost always called the beauty queen these beauty queens win for various purposes including empowering women 21 embodying national pride 22 promoting certain products charities or organizations 36 and espousing inclusivity diversity and cultural identity 2123 aside from signing a oneyear contract to live the purpose of the organization winners are also granted the voice to speak publicly to advocate for a specific cause material rewards that go along with winning and powers for social and political purposes 324 perspectives on pageantry and beauty to have a deeper understanding of how beauty pageants have evolved from historical reenactment with performative educational function 19 to a global spectacle of socially constructed physical beauty with performative political and commercial functions 3625 it is important to have an overview on the different perspectives surrounding the origins culture and workrelated underpinnings of modernday beauty pageants feminism by the 1990s the media discourse about the world of pageantry conveyed how it served as a platform of feminism due to its empowering nature whereby women are granted a voice to speak up a stage to showcase their talents and skills and an opportunity to be publicly recognized for society to emulate 26 supporters who feel pageants embody feminism declare that beauty pageants give a voice to diverse women everywhere especially as contestants come from all different socioeconomic and ethnic backgrounds and even bring certain disabilities to the world stage 27 however in spite of the popularity of modernday beauty pageants feminists around the world have seriously opposed the existence of beauty pageants which they denounce as degrading sexist and racist 28 miss america is the oldest beauty pageant that is in operation today and recently shifted its rhetoric from seeing pageants as sites for the objectified feminine body to spaces in which this feminine body possesses choices and freedoms 928 mainstream feminists challenge the normalization of flawless femininity which means having firm breasts and buttocks no cellulite white sparkling teeth and beautiful healthy hair among others 9 in some instances achieving these beauty standards requires the unending effort to modify the natural body through cosmetic surgery weight control and consumption of endless beauty products 529 this kind of body transformation is supported by a postfeminist standpoint where women have the power and control over their bodies as a result of choice and selfimprovement 9 postcolonialism history of colonisation has greatly influenced the beauty pageant culture in previously colonised countries in asia central and south america and africa according to postcolonial theorists western structures of knowledge are imposed and deemed superior to southern peripheral contexts in terms of political socioeconomic and psychological aspects 630 this western influence bred a cultural hegemony where the ruling class from the colonising countries constructed cultural values and norms including the standards of beauty to maintain their powers privileges and dominant status 31 an example of this is the santacruzan an annual festival celebrated all over the philippines in the month of may it is a roman catholic tradition in honour of saint helena mother of constantine the great which was introduced in 1854 to the filipinos during the spanish colonisation in 1865 as a means to further cement the catholic religion into the filipinos way and image of life 32 from a primarily religious event presentday santacruzan has become a beauty pageant of sorts which expands beyond the archipelago such as in canada where filipinoinitiated pageants are shaped by presentday forms of colonialism 33 trying to fit in the white settler context as migrants these beauty pageants struggle to serve as an opportunity for the unique filipina traits to be recognized even in the play of multiculturalism in hong kong filipina domestic workers enjoy the idea of being a sunday beauty queen which signifies how even for one day they can be free from their oppressed roles as a domestic helper and have the control on how they want to express themselves 34 in indonesia the practices of beauty are highly influenced by the history of dutch colonialism 35 indonesian transgendered women also known as waria hold beauty pageants across large cities to promote glamor and transnationality while beauty pageants are not reflective of southeast asian culture pageantry still persists due to the colonial influences rooted from the european model of commodifying beauty 35 dominance of white beauty standards for over fifty years in america black women were excluded from the miss america pageant kinloch asserts that with the obvious exclusion of black women the pageant maintained its principles to value the beauty of white women while devaluing that of black women 36 p105 however on the politics of sex beauty and race kinloch discusses the cultural political context and what this signified suggesting that the pageants acceptance and public construction of vanessa williams the first africanamerican to win miss america in 1984 reiterated momentarily its own discourse of power to prove despite a racist history that the pageant was raceless in its representation of all american women 36 p99 capitalism and consumerism beauty pageants are largely commercialised and are usually run by transnational corporations across the globe to capture the eastern societies with westerns standards of beauty through cosmetic promotions and tourism campaigns impacting economic development 25 there has been an assumption that most titleholders are chosen from countries belonging to the global south because these transnational cosmetic conglomerates want to capitalize on the lucrative market for their beauty products for women in southern peripheral countries 6 while most women are cognisant about the huge gaps between their natural beauty and the beauty standards constructed by world cultural political and economical hegemonies 6 the capitalists in world dominant core countries take advantage of this corporeal dilemma among women from the global south so that they can blindly patronise their products no matter how expensive or dangerous they are the capitalist perspective of modernday beauty pageants intersect with the postfeminist standpoint where women are seen as powerful citizens and consumers who have control over their physical body through materialistic consumption and cosmetic surgeries 9 this intersection is called consumptive femininity in which products such as beauty products apparels and clothing mark idealized gendered norms that are classbound through purchasing power 4 classism and class politics modernday beauty pageants must have risen as an opportunity to address political issues in the façade of a ritual performance these pageants reflect the perspectives of women in modern society and officialise the role of women as part of the community 3 ironically being a beauty queen does not entail political power but rather acquires a symbolic capital contestants are usually sponsored by capitalists social entities or local communities which implies that if she wins and becomes the beauty queen she is expected to represent her sponsors based on their hierarchies 37 evidently beauty pageant contestants come from middle class backgrounds 42138 because they have the appetite for consumerism and the resources to pay for personal pageant training gym memberships social media managers and highfashion apparel in order to remain competitive seeing many titleholders and beauty queens coming from middleclass backgrounds suggests that pageant organisers select women who received formal education can speak the english language eloquently and are striving for upward mobility ie moving from middle class to elite social class or at least close to that 46 the process of upward mobility however can necessitate doings that may seem risky illicit or even immoral from the eyes of society but may be considerably meaningful to the aspiring beauty queen morality and religion in the world of pageantry being physically beautiful is closely associated with embodying wholesome and moral values 9 religion also plays a part in the existence or abolition of modernday beauty pageants for instance when miss world 1996 was hosted in india indignant protests from feminists and hindu rightwing organizations fled the streets to condemn the beauty pageant 39 to appease the protesters the swimsuit competition was held on an offshore island in seychelles indians who opposed the beauty pageant were under the rhetoric of banning pageant hosting in india because indian women are pristine commodities 40 they believed that to bring honour indian women must embrace femininity purity submissiveness mothering caretaking instincts compassion and moralityand upholding these values protects indian women from the corrupting influences of the west including beauty pageants that bring nudity dubious morals and aids in their wake 40 along similar lines the islam religion also has a conservative take on beauty pageants in indonesia miss world 2013 was afflicted with much protests from dominant muslim groups stating that the beauty pageant is an immoral event hence there was a need to transfer the events venue to bali a predominantly hindu province in indonesia 41 in islam marriages the criteria a man looks for a woman to be his wife in addition to her religious commitment are her wealth and beauty 42 this moral perspective implicates that beautiful muslim women are bound to get married and fulfil their duties of taking care of their children family life and home that brings peace and contentment 42 thus joining beauty pageants is not part of a muslim womans duties in response miss world muslimah usa was presented as a peaceful protest to miss world and aims to advocate for womens modesty in islam and how muslim women should be honoured and poses a great alternative to other globalscale glamorous pageants which may not be in line with what islam permits 43 in christian religion biblical values perceive female beauty in terms of piety and labour rather than any transient form of physical appearance 44 while physical beauty is not discounted in biblical texts beautiful women are noble when they uphold modesty and ingenuity through entrepreneurship and do not use charm and vanity for their own advantage 44 typical eligibility rules in beauty pageants include being between 18 to 26 years of age unmarried to not have had children and being biologically female at birth in some instances racial purity is also considered being able to speak a certain language and have never posed for any mens magazine 25 these pageant rules could have been drawn largely from the aforementioned and oldest existing beauty pageant miss america which originated from the united states of america a country that is statistically predominantly christian occupations associated with participating in beauty pageants the pursuit of participating and working to win a modernday beauty pageant has never been as serious and competitive as is in recent years with all the entitlements material rewards and social glory accompanying the beauty queen title the journey requires more than mere hard work being healthy and mental preparation that is to some hopefuls to win a titlefrom a small town a national competition or the world stageentails engaging in hidden occupations to various extents 45 before discussing perspectives regarding the dark side of occupations it is important to outline the occupations that are commonly involved before during and after participating in a beauty pageant the nonexhaustive list of occupations for beauty contestants involve going to the gym exercising eating nutritious food formal andor informal schooling grooming dressing up and communicating through various media outlets contestants participate in these occupations many months and even years before they decide to join the pageant the expectation to be in a certain body shape is prevalent in the beauty pageant world hence it is imperative for contestants to have a gym membership exercise routine and a strict nutritional diet 21 in order to adhere to social and cultural standards 38 produced and reproduced within the pageant industry moreover desired winners in beauty pageants are contestants who are formally educated and who have undergone beauty pageantrelated training sessions 4 possessing knowledge and skills obtained from formal and informal schooling or camps is advantageous not only for the beauty queen but more so for the organisers who will not have to exert much more effort to train the beauty queen who got the job 23 unpublished data grooming and dressing up are occupations for pageant contestants as they are always on photoshoots press conferences social events and social media since female beauty pageants are largely sponsored by cosmetic and beauty product companies their contestants are expected to use bodyenhancing products like toiletries lotions and shampoos not only to maintain their personal hygiene but also to build their personal identities social bodies and the bounds of femininity 4 one of the most important occupations beauty queens are expected to engage in is autodidacticism in order to prepare to be deemed a wellinformed contestant as their interpersonal communication and expression of self is judged through questions interviews and during public speaking this occupation can only be maximised by the beauty queen who is granted the platform to publicly voice out her ideals advocacies and opinionsthough always in consonance to the organisation she is representingtowards social issues 3 during the competition several occupations are also performed in a ritualistic manner with feminine meanings as finol 46 described in his article he talked about the male pageant held in venezuela which he found to have similar elements to the womens beauty pageant such as having a master of ceremony the judges the spectators and the contestants he even outlined that the 12step ritual commonly seen in a beauty pageant includes introducing of the contestants singing and dancing presenting of judges parading singing and dancing parading singing and dancing parading singing and dancing presenting of the past winner selecting the finalists and announcing of the winner additionally the format in female beauty pageants usually has a question and answer portion upclose interview and a series of competitions 25 in principle these series of ritualistic tasks and activities can only be performed by pageant hopefuls who made it to the final show after being able to routinely participate in most if not all of the occupations aforementioned the occupations that were discussed are traditionally perceived as socially acceptable activities that are performed by pageant contestants to adhere to the beauty standards of the competition hence increasing their chances of winning the beauty pageant these occupations to some extent adhere to the many definitions as illustrated by law and baums 7 for example wherein they restore maintain or enhance good health and promote a state of wellbeing towards occupational participation alternatively the dark side of occupations 1747 are to a certain extent silenced hidden or secretive and are engaged in by pageant hopefuls with the shared goal of winning the beauty pageant regardless of how they may be socially culturally politically or morally perceived judged or experienced however the authors of this article would like to make a crucial point of clarification there has been misuse of the phrase dark occupations and a misinterpretation of the intention of twinleys concept of the dark side of occupation for instance twinley has explained this is not about labelling occupations as darkas kiepek 48 p4 refers towhich would of course connote a moral judgment towards individuals who engage in the occupations under consideration conversely the phrase the dark side of occupations explicates a metaphor for occupations that are not acknowledged hence lacking exploration and understanding 1418 in the context of beauty pageants the dark side of occupation is very much about illuminating an aspect of human experiencein the form of doing beauty for competitionthat is masked in secrecy and is known to have a hidden side 45 dark side of occupations within beauty pageants before discussing the dark side of occupations within beauty pageants it is imperative to clarify that the following discussions do not espouse dualism or promote othering or exoticising 48 of individuals who engage in occupations that resist or are in opposition to the expected and accepted social and cultural norms rather the discussions challenge these aforementioned conceptions of occupations to work towards more critical and integrative understanding of occupations 174849 hidden occupations in modernday beauty pageants include doing some things away from others that might be perceived and experienced to be rather mundane or tedious such as use of instant teeth whitening strips and skinlifting tape hidden occupations can also then include use of excessive use of whitening products cosmetic surgeries occupations that ensure survival or involve risk and sex work use of illicit beauty products despite the controversies surrounding the use of glutathione as a skin whitening drug 50 and its nonsanctioned distribution in some countries more people in the southern peripheral countries have started using it due to its whitening effect for instance in the philippines oral glutathione is not restricted while the use of intravenous glutathione is given public warning due to its adverse effects 51 while healthrelated harm can be incurred by glutathione users the desire to be whiter remains more compelling than the health risks this can be explained by the continued valorisation of whiteness or lightness impacting the biggest international pageants 25 which could be the impetus for beauty pageant contestants to engage in this occupation in male beauty pageants the values of masculinity including showing of muscles physical attractiveness heterosexuality are extensively promoted 46 where physical attractiveness is the determining factor to win a title in mens beauty pageants some male contestants resort to using anabolicandrogenic steroids an illicit substance to increase muscle mass hence becoming more physical attractive at least subjectively 52 some male bodies are genetically ectomorphic which make it difficult for them to gain muscle mass in spite of consistent workouts hence the urge to use aas to hasten gaining muscles especially when the pageant is forthcoming although the popularity of using glutathione and aas may reinforce its normalisation as a selfcare routine for beauty contestants in the beauty pageant context where natural beauty is being espoused some contestants may still feel the need to hide this reality to adhere to the ideals of the competition cosmetic surgery routine the effort to control the body is evidenced by the proliferation of a weight control culture and cosmetic surgery 29 before further discussing cosmetic surgery it is important to differentiate it with plastic surgery plastic surgery is commonly defined as a surgical procedure done for the reconstruction of facial and body defects due to birth disorders trauma burns and disease whereas cosmetic surgery involves procedures and techniques focused on enhancing a persons appearance for aesthetic purposes 53 common cosmetic surgery procedures done to these beauty pageant contestants include breast enhancement facial contouring facial rejuvenation body contouring and skin rejuvenation the normalisation of cosmetic surgery through reality television shows botox parties cosmetic gift cards and even social media endorsements has reified the postfeminist slogan girl power where women young and mature are lured into the belief that they have control over their bodies 9 the bombardment of this rhetoric to women in turn legitimises the practice of cosmetic surgeries globally the problem lies not in the surgical procedures per se but when pageant contestants undergo cosmetic surgeries when pageant rules forbid it contestants who were suspected to have had cosmetic and plastic surgeries are expected to conceal these doings otherwise their chances of winning the beauty pageant would diminish instantaneously although it is rare for contestants to be expelled from the pageant due to cosmetic enhancements some contestants choose to showcase their untouched beauty to evoke the other end of the spectrum within the postfeminist rhetoric weight control regimen to more conservative contestants choosing a stringent weight control regimen could be the only way to adhere to the thinnesspromoting norms in the pageant world excessive weight control involves overly selective nutritional diets intensive exercises and misuse of laxatives diet aids and enemas which heightened eating disorder symptoms among pageant hopefuls 21 one of the participants in crawfords study 21 expressed that while contestants were mindful of the fact that they need to eat regularly to sustain their physical fitness routines some still engaged in starving or noneating in more extreme cases women in south america could access a quick weightloss alternative called tongue mesh with the help of plastic surgeons a piece of plastic mesh is sown on the contestants tongue with six stitches which promises instantaneous weight loss as illustrated by sayej 54 the patient keeps it in their mouth for a month from day one it becomes incredibly painful to eat any solid food so they stick to a strict liquid diet all they can drink is broth smoothies juice and soup it costs as low as 600 to get the mesh sewn to your tongue for a month the results shed 30 pounds in 30 days these procedures are usually done in preparation for the big pageant and are hidden from the media until the beauty queen wins and finishes her reigning contract sex work escorting and sexual exploitation the issue on distorting the female body and mind for the sake of beauty has been raised to public consciousness since the womens liberation movement in 1971 but wolf 55 argued rather succinctly that the real issue was not about wearing makeup losing weight and undergoing surgeries but womens lack of choice for some women who may experience a lack of choice especially when competing for a beauty pageant and being judged by others as part of the competition the exchange of sexual services can be one way or the only way to achieve more choices more broadly speaking rule and twinley 56 recently provided an occupational perspective of women involved in sex work in which they asserted sex work is interpreted and performed differently depending on the political religious cultural and legal context all of which shape the dominant cultural narrative of stigmatising perceptions of sex workers while sex work can either be perceived as empowering or oppressive 57 engaging in the exchange of sexual services within a beauty pageant context is fraught with issues related to risk danger stigma and exploitation in 2018 the miss venezuela organisation was accused of offering its contestants for sexual activity to seek sponsors from political figures and bigtime businessmen to obtain houses luxury cars trips designer clothes and jewelleryjewelry 58 this exploitation led to the suspension of the miss venezuela organisation from operating which instigated the restructuring of the organisations leadership in order to restore its reputation to the venezuelan public when sex is not viable time is exchanged for pageantrelated funds or sponsorship through escorting escorting is the provision of entertainment or companionship to a client in exchange for money or something else 59 escorting constitutes accompanying the client to entertaining events such as an opera club or dining experience the temporal aspect of escorting depends on the mutual agreement between the escort and the client but escorts can either choose to engage in repeated transactions through wordofmouth advertising 59 or shortterm mating via easilyaccessed online websites or social media applications 60 wright 57 argued that from a capitalistic standpoint sex work and pageantry create a sex class where women are relegated to service work and provide pleasure to the males of society however when applied with critical reflexivity at the societal level of analysis to occupations as proposed by kiepek 48 we can also understand modernday sex work as an occupation that can be enjoyable empowering rewarding it can help one build social networks and friendships experience healing and companionship to another and feel independent 61 discussion this commentary recognised the diversity of human beings and their diversity allows for understanding them through their contexts situations and occupations the motivation to write this piece is largely in response to recognising the need to expand the scholarship on less explored and acknowledged occupations in this instance we have discussed beauty pageantry as a work occupation in order to contribute to the wider challenge regarding common assumptions that have been made about occupations people groups and populations engage in 1217184749 modernday beauty pageants are perceived differently by people including scholars depending on factors including their social and political identities personallyheld and political beliefs history and culture and social status while multiple perspectives can ensue agreements and disagreements looking at modernday beauty pageants as a context where diverse and hidden occupations are at play initiates a new way of understanding the things people do a nonexhaustive list of occupations was outlined to build on the growing knowledge about the dark side of occupations from these intersecting discussion points the authors argue that modernday beauty pageant as a form of work is both a means and an end to achieving a work role career or profession that can afford public recognition but that can belonging to the global south apart from the usa this paper has contextualised the literature review on beauty pageants by citing examples from countries like india indonesia nigeria philippines and venezuela to illuminate issues and forms of work that are distinct in these cultures and social realities using an occupational science perspective this commentary is intended to be nonexhaustive and datafree since the goal was not to generalise but rather to consider and reconsider the conceptualisations of occupations within exposed and hidden social realities and contexts while this article largely extracted literature from pageants for women it is valuable to note that modernday pageants have catered to more diverse groups such as babies children teenagers married women grandmothers 28 men 46 gay men and trans people 22 in conclusion we hope to contribute to the ongoing discourse on the dark side of occupations so as to challenge occupational scientists and indeed all those interested in studying people as occupational beings to explore occupations beyond the more traditional boundaries of thought and scholarship of human doings and work concretely we would like to raise consciousness in considering occupations from different cultures and subcultures by sharing this work through online and offline discourses and debates in higher education institutions and more informal platforms such as podcasts vlogs and social media for readers coming from the fields that intersect with occupational science we hope to offer a critical understanding of peoples diverse doings to guide in reconceptualising their practice research and policy making especially when involving people who engage in hidden occupations and work in the context of desiring to be beautiful whilst being judged against unrealistic beauty standards involve engagement in some occupations that are perceived as healthcompromising for instance occupational justice is defined as having the right to meet basic needs and equal opportunities to reach ones potential to engage in diverse and meaningful occupations 62 coming from an occupational justice standpoint posits how modernday beauty pageants could potentially give winners the beauty queens the socialised rewards of possessing power fame money and the voice to be able to choose and participate in more and varied occupations than before moreover the beauty pageant also characterises the rhetoric the end justifies the means this suggests how beauty pageants its organisers and fans have the tendency to highlight the end or the goal rather than the means since these means towards the goal were commonly perceived to be illicit tricky harmful or unhealthy with the purpose of better understanding occupations it could be possible that some pageant hopefuls have experienced injustices and have caused injustices on others during the process of participating in beauty pageants this is supported by angells 13 argument that occupation is not only a means of resistance and change but also a site where inequality and social difference are constituted it is also an opportunity to recognize the identity of humans as autonomous agents who are capable to choose occupations beyond the barriers of social differences such as gender class caste religion education poverty ethnicity age culture geographic location sexual orientations and other axes of difference 12 and that challenge the social order 13 contributing to a more critical and socially responsive occupational science we can therefore consider modernday beauty pageants as work sites where occupational injustices are experienced and occupational justice are achieved whether this is true or questionable the authors perceive contradictions as spaces for future debates and potential scholarship furthermore this commentary articulated underrepresented and unique occupations that affect the health and wellbeing and envelope majority of individuals and collectives

background the desire to be physically beautiful is inherent among human beings in particular some women who participate in modernday beauty pageants tend to spend more time energy money and emotional resources to alter their natural body and looks to fit socially and culturally constructed standards of beauty objective the authors frame beauty pageants as the context where diverse occupations are at play with the purpose of becoming a beauty queen this commentary aims to discuss the origins and culture of beauty pageants the different perspectives on pageantry work and essential and hidden occupations performed within the context of this form of performing art approach using the conceptual lens of the dark side of occupation hidden occupations are characterised by the doings of pageant hopefuls that are less explored and acknowledged because they are perceived as healthcompromising risky dishonest illicit and socially or personally undesirable conclusion furthermore this commentary calls for the exploration of occupations beyond the conventional scope of its understanding and the acknowledgment of hidden occupations intertwined into peoples everyday doings specifically in the context of desiring to be beautiful

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introduction brazils family health strategy has stood out among the elements of the countrys unified health system and is considered an important element in the process of transformation of the healthcare model which was previously traditionally marked by biomedical references 12 accompanying an international movement of increased attribution of value to primary healthcare 2 this strategy seeks to plan actions guided by the needs of the communities served further the family health strategy shares a wide conception of primary care including primary healthcare as a strategy of organization of the healthcare system within healthcare networks 34 as mendes 4 sums it up in this point of view three functions articulated by primary healthcare stand out the solutionproviding function of attending 90 of the most common health problems not necessarily the simplest the coordinating function of ordering the flows and counterflows of people products and information through the healthcare network and the function of assuming or allocating responsibility for the health of the user population which is restricted in the healthcare network to the teams of the family health strategy in the esf provision of care is territorialized and provided by multiprofessional teams responsible for the planning of actions in accordance with the local needs of a community 2 in this strategy the figure of the community healthcare agent is distinguished by the fact that she lives in her area of activity and has knowledge of the territory and its peculiarities and needs 56 the acss are central players for the good functioning of the esf in that they carry out actions ranging from involving and adding people of the microarea to orientation of families on the use of the health system educational action and monitoring of programs that are in place for transfer of income and dealing with vulnerabilities 2 considering the diversity present in the activity of an acs nogueira et al 7 defined the acs as a sui generis worker hisher involvement from within the territory enables identification with the community and construction of a relationship of proximity with it often characterized by a propensity to solidarity mutual help and community leadership according to silva and dalmaso 8 two dimensions can be identified in the practice of an acs one is technical relating to attending to users interventions to prevent worsening of situations or monitoring of groups or problems and the other is political related to solidarity with the population the involvement of healthcare in the context of peoples lives and organization of the community and transformation of its living conditions this political dimension can result in two expectations about the role of the acs that she should act as an element of reorientation of the conception and of the model of healthcare and at the same time play a role in fostering organization of the community in a concept of social transformation as well as these aspects we highlight the activity of the acss with social networks that is to say with networks of relationships that are perceived as significant in peoples lives including relationships of family friendship work study and community and including social and institutional agencies 9 as various authors indicate work in close proximity to communities can help organize and structure social networks in such a way as to strengthen the relationships both between people of a similar territory and also between care systems 10 11 12 analyzing the work of acss with social networks pinheiro and guanaeslorenzi 9 highlight two central functions that they exercise that of articulator of the social network of an individual considering hisher health needs and that of mediator of interpersonal relationships intermediating tensions and conflicts especially in the context of family relationships according to these authors these forms of activity characterize interventions in networks of relationships and sociability and are thus different in kind from an individualist conception of healthcare and they also demand from the acss skills in communication and negotiation thus in the acss practice the fact of territorialization goes beyond a merely geographical dimension since the acs lives in the area of hisher work she participates in the local culture and this favors the establishment of links and construction of a relationship of trust with the residents who feel more at ease to talk about their reality of life and difficulties 5 according to fontes 13 the work done by acss favors democratization of information and can stimulate participation by the population in health both in care and in policies which is indeed envisaged in the legislation of the sus the acss live and interact with different people and circles which can be described as different fields of sociability and this when these cross over expand the view on health practices in spite of the recognition of the central nature of the work of the acss and their important role in construction of networks favorable to integrality intersectoriality and social participation studies on the practice of acss point to tensions and difficulties in their daily routine jardim and lancman 14 for example reflect on the complex relational dynamic established between the acss and the community among other aspects they report that the roles of health worker and of friend or neighbor are frequently confused which can generate stress and suffering further because they are the link with the community the acss receive the populations responses in relation to the sus more strongly which can directly influence the way in which the population conceive their practice difficulties related to the dynamic of work in teams also occur in the daily practice of the acss peres et al 15 discussed the creation of a hierarchy structure that is present in health teams in which those who have a specialized technical knowledge or superior training occupy a highlight position and emphasize the need for horizontalization of actions in the esf with responsibilities shared between the members of the health teams sakata and mishima 16 put forward a discussion on the relationship of the acss with people who have more technical knowledge such as in situations where they might feel deterred from questioning or taking a position visàvis workers with university education pupin and cardoso 6 report nonattribution of value to the work of the acss who complain among other things of the low remuneration considering their working hours and their many responsibilities this paper interacts in a dialog with this literature which points to various different meanings surrounding the work of acss sometimes pointing to their being attributed higher value and at other times attributing them lower value considering the challenges that are a part of the acss daily practice especially in hisher work with social networks we ask in its relationship with the community and with the teams of the esf how does the acs construct meanings about hisher practice and does she attribute more or less value this paper aims to understand through what meanings acss refer to their work with social networks focusing especially on the meanings they make on the subject of whether or not they are well recognized within the context of the esf based on the analysis of the tension between meanings of greater or lesser attribution of value to the practice of the acs we seek to reflect on the implications for the social construction of the esf in daytoday working practice methods this is a qualitative study based on a social constructionist epistemology emphasizing the quest to understand the ways in which people explain describe and narrate their lives and the world in which they live and the resulting implications for the construction of ways of living and social realities 17 this view underlies the method chosen for this study of analyzing the discursive practices of acss focusing on comprehension of the meanings they present about their practice with social networks in the esf this study was carried out in a small town in the interior of são paulo state which has 100 coverage by the esf through six family health teams and a family health support center 28 acss of six family health teams took part in the study 27 of them were women only 2 acss were unable to take part due to vacations ages of the participants varied from 18 to 57 and their time in the profession from six months to eight years their schooling varied four had completed primary education 15 has completed secondary education one had a nursing course seven were in higher education and one had completed higher education the proposal for this study was approved by the research ethics committee and the study was carried out in accordance with the guidelines of national health council resolution 46612 on research with human beings 18 all the participants of the study voluntarily accepted to take part and signed an informed consent form to protect the identity of the participants the family health units were referred to by colors and the names of individual acss health professionals and patients finally used in the analysis are fictitious the information was obtained through discussion groups an investigative technique based on interaction between the participants as a source of information for the research the technique enables interactions and enlargement of discourse between participants and researchers 19 the aim was to use the context of dialog to development concepts that would provide the information of the investigation two discussion groups were held with each of the six teams of acss a total of 12 groups the first meeting in each unit was of a more general nature in an effort to understand the relationships that the acss understood as being created between social networks and health the discussions of the first meeting were taken deeper in the second following the particularities of each group usually the second meeting explored the acss work with social networks in practice with practical examples of their daily work routine with the community and as a part of the health system each group meeting lasted about two hours these meetings were held in the health units themselves and were audiorecorded and transcribed the transcriptions aimed to preserve the participants ways of speaking maintaining colloquial expressions and any grammatical errors for qualitative analysis of the transcriptions we adopted the proposal of spink and medrado 20 of analyzing the conversational flows and interactions between the participants considering the analytical categories as discursive practices emerging from the contact between the investigator and the material initially we made a close reading of the transcriptions seeking to record regularities noting themes that seemed to be more common and recurring and also irregularities highlight singular moments or moments that pointed to aspects that were yet little explored in relation to the practice of the acss in this first analysis we noted that in many dialogs the acss referred to the importance of their activity with social networks in the esf and emphasized their role as a link or intermediary bridge between the population and the sus as defined in official documents 21 however at other moments this concept of attribution of value experienced a tension with an opposite meaning of nonattribution of value these were moments in which the acs pointed to a possible distancing between what the sus specifies and what in reality they feel in their daytoday work activity both in relation to the families attended and also in relation to the other professionals of the team it was identification of this tension that led to the proposal title and concept for this paper is the value of community healthcare agents in brazils family health strategy receiving full recognition taking this decision on theme as a starting point the transcriptions of the groups were then analyzed in the following stages identification of moments of dialog where when talking about their practice with social networks in health the acss referred to attribution of value or absence of attribution of value to their work recognition of the meanings that are present in these reported attributions of value to the work of the acs with repercussions on their implications for building the family health strategy in daily routine and choices of excerpts that illustrate the tension between discourses on recognition of the value of acss results and discussion nobody gives any value neither the sus nor anybody the tension between meanings that attribute value to the acs and those that do the opposite appeared in the references by acss to their participation in construction of the care model at these moments at the same time that they repeated their having learned about the importance of the acs as the link or intermediary bridge between the population and the health system as the official discourse of the esf specifies 21 they questioned the real importance of their role based on elements of the daily routine such as the low level of appreciation attributed to them by the community or their low salaries a dialog that illustrates this tension took place in the first group meeting held at red unit which had begun with an invitation for the acss to discuss what view they had about the concept of a social network based on the overall definition of a social network as people who an individual recognizes as important in his or her life 9 elisa raised the question of what is meant by important setting off a discussion about the practice of the acss with a view to assessing whether they could be considered as important in the social networks of the people of the community paula we who are community agents go to a persons home and teach that person perhaps the person learns from us but that doesnt mean that we are important in the life… in that persons life vitória nor that that person is important in my life tereza no but it happens that for the health system for the sus we are important for that family elisa for the sus not for the families tereza we are a link that joins the families… the families with… with the health system paula at this moment there is a tension between different discourses at one moment there are meanings of recognition of value and at another meanings of denial of value tereza argues that the acs and the psf are given value since the government sends funding for their installation and maintenance she also believes that some families give value to the work that they do an aspect which to her appears to be indicative of attribution of value on the other hand paula vitória and especially elisa highlight the lack of attribution of value to the acs herself perceived both in the relationship with the community and in the relationship with the health system on this aspect the question of salary appears as a concrete argument in favor of nonattribution of value to the acs and this exercises the rhetorical effect of persuasion in the group closing the discussion on the subject santos et al 22 in a study carried out with acss of units of the esf in the interior of são paulo state reports that they cite the low remuneration as one of the principal negative points of their practice and causing a sensation of nonattribution of value to the work by the acss themselves at the same time the authors discuss that the acss also defined their practice as very important providing elements of solutionproviding link with the community and trust of the population which they say sustains a feeling of realization in this present study just as in the work of those authors both these aspects appeared in the groups indicating attribution of value to the work of acss both in the relationship with the community and in the relationship with the health system however at this specific moment of the dialog the weight given to salary questions seems to have the function of pointing to a contradiction or failing in the policy of the esf if the acss were in fact so important for the sus as tereza enunciates it the acss should be recompensed for this this is what elisa argues the silence after elisas speech and the laughter at the end appear to have delivered a certain consensus between the acss at this moment of the meeting independently of the recognition experienced in the relationship with some families the low remuneration reveals the absence of attribution of value to the work of the acs in the policy of the esf the dialog on attribution or lack of it of value to the acs continues in this same group now elisa expands the argument of nonattribution of value to the acs reflecting on the low recognition of her work for the community in comparison with the other professionals with higher levels of qualification once again elisas speech finds support from vitória and paula elisa ill just say one thing which indeed happened … i visited a womans home you might say that i gave her some orientation but then after a time i went there with the doctor and the doctor said okay and how are you goingah im well the doctor said suchandsuch to me this was actually the same orientation that i had given her before and she hadnt given it any importance… paula he was important he was important elisa what he said was important me no paula you arent important … youre important to god only vitória were important only to our own family understand and no one else paula makes the comparison with the value given to the orientation when it comes from the doctor showing that her own technical knowledge was diminished when compared to this position that was socially valued this illustrates how the transition in the healthcare model is still suffering difficulties the centrality of the doctor in the process of care is a relic of the biomedical model and of the practices centered solely on medicalization and on cure 23 the change in the model has brought in the importance of other health professionals and of their technical competence to exercise care into the official discourse however in the daily routine there is still a running tension between the new and old discourses in the excerpt recorded above elisa feels that her technical capacity for orientation was not recognized when compared to the value that is given a priori to the doctor as a holder of knowledge at the same time it is often the acs herself who does not attribute value to her own technical competence and indeed attributes greater responsibilities to the professionals of the team that have higher qualification at these moments the acs may question her potential for action and feel pressured by the demand from the community that the acs herself experiences for problemsolving capacity one significant moment when this happened was in the first group discussion meeting held at the white unit which we present below what will be done has to be come from them not from the agent this dialog took place when the acss were discussing the importance of knowledge about the limits of their practice they were talking about the importance of knowing how far to go in the relationship with the community respecting people knowing how to listen and not to give direct advice about their lives and to take cases to discussion with the other professionals of the team they described a potential stress in their relationship with the community due to a demand for solution to problems which often cannot be met larissa a lot of stress because… its often like i said there are some people who want us to solve their problem while we dont have… the agent he is the populations intermediate bridge to the psf so what do we have to do take his problem to the psf to our… to our bosses isnt that right we make a case study things like that to see whether… what will be done has to come from them not the agent and in this case the… the person doesnt understand the person wants… he saw the agent he wants the agent to resolve the whole of the situation like the case of carmen with the water helena shes from my area she lives in my street and everyday she comes to my house at … she sees me arriving at lunchtime in the afternoon she comes to home and says that her husband is putting poison in her water she has a mental problem shes doing treatment and everything she wants me to talk to her husband i cant intervene in that so ive already brought it here and she is doing psychiatric treatment … but everyday shes there and then everyday i say no i wont talk to him larissa yes its stressing in this excerpt larissa describes the acs as a bridge between the community and the psf which for her defines her function as one of bringing problems back to be discussed in the unit it being up to the bosses to decide the actions to be taken in the definitions of function of the acs it is specified that the acs should identify risk situations and take them to the sectors responsible 1 sakata and mishima 16 discuss that the activity of the acss focusing principally on operational aspects of the work as in the excerpt transcribed reinforces a rigid closed conception of work as a link in a chain something immovable cold on the other hand attribution of value to the interrelationship between the acs and the rest of the health team could result in value being attributed to integral care for families and be part of an activity with greater mobility adjustable to the communitys needs in the view of these authors when the acss carry out actions integrated with the work of the health team there is more potentiality in their work and this can help the team to go forward to a place beyond a purely biomedical focus based on reports of other members of family health teams these authors discuss how the acss greater knowledge about the families that are served can result in greater security and tranquility for the team to carry out its work this recognition of the importance of acss in health teams also helps them to be included in the planning of health actions which causes increased value to be given to dialog between different areas of knowledge in the context of the esf however in the previous excerpt larissa has described the acss as professionals who only listen to complaints and deliver them to the rest of the team saying that the initiatives on what to do should come from the bosses this would seem to reduce the potential for acss to contribute to a type of care that integrates the various areas of knowledge within the esf as regards the example given by larissa ribeiro et al 24 indicate that often health professionals do not recognize their resources for work with mental health in basic healthcare leaving out of account fundamental dimensions of the process of care such as accompaniment involvement availability recognition of the health needs actions for prevention and construction of partnerships with specialized services capacity for listening and dialog and indeed construction of links of trust and respect with the residents of communities according to these authors 24 there is an expectation of ability to solve problems that is very little aligned with the seriousness of the cases attended to and an apparent hierarchical structuring of the therapeutic actions which tends to give pride of place to actions of a medicationbased type to the detriment of the light care technologies we highlight that the practice of the acs has particular features that help establish a link of proximity to the population 57 however as jardim and lancman 14 point out this relationship is not always harmonious and it is necessary to establish a relationship of credibility and trust between the acs and the population we agree with these authors that the credibility of the acs is dynamic and relates directly to the solution of the problems raised by the community which often is made impossible not by a specific technical difficulty of the acs but by the very complexity of the organization and functioning of the health system and also difficulties in the transition of the type of care model complementing this pupin and cardoso 6 based on an investigation involving acss discuss that the proximity with the people of the community can also be experienced by the acss as a negative element especially when they are unsuccessful in establishing distinctions between their role as worker and resident outside working hours at the same time there were many moments of dialog in which meanings of attribution of value to the work of the acss appeared especially considering their central role in the relationship with the community and the quality of the link established with the families served in these cases the acss feel the attribution of value to them as professionals and people part of a community that knows how to recognize their value not only as an agent but as a person too… the following excerpt occurred in the first group meeting held in the yellow unit the acss were making a close comparison between the notion of social networks and their own history and reflecting on who would be the most important people in their own lives in this exercise they initially cited as people significant in their social network only their own family afterwards expanding this meaning to colleagues and friends at this moment cláudia brought up in the group the case of carmélia a user with whom the team had a close and affectionate relationship the conversation moved to the view that the acss are a fundamental part of carmélias social network which is important for her health and that the reverse also is true cláudia everyone knows carmélia shes in fact in jarbass area jarbas is an acs who did not participate in the group but in fact everyone has a great affinity friendship and affection for her maurício the units doctor also has and ângela also has and i have too rafael and theres a contact… like almost everyday shes here in the unit … she has contact with all the people of the team so… … shes a person who… i think that she considers the health service as a social network … she sees that it has importance in her life and thus for us too i think that she also has importance because outside the… the community agent service we also converse with her the acss describe carmélia as a person who considers the health service as a social network which takes place not only at moments of work but also in other contexts in this aspect the acss highlighted their relationship with people whom they know with family with friends and also users giving value based on the example of their relationship with carmélia to the involvement of affection that exists in this relationship in this excerpt there is recognition of positive elements of the practices carried out by the acss and their participation in the life of the community it is exactly this vision of the acs as part of the social network of the community that is as a person who is close and significant who according to the original proposal of the esf 1 and studies in the literature 101516 can favor the establishment of links of trust increasing the possibility of the practice of the acs offering to the health team elements for a healthcare that is linked to the needs of the population in the context of this investigation building this meaning appeared to have the function of empowering the acss about the importance of their work enabling them to see themselves more than a mere vehicle of information between users and other professionals of the health team in the same way the following excerpt expresses meanings of attribution of value to the relationship between the teams and users at this moment the acss were conversing between themselves and with the researcher on the realization of groups in the family health unit and the participation of ascs in this type of proposed action ângela well you know they arrive they hug each other … and then i think like between the group theres like a friendship thats solidifying like very… its… for example if one of them isnt there one day the other says hey but why… you mean soandso didnt come today rafael people… think the presence of the agent is important not just as agent but as a person also its like you said its not only the function the work that is carried out but its the presence of the person its also important in the group the attribution of value to the relationship between the community and the acs is built based on the recognition of the relationship of friendship and proximity between them this proximity favors the carrying out of actions that consider the users as human beings inserted in context and as cobuilders of the health system based on a more horizontal relationship the meetings between acss and the population that take place in the unit itself such as the groups referred to in the example can help make this relationship closer these meetings favor the sharing of lives and histories with the peculiarity that when they happen within the health system they show the relationship of the acss with the population as health professionals which can help increase the credibility of the professionals 16 in turn this credibility helps at the moments of home visits making it possible for them to have better access to families final considerations attribution or absence of it of value to the practice of the acss is not a dimension that can be precisely specified with well delineated frontiers in their discursive practices the acss move between meanings of attribution and nonattribution of value to their work using different social discourses to sustain their arguments in relation to each of these two aspects reflection on when the discourses on attribution or nonattribution of value to their work become more significant in the dialogs on their daytoday practice can be a fertile resource for thinking about how to continue to build the family health strategy in daily routine and its relationship with the wider plan for primary healthcare that it should bean important element in the coordination of the ras and in organization of the sus as a whole our study indicates that the acss frequently have recourse to the official discourse of the esf to define and conceptualize their practice defining their role as central for successful activity of the esf because of their being the intermediary bridge between the health unit and the population however the sense given to this official discourse varies in accordance with the negotiations in progress sometimes the official discourse is brought up as a form of praising the work of the acss and strengthening their particularities especially giving value to their skill in building links and articulation of social networks which are fundamental aspects for construction of healthcare based on the health needs of the communities served at other moments however this discourse is brought up as an indication of the contradiction that is present in the sus where it is expected that health professionals should act in an articulated horizontal and interdisciplinary manner with the community in practice however there seems to be little sustaining of this horizontality in other aspects of this relationship especially those relating to policies of recognition in terms of salary at these moments the comparison of the work of the acss with that of other professionals seems to serve a double function to denounce the continuing existence of a doctorcentered healthcare model and to reduce the importance of the work of acss with the community as they come to be seen as not very responsive to the efforts to implement a new way of providing healthcare among the many possibilities of discussion of this tension on the question of attribution or not of value to the work of the acss we highlight two related aspects that we judge to be fundamental the fragmentation that exists in the microprocesses of work and the expectation of capacity to resolve problems in the cases attended based on individual actions usually centered on the practice of the acs himherself in the exclusive context of the esf and without articulation from other services of the ras as we have discussed the concept of the esf emphasizes work as a team as a way of articulating different knowledge and practices in production of healthcare this is to state that the work of the acs in isolation will not succeed in covering the whole of the complexity of the questions that emerge in the daily work in spite of this the acss who participated in our study deny value to their practice by evaluating their actions in an isolated manner presenting an expectation of immediate capacity to solve problems that is hardly in line with the complexity of the cases dealt with and which leaves out of account the various dialog resources used by them in care for the community 24 based on a criterion of assessment that considers the result of the process of care as an objective product absence of attribution of value to their practice clearly prevails this practice which is traversed by so many aspects that interact with it another factor that complements this discussion is the strong hierarchy that is present in the professional categories which has been indicated as a prejudicial factor in the literature 1516 and also in the reports of the acss in this study an organization of the family health units that gives value to the different knowledges and practices involved in the diversity of functions carried out is a fundamental aspect such organization can be important for the acss that perceive themselves as important in the teamwork perceiving their function as central to the good functioning of the esf not as a mere transmitter of information to the higherlevel professionals but because of the qualities inherent in their activity itself thus the way in which the work team itself builds its practice in the daily work often sustaining distinctions between which actions are more or less important in relation to the community to the detriment of a global vision of healthcare offered by the group of the professionals contributes to less value being given to the acss on the contrary recognition by the team in relation to the work of the acss can help to build attribution of value to acss in the daily routine above all helping the acss in development of resources to deal with the populations demand for capacity to resolve problems immediately if the unit organizes itself horizontally and there is communication between the team as discussed by peres et al 15 the logic of healthcare in a biopsychosocial health model can become clearer too for the population and the practice of the acss can be carried out with emphasis on their resources for strengthening of links and a close relationship with the community while at the same time recognizing the functions and limitations of their practice on this aspect it is fundamental to consider that the demand for capacity to resolve health problems immediately is characteristic of the change in the healthcare model but tends to dilute as the community with the help of the health teams acquires a broader understanding of the concept of primary healthcare and its role in the coordination of the healthcare network and in the organization of the sus we hope that this present study by giving visibility to the acss making of meanings in their discursive practices in relation to the degree of recognition given to them can contribute to reflection on the construction of the family health strategy thus helping to strengthen primary healthcare as a public health policy that is being built in daytoday practice on the tense relationship between meanings and practices collaborations c guanaeslorenzi participated in all text development steps including its design data analysis and writing having guided the research project that gave rise to the same rl pinheiro conducted field research and collaborated in the design and revision of article

this paper discusses meanings produced by community healthcare agents acss on whether or not they feel that acss in brazils family health strategy are receiving the recognition they deserve considering their work with social networks discussion groups with 28 agents of six health units were held soundrecorded and transcribed qualitative analysis of the material enables us to identify in the discursive practices of acss a tension on whether proper value is attributed to their work or not there was attribution of value when they talk of their activity in close proximity with the community and their potential for construction of human connections but there was nonattribution of value when they talk of the systems macrostructural aspects such as low salaries and low recognition of their function in comparison to higherlevel professionals we conclude that the view of their work still involving fragmented work processes and expectation by the population that they will be able to provide immediate solutions to demands might be preventing them from taking on board a more wideranging concept of primary healthcare as a structuring and communication agent of the healthcare network and as an organizing agent of brazils unified health system

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introduction the focus of this article is the introduction of the term spatial capital by a number of writers employing bourdieus social theory to interpret how people engage with place and space although critical of this introduction in theoretical terms this article asks if nevertheless there is potential in having spatial capital become common currency in planning practice to date engagement with bourdieus work has been more through planning theory this engagement is unsurprising he was a polymath whose interests included research methods the nature of knowledge and the importance of taking a reflexive approach to academic practice reflecting this his work has appeared in planning theory literature in support of a range of different theoretical perspectives this includes calls for planners to engage with his work in order to refine a more reflective practice in relation to both the nature and quality of knowledge employed in planning and in the institutions and processes of practice bourdieu also helps draw attention to the subtle means through which power runs through planning practice these are examples of planning theory seeking to bring bourdieus work to bear on the practitioner on flows of power within on and from the profession here the focus in on the possibility of spatial capital providing a useful trope for the practitioner spatial capital might provide a shorthand term that planners can readily employ that could further a dialogue about people as active agents in seeking preferential social positions within and through physical places just as places are not bounded but acquire meaning in relation to other places so a persons experience within a place is formed in relation to others who occupy that place spatial planning could help planners in practice to draw greater attention to the combined effects of people seeking positions within place to the power of homology of fields in bourdieus terms this adds another dimension to calls for a relational sense of place in planning which could help to focus the planner on the multiplicity of ways in which the social plays out in within place ready comparisons might be made with social capital that has found its way into everyday practice however this highlights the dangers as much as any advantage in introducing spatial capital as a planning trope it is shown here that spatial capital as a derivation of bourdieus theory has been given multiple meanings and could be overlaid with many more like social capital it would therefore be open to broad appropriation and interpretation to develop the argument the article is structured as follows in the first section the spatiality of bourdieus perspectives is examined this starts by looking at why bourdieus work is sometimes regarded as lacking a sufficient spatial dimension leading to calls for the addition of spatial capital the second section is used to look at examples of work that propose the idea of spatial capital the identifications of spatial capital come from a range of disciplines and cover different aspects of urban life all use bourdieus theory although with differing emphasis and depth and all introduce spatial capital to emphasise the use of place or place plus mobility as an asset in its own right which creates powerful social advantage through the command over place andor place plus mobility it is argued that while the case for requiring the addition of spatial capital to bourdieus schema is questionable there may be a useful unintended outcome for planning practitioners all of the studies look at aspects of the built form that are of concern to planners neighbourhood belonging sense of place access to services and employment mixed communities and the role of governance and time in influencing change in the built form given this in the third section the use of spatial capital by planning practitioners is considered what might it bring to planning practice spatial capital presents itself as a readily useable tool for practitioners that might help to segue from bourdieus expansive theory to practice however it is argued that the benefits are not unequivocal the potential pitfalls of seeking to bring spatial capital to planning practice are considered and where it is argued the experience of social capital is analogous the spatiality of bourdieu there are two related reasons why bourdieus spatiality might be uncertain first his works have appeared in english translation over an extended period and not in the order they were produced with much still awaiting translation second and related bourdieus prioritisation of space varied during his career as he developed different aspects of his theory the variable emphasis of the spatial is reflected in writing from english language academia that draws on his work indicative of this is that while he is absent from the first edition of key thinkers on space and place he appears in the second a complete edited work is dedicated to seeking out the links between bourdieus concept of habitus and place meanwhile citations of his work appear only in later work on relational planning despite growing recognition one reason why bourdieus work is still not mainstream in urban studies is because in his later career bourdieu remained attached to social analysis understood within national boarders resisting the implications of globalisation published in the same year as savages chapter a book by fogle is premised on the inherently spatial character of bourdieus sociology there are certainly points where bourdieu foregrounds the role of place including his earlier work which is marked by an interest in how physical space reflects social relations in the case of the kabyle household this he argues reflects social particularly gendered relations here it is possible to see bourdieus direct treatment of how the materiality of place plays an important role in representing and maintaining social relationships gender relations are written into the layout of the house and because people experience this physical environment all the time it is a powerful way of maintaining the power relations depicted in later work bourdieu again pays direct attention to how the materiality of place might itself impact the social elsewhere in his work he is not so specific about place however as has been seen where he addresses place its ordering is powerful precisely because it is ubiquitous and subliminal therefore where place is not specified in his work it does not follow that its importance is not sufficiently recognised a significant shift is marked in distinction where bourdieu starts to stress field over habitus habitus describes a disposition inclining people to a way of seeing and acting in the world its purpose is to lay greater stress on individual agency than marxist analysis with its emphasis on production classes through habitus bourdieu seeks to give weight to individual agency while recognising that a persons character or inclinations are still significantly socially determined in short he seeks to go beyond but not to dismiss class given the work that habitus is asked to do mediating between agency and determinism bennett et al argue that it is particularly problematic although bourdieu did not abandon habitus he did turn to give greater emphasis to field while others such as lefebvre point to the relationship between physical and social space it is field theory that highlights the mechanisms of the relational nature of social and physical space as people seek to take social positions and are socially positioned within place from the perspective of field theory habitus helps or hinders a person in recognising the stakes within a field that justify engagement despite the material basis of the metaphor fields are more akin to an unseen force field it holds together people who have a stake in the field it exists because there is something to compete for and for those engaged in the field it holds within its force field a set of rules a field can exist wherever a set of interests and forces exist for example through the expression of preferences for particular types of art and housing any field contains a set of tacitly understood rules these are not immutable but they are durable not least because they work to the advantage of those with higher status habitus and greater amounts of capital the field serves to limit what is open for discussion in any encounter what will be seen as reasonable and what will be seen as unreasonable the field obscures acts of social power by making the range of reasonable discussion appear as natural as common sense this obscuring of social power is also a feature of bourdieus conceptualisation of capitals returned to below along with a more general disposition or habitus the possession of and ability to deploy capital allows a person to gain social advantage to seek distinction within a field distinction is the making of choices that confer social advantage the right education preferences in art and entertainment housing and neighbourhood and so on social cultural and economic capital all have a symbolic quality to them this symbolic aspect refers to the misrecognition of the qualities of a capital as given rather than as being socially created this hides the fact that the legitimacy of a capital comes from what it can do rather than from any intrinsic worth …symbolic capital is not a particular kind of capital but what every kind of capital becomes when it is misrecognized as capital that is as a force a power or capacity for exploitation and therefore recognized as legitimate the combined effect of the field and the symbolic nature of capital is to hide the exercise of power by making selfinterested choices appear as natural or taken for granted that there is no alternative finally for this brief overview if habitus and capitals make an individual relatively effective in one field it is likely that they will be in an advantageous position in a number of fields this produces a homology of field a compound advantage this is not a simple translation of advantage from one field to another but persists as something more familiar as a class relation these concepts are return to below as consideration is given to how spatial capital has been drawn from and overlaid on them in various ways in the following section an outline of how spatial capital has been conceived and employed is set out before looking at its potential use for planners spatial capital the instances of work identifying spatial capital are notable for being rooted in empirical studies of urban social dynamics describing urban events close to the everyday concerns of planners with a political economyjust city orientation all four cases look at how privileged groups employ urban place and space to their advantage utilising place sometimes in combination with mobility and which produce inequitable opportunities this starts with the work of centner who pays the closest attention to the breadth of bourdieus theory and in particular to field theory he looks at the dotcom boom period in the late 1990s and how groups of socalled dotcom workers flush with cash combined privilege with freeranging territorial claims to the city he is focused on how they enjoyed a sense of entitlement allowing them to occupy dominate and define particular places he gives the example of a wine club meeting in missiondolores park described as one of the few sites in the neighbourhood for families in the areas to bring their children to play outdoors the dotcom group crowded out local families from tables in the park and were approached by police in a most prudent manner despite the groups …flagrant infraction of public alcohol consumption this provides us with an example of what bourdieu refers to as symbolic violence that is the imposition of ones groups norms on another for centner this serves as one illustration of how the dotcom group was able to deploy their individual capitals to have their behaviour accepted where others would not attention is given to the process of misrecognition whereby the inclinations of habitus and the exercise of capitals appear to render as natural the domination of space by the dotcom workers this misrecognition of economic social and cultural capital permits the legitimisation of claims on space he argues that this represents a separate spatial capital spatial capital then is a form of symbolic capital in a field where material space is at stake to the extent that choices made by deploying social cultural and economic capitals in a field appear to be natural the spatial consequences will similarly appear to be a given the next usage comes from barthon monfroy who focus on the interplay between place and space fixity and mobility in the schooling strategies of households from a range of social backgrounds in lille the work looks at the familiar subject of the strategies of middleclass households aimed at securing access to better schooling in so doing it employs statistical methods to test if it is possible to envisage spatial capital existing independently of other capitals as …a capacity in its own right to bring into play spatial resources which have a specific impact in terms of equality in a study that lightly references bourdieu they apply regression analysis to test for the significance of both locality and mobility in relation to social background in terms of accessing high quality schooling of particular significance for planners is the joint impact of position and situation to give an examples where pupils with lower social backgrounds are in a favourable position because they live in uppermiddleclass neighbourhoods they are more likely to attend privileged schools however the proportion attending is much lower than pupils from higher social backgrounds and although children from both higher and lower social backgrounds are both quite mobile in moving to schools outside their area of residence in general pupils from poorer social backgrounds are commuting from a place with very poor schools to somewhere with less poor schools in short those with a higher social background are more able to exploit the potential benefits of place and mobility the combined ability to capitalise on place and space on location and mobility leads barthon monfroy to conclude that place and space strategies powerfully reinforce one another the link between location and mobility is also the focus of the third example where rérat lees look at gentrification in the swiss cities of neuchatel and zurich west one of the key arguments of their paper is the need to balance an approach to residential place that takes into account both mobility and rootedness …by looking at the mobility experiences of individuals and the fixity of place this focus is identified as a corrective to an overemphasis in mobility in recent work on the city they argue that the traditional cultural distinction made between the suburbs and gentrification …is breaking down in the face of recent studies that point to the suburban mindset of contemporary gentrifiers… and that differing mobilities between suburban and gentrifier residents better distinguishes the two groups focused on the interplay between fixity and mobility and building on the work of flamm kaufmann kaufmann mobility is conceptualised as a form of spatial capital they find that gentrifier households rated highly a series of mobilityrelated aspects when evaluating their choice of residential location the highly rated characteristics allowed them to be both mobile and rooted they valued city centre living because it provided closeness to work shops and other facilities such as childcare but also because it provided ready access to train stations allowing fast access to other city centres rérat lees describe these two forms of movement as proximity and connectivity patterns and compare them to suburban patterns which are characterised by the need for the household to access other sites through multiple and diffuse travel patterns in essence mobility or spatial capital in this context represents the ability to minimise journey times to work and services and to transport nodes that give access to the centre and other city centres last is the work of marom who employs the term spatial distinction rather than capital and so focuses on the outcome of engaging in fields rather than the capitals that people take into any given field his work is introduced here for a number of reasons first like barthon monfroy but with a very different method he seeks to focus on the outcome of competition within fields at the citywide rather than the neighbourhood level linked to this and relevant to planning he looks at how officials and administrators within the city authority have acted to support a spatial logic rather than focusing on the actions of residents finally he attunes us to the changing of strategies over time he charts the development of tel aviv identifying three distinct periods and noting how the relationship including separation between tel aviv and its sister city jaffa is managed from its early phase of development he traces the effort to retain both a physical and cultural separation between tel aviv and jaffa as tel aviv expanded the maintenance of spatial distinction faced two challenges as tel aviv and jaffa became intertwined and also as tel aviv itself developed sociocultural distinctions within the hebrew city this leads him to conclude that by taking a long historical picture of the whole city it is possible to trace shifts in the scale at which spatial distinction has occurred in parallel to the study by centner he focuses in particular on how spatial distinction comes to be seen as natural the limits of spatial capital as theory the claim to a need to bracket out spatial capital implies that bourdieus work is lacking a sufficient treatment of the spatial dimension as has been seen the spatiality of bourdieu is more evident when the focus is on the field a field itself can have a spatial element to it a neighbourhood other public realm or housing can be construed as a field in the case of the latter bourdieu works through an extensive example rather than a spatial element such as housing being another form of capital it can rather be treated as a field through which the existing capitals are deployed moreover housing to continue the example may add to other capitals it can increase economic capital through an increase in asset value social capital by giving more ready access to high status individuals as neighbours and cultural capital by exhibiting distinction through the choice of a house to give just three examples insofar as spatial elements can enhance the three existing capitals this might be a case for distinguishing it by viewing it as a capital in its own right however even where less advantaged individuals reside in close or relatively close proximity to advantaged individuals differing levels of social and cultural capital override any spatial advantage therefore the spatial may not in and of itself be advantageous as barthon monroy demonstrate where higher and lower status households live in close proximity with access to the same range of schools higher status households access better performing schools to a greater degree than lower status households and where they travel to schools it is to better schools than pupils from lower status households therefore spatial capital is not so much an independent capital taken into a field rather it is describing an outcome of successful engagement in a field this is reflected in the conclusion of barthon monfroy that it is not possible to identify with certainty the operation of spatial capital independent of social cultural and economic capitals however this is not a conclusive dismissal of social capital as it is important to remember the different authors are seeking to define it in different ways therefore barthon and monfroy are simply able to discount social capital in the terms in which they seek to employ it in more practical terms adopting spatial capital as an addon to or specification of bourdieus theory contains the danger of encouraging the generation of ever increasing categories of capitals ethnicity gender and so on while failing to recognise how these are already accounted for through field theory this danger is recognised in relation to habitus by butler robson who in seeking to identify a metropolitan habitus recognise the danger of proliferating different subtypes of habitus it is noteworthy that a body of work exists which draws on bourdieu to describe social positioning in place without invoking spatial capital for example in their extensive work on bedford an upmarket suburb of new york city duncan duncan have looked at competition to define place within the upper middle classes other work in this vein includes butler robson on different groups of gentrifiers in london and savage et al on suburban residents in manchester these examples are focused on intramiddleclass struggles over space and given this different focus it might be argued that the need to invoke spatial capital is less apparent however a final example is that of fleischer who provides a perspective from outside north america and europe when she focuses on suburban residents vying for social position within a growing suburb of beijing here she describes disputed definitions of space across actors with strongly contrasting class backgrounds but again does not seek to use spatial capital to do so notwithstanding fleischers work spatial capital has been invoked where there is evidently gross inequity across classes in the ability of people to position themselves advantageously within a given place rather than where intraclass struggles exist while only marom relates directly to planning spatial capital may therefore suggest itself to planners as having political purchase in drawing attention to gross inequalities emerging from social positioning within place with this in mind in the following section consideration is given to its potential as a tool for planning practice employing spatial capital in planning practice while the need to add social capital to bourdieus schema has been argued to be a case unproven spatial capital may still have a utility for planning practitioners it is this contention that is developed in this section in charting the development of planning as a practice and an academic discipline hall noted many years ago that planning theory and practice appear to have taken divergent paths this point continues to be noted by practitioners and theorists as noted bourdieus theory is expansive and is not readily transferable to practice rather it has been used as means to analyse practice referencing spatial capital may have the benefit of grounding a complex and subtle theory in practice its use could provide a familiar term reflective of social capital through which to have practitioners engage with the significant interplay between social and physical space in order to be useful to practitioners theory should address issues of power and spatial capital provides such a focus the potential utility of spatial capital is broken down into a number of related elements although they are treated separately here for clarity they are in practice closely related first it allows planners to bring together a series of urban events under a common conceptual framework making connections between events could offer a more holistic insight into the operation of power in the built environment second it could contribute to the development of a more reflexive practice by highlighting planners assumptions of what is and is not a given and third it could direct planners to the distinction between place and position that highlights the limits of deterministic approaches to the built form first spatial capital may be a useful trope that helps planners to bring together a series of urban events that could offer considerable insight into the operation of power in the urban environment it can draw attention to the homology of actions where people seek to employ capitals in ways that have a spatial dimension and that taken together produce powerful advantage for some over others people with a particular disposition and capitals are likely to be successful across a series of fields including through the interplay of fixity and mobility drawing on the earlier examples groups are at liberty to take possession of parts of the city households are able to game play advantageous schooling provision which they do both through fixity and mobility in the same way as households seeking optimal access to work and other offers of the city such as cultural attractions any particular household may do all of these therefore spatial capital may be a powerful trope for planners seeking to describe and address powerful compound effects the implication of this is the need for a holistic approach to social disadvantage rather than a piecemeal focus on particular events such as gated communities the works detailed readily reveal connections that planners would need to bring together as they seek to challenge disadvantage as centner shows it is not enough to simply provide a park planning needs to work with other agencies of city governance to ensure fair access to all centner barthon monfroy second spatial capital could draw attention to the power of the possible by drawing practitioners to original aspects of bourdieus work including misrecognition in this case the natural or the takenforgranted in the built form the role of planners in consciously and unconsciously lending weight to the exercise of capitals by residents is emphasised by marom who focuses on the governance of tel aviv and the hidden assumptions the natural choices that have shaped the city leading him to note a generic and generative process by which social difference is inevitably and intricately objectified in urban space is left undertheorized in essence this directs us back to a more general literature on the reflexive practitioner insofar as spatial capital directs planners to the concepts of misrecognition and field it could prove useful to planners in reflecting on their assumptions of what is given and what is open to contestation and why things are as they are third spatial capital could provide a link to bourdieus differentiation of place and position which highlights the limits of deterministic approaches to the built form a longstanding criticism of planning and one seen as increasingly inadequate in the contemporary world bourdieus focus on the interplay of the social and physical worlds is powerful for planners because it emphasises the ways in which people have acted and will act within any given planned place deterministic attempts to influence people through place may be limited by the positional power that people exercise within place although founded in very different philosophical roots the use of bourdieu may inform a common criticism of planning levelled by some urban economists in an extended critique of urban planning and regeneration policy in the uk cheshire et al conclude that despite much focus by policymakers on the effects of place on peoples life changes when it comes to determining your life chances and welfare who you are is much more important than where you live in a city put another way being poor is a problem rather than where in the city you are poor they make temporary bedfellows in directing planners to the importance of the individual both for example cast doubt over the efficacy of policies aimed at social mixing across classes however they are clearly distinguished by their interpretation of the socioeconomic drivers of individuals and the extent of their choices bourdieu roundly dismisses explanations of socialspatial sorting in the city based on the choices of homo economicus for him social power a lack of the power to choose is key not the hidden hand of the market however bourdieu while offering an alternative premise positively contributes to critiques of planning as overly focused on the built form the limits of spatial capital in practice while employing spatial capital might appear to provide a ready term with potential leverage comparisons to social capital help highlight a potential pitfall if spatial capital were to come into use in planning it would be a term at some distance from its theoretical roots and as such it could be particularly open to misappropriation social capital has had considerable impact on the political and policy community in the uk especially under the new labour administration of 19972010 however it was not bourdieus version that was employed but rather that of putnam this is explained by the attraction of putnams version to the body politic while bourdieu provided a version of social capital that was part of a process of seeking individual gain in competition within fields putnams version provided a focus on intraand intercommunal help that could help facilitate the rollback of state help and make citizens more work ready illustrating one way in which social capital has been interpreted to suit a conservative rather than a radical agenda kearns argues social capital turns the focus from financial poverty to network poverty a recent illustration of how social capital is adapted readily to contemporary political agendas in planning comes from uk where the present government has included in its justification of neighbourhood planning its potential to increase social capital where spatial capital is introduced it is conceptualised in different ways and therefore like cultural capital reflects different emphases in different sources rather than providing a single concept of spatial capital the literature cited indicates that the exact meaning and significance of the term can be contested as has been the case for social capital spatial capital has arisen in other fields where there appears to be an intention to emphasise the inequity of position taking within place transferred to planning spatial capital could play a similar role but the very appeal of spatial capitals ready portability into planning practice brings with it the risk of multiple appropriations of being deployed in multiple ways it could be usurped by a range of parties potentially hiding power interests rather than illuminating them it could easily become another slogan foisted on planners rather than being a tool of their own making beyond cultural capital ready comparisons could be made with terms such as community and sustainability that are equally open to reappropriation as brent argues in relation to community it could be a powerful organising term because of its adaptability and flexibility but because of this it would be open for adoption and use by both conservative and socially progressive forces the final point returns us to a broader critique of bourdieus work he recognised that position taking in a field can and will produce a reaction fields may constrain the terms of the debate they do not eliminate resistance however bourdieu is relatively silent on the agency of the less privileged while the upper and middle classes are engaged in a battle for distinction the working classes are confined to choices and actions born out of necessity this is reflected in all of the works reviewed where the actions described are those of the more privileged acting spatially while the resistance of the less privileged is absent from the accounts here urban economists might argue that bourdieu is unhelpful in rendering those less privileged overly the victim of their circumstance and underplaying their ability to act connected to this is a further criticism articulated by rancière who argued that bourdieu fell into the marxist trap of assuming the necessity of an educated and enlightened elite to reveal to the working class the condition of oppression under which they labour there is therefore a danger in interpreting bourdieu for planning practice that planners will be encouraged to pursue an expertled topdown approach by perceiving of a largely passive client group of those lacking spatial and other capital this could focus planners away from the proactive qualities of communities in resisting the practice and outcomes of others spatial capital these are very real limitations to be set against the possible beneficial uses of spatial capital in planning practice conclusion planning theory like many other disciplines is increasingly employing bourdieus theory and therefore developments aligned with it are of note including the identification of spatial capital while the article has been used to question the need to add spatial capital to bourdieus theory its planning interest has been on whether spatial capital might nevertheless prove a useful trope for planning practitioners whereas bourdieus work has mainly been applied to an analysis of planning practice spatial capital offers up a ready tool for planning practitioners it might be readily owned by planners with its referencing of the spatial and with recognisable links to social capital which is already common currency in planning and which could travel between the agencies of governance however its appeal as a readily available trope is also its danger as a construct at one step removed from the root theory it is particularly open to all parties to impose their meaning on it it would not be hard to imagine that if spatial capital were to come into common usage it could simply become a shorthand term that loses its analytical purchase or worse still comes to be reflected back on disadvantaged communities just as social capital has sometimes been interpreted to focus on communities as lacking an asset that they have failed to acquire this directs us to a general critique of bourdieus work that it emphasises the power of the already powerful and the passive role of the weakest which transferred to planning practice might reinforce topdown models of planning focusing on the planner seeking to compensate those with less spatial capital although these are very real limitations there remain a series of potential benefits to employing spatial capital from a practitioner perspective spatial capital has potential as a useful tool in developing narratives of place with a socially progressive intent possibly a reason why it has suggested itself to the authors outside planning who have used it to date directly it could prove useful for planners seeking to narrate the ways in which a series of diverse events can in combination produce powerful social advantage and disadvantage this would allow planners to gain purchase on the combined effects of social actions by for example looking at how households areare not able to vie for school places areare not able to exploit connectivity within the city core and between city cores and areare not able to claim neighbourhoods as their own none of these are unremarked events in the city but spatial capital can draw on bourdieus idea of the homology of fields how advantage in one field or setting tends to be reinforced by advantage in another with the same reinforcing mechanism being true of disadvantage this demands of planners that they seek to understand disadvantage in the city in a joined up way and not focus on a series of events spatial capital also has the potential to contribute to a more reflexive practice insofar as it directs planners to bourdieus work it opens up planners to the concepts of misrecognition and the symbolic nature of capital practitioners will already have an awareness of many of the institutional constraints within which they operate however misrecognition and the related concept of the symbolic aspect of capitals help reinforce the extent of the subtle nature in which power operates through planning by rendering as natural the choices of different actors it directs planners beyond the direct limitation of planning law and regulation facilitating a more fundamental questioning of why things are as they are finally spatial capital directs planners to the effects of social agency within place rather than place effects it facilitates an emphasis on the role of social actors seeking to position themselves within any given place this could serve as a corrective to assumptions that that getting a place right will lead to desired social outcomes in this it usefully draws planners focus to the actions of people within place alongside the influence of place on people

this purpose of this article is to look at the potential benefits for planning practice of engaging with spatial capital a concept derived from the social theory of bourdieu doubt is expressed about the theoretical basis for spatial capital nevertheless it is argued that it may have merit as a trope for planning practitioners spatial capital has a strong empirical basis making it accessible to planning practice and offering a new means for interpreting and communicating the combined effects of a range of individual urban events such as the gating of communities differing mobilities and schooling tactics by focusing on the interplay of social positioning within place it emphasises the joinedup nature of disadvantage and highlights the limits of environmental determinism however its use is not without possible drawbacks here the experience of social capital is informative as this has been appropriated by groups with quite different readings of its implications for policy

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are people addicted to social networks more than 42 billion people use social media with the onset of covid19 and the drastic reduction in outings and gatherings social networking sites have assumed a more crucial role in daily life as people use them to connect with others these social sites are an internet success story they have been adopted as a vital means of communicating interacting and sharing with others thereby increasing interpersonal sociability and connectivity this public forum enables the exchange of digital information like text pictures audio and video the rapid growth of sns users has attracted marketing and advertising interest from firms that seek online exposure and increased brand loyalty most sns depend on online advertising as their main source of revenue thus they enhance network externalities to achieve economies of scale to propagate their business model in turn the increased use of sns generates profit the popularity and growth of commercial sns are considerable new and specialized sns have emerged further signifying the success of this new business model although the total number of sns has grown at an astonishing rate some networks have lost users or been discontinued because of fierce competition the main business strategy for sns practitioners is to retain existing users and attract new users studies have explored the main functions of sns in terms of social networking impression management selfpresentation in profiles proliferation of special interest networks gender differences and social network structure however few studies have been conducted on factors that influence user addiction to sns empirical studies are needed to address the popularity of sns and increase in sns addiction the current study was motivated by a broad interest in sns addiction in addition numerous sns privacy and security issues merit serious consideration this is the first study to apply the social capital theory and explore the moderating influences of both privacy concerns and perceived security in sns addiction the notion of social capital was originally used to describe relational resources embedded in interdisciplinary personal relationships that support the development of social communities it is an elastic construct used to describe the benefits of relationships with others the concept of social capital began with the formation trust within social communities and human interactions social capital is a pool of resources that can be harnessed through social connections embedded in social networks sns enable people to display themselves express their social network and develop relationships with others intense sns use is closely associated with the maintenance and formation of social capital sns support both the maintenance of existing social connections and formation of new ones tang et al stated that social capital on sns affects information exchange and personal wellbeing however few empirical studies have addressed whether people use sns to maintain existing connections or make new ones thus this study applies the social capital theory to explore privacy and security of sns through the development and empirical testing of a theoretical research model of addiction the framework of nahapiet and ghoshal which integrated prior work in the field provides three specific dimensions of social capital structural relational and cognitive a behavioral research model of the relationships among structural capital relational capital cognitive capital and addiction to snss was developed this research model was used to empirically examine how social capital is fostered within an sns through communication and interaction among users in addition this study examined how stickiness mediates the relationships between social capital and addiction to sns privacy concerns and perceived security are key issues related to sns hackers aim to gain unauthorized access to sns or accounts to retrieve private information by watching the sns user type in a password anyone can gain access to private and confidential information sns providers may make private sns information available to third parties through application programming interfaces which third parties can then control sns user privacy is at substantial risk when publicly available data can be tracked user activities can be linked to this data to mine and extract sensitive information the challenge for sns designers is to simultaneously ensure personal security and promote information sharing and sociability few studies have evaluated the influence of privacy concerns and perceived security on addictive behavior in sns this is the first study to analyze how privacy concerns and perceived security moderate the relationships between stickiness and addiction for sns users the researchers applied economic sociological and cognitive psychology to develop a model to explain addiction to sns the proposed model is based on the social capital theory the roles of social capital privacy concerns and perceived security in user addiction to sns have not been examined this study conceptualized and examined a research model of the social capital theory including privacy concerns and perceived security to explore addictive behaviors on sns in addition this is the first study to propose that stickiness mediates the relationships between social capital and addiction thus this research contributes to the literature related to social networks first predictors of addiction have not received much attention in addition the literature lacks comprehensive models of addictive behaviors second the research model provides a theoretical foundation for identifying a key mediator between social capital and addiction this study examined these relationships empirically in the context of sns third the researchers proposed key moderators privacy concerns and perceived security finally the study considered how this research model can be used to propose novel predictors of addiction and discussed theoretical and practical implications literature review sns sns are webbased communities that enable individuals to connect with others over the internet to share or exchange information sns play a key role in providing information to users individuals use sns to improve social relationships communicate produce meaning and exchange information the most basic sns enable users to build online profiles and interact with others to join an sns people must sign up as members this process may include providing personal information like a name and email members engaged in social networking activities create public or semipublic profiles that include data like their gender date of birth religion hometown political views and a selfintroduction moreover sns enable users to create personal or shared lists defining social networks by joining groups adding friends and viewing lists members can search for profiles on their network share information send and receive messages and display what other members can see in their profiles social capital theory the social capital theory which emphasizes the importance of strong interpersonal networks that develop over time first appeared in sociology this theory provides a useful theoretical basis for understanding information technology and information systems social capital refers to the resources people can access from their social connections and networks the literature has shown that social capital influences community issues like crowdfunding and social media therefore social capital is dependent on the relationships between people and their connections to the community social capital comprises structural relational and cognitive features the structural dimension refers to the formation of information networks the relational dimension concerns the nature of connections between people in an organization the key aspects of this dimension are trust identification and norms the cognitive dimension is the degree to which people in a social network share opinions many studies have explored the impact of social capital on knowledge sharing in online communities yan et al found that structural capital and cognitive capital affect the quality and quantity of knowledge contribution in online user communities zhou reported that relationship capital and cognitive capital positively affect the acquisition of social network knowledge in online health communities wang et al stated that social capital is a vital variable that mediates the relationship between knowledge search and knowledge contribution in online q a communities the key resources for this dimension are the existence of a shared language and goals this study explored the possibilities that sns hold for building social capital among users the researchers used social network ties as the variable for structural social capital they used trust in sns trust in members of sns social identification and social norms as the variables for relational social capital finally they used shared language and shared goals as the variables for cognitive social capital addiction addiction refers to the compulsion to repeat behaviors regardless of the consequences it is considered an unhealthy and compulsive preoccupation with trivial or repetitive behaviors with irrational motives for such behaviors addiction has been discussed by social psychologists and pharmacologists griffiths argued that addiction comprises six components tolerance relapse conflict salience mood modification and withdrawal symptoms larose et al noted that the general symptoms of internet addiction include tolerance preoccupation relapse withdrawal adverse life consequences loss of control escapism and concealment sns addiction refers to the compulsive use of sns and strong psychological dependency on sns people with sns addiction have strong cravings to use sns repeatedly they experience withdrawal symptoms when they stop using sns studies have also explored sns addiction from different perspectives tarafdar et al found a possible relationship between social networkrelated stress and sns addiction gong et al indicated that snsrelated addictive behavior depends on an individuals perceived benefits especially social and hedonic benefits miranda et al examined the mediators of the influence of sns usage motivation on the development of addiction in sns users furthermore seo and ray explored the negative impact of sns addiction on the use and outcomes of goal congruence privacy concerns and perceived security in sns privacy concerns and perceived security are based on user perceptions privacy concerns refer to a users concerns about the possible loss of privacy due to voluntary or surreptitious information disclosure on sns perceived security refers to the degree to which users perceive that using sns is free of risk however sns involve privacy and security risks through various exposures frequent users often attract the attention of attackers sns users face privacy and security threats because of the high number of sns users therefore privacy concerns and security issues are critical in social media however privacy security and access controls are weak by design in most sns for example privacy and security risks in sns involve social phishing phishers use sns to mine information about relationships and shared interests within communities thus protecting user privacy and security has become a key concern for sns marketers research model and hypotheses figure 1 illustrates the theoretical research model based on the social capital theory this study examined the influence of interpersonal relationships through the structural dimension relational dimension and cognitive dimension these serve as antecedents and are assumed to have a positive direct and indirect influence on the dependent variables in online social networking the study also explored how privacy concerns and security moderate the relationship between stickiness and addiction structural capital social network ties are a key element of the structural dimension of social capital which is the foundation of information networks social network ties are the impersonal configuration of connections between humans these social ties serve as channels for the flow of information and resources social network ties are created as sns users communicate users who are central to the network and are connected to a large number of other sns users are more likely to continue to contribute to collective activities these efforts are key to sustaining and maintaining digital social communications and interactions social network ties provide information channels that increase user stickiness and addiction to the sns h1 social network ties are positively associated with stickiness h2 social network ties are positively associated with addiction relational capital trust is a fundamental relationship building and maintenance mechanism trust is also a confidence in the behavior of another party existing when a party believes that another party is trustworthy perceived lack of trust and confidence in the other party reduces an individuals motivation to maintain relationships trust influences perceptions attitudes and intention to engage in behaviors dependent on others sns users have trust in both sns and their members numerous people on sns have profiles that reveal private information the reputation of sns has diminished because of privacy incidents publicized by media as users develop trust in sns they tend to use it more often in addition trust increases with and affects the popularity of sns therefore this study hypothesized that stickiness and addiction are the results of trust in sns and their users social identification the ability to selfidentify as part of a larger group plays a critical role in determining online community participation individuals are incentivized to engage in behaviors required to maintain relationships with online community members a key to maintaining these relationships is actively participating in online communication and interactions social identification refers to a users sense of belonging to a sns when users have a strong sense of identity with the sns they are more likely to participate in the sns identification requires positive selfdefining relationships with other sns users therefore individuals are motivated to engage in these behaviors social identification prompts grouporiented online social networking behavior sns stickiness and addiction are influenced by social identification social identification reflects users efforts to present and express themselves to others enhancing intention to use sns h7 social identification is positively associated with stickiness h8 social identification is positively associated with addiction social influence profoundly affects individuals perceptions and behavior social factors positively influence internet technology use the theory of reasoned action provides a theoretical basis for exploring a hypothetical relationship between social norms and individual behavior some empirical studies have suggested that social influence positively affects behavior this study proposed that social norms affect stickiness and addiction to sns h9 social norms are positively associated with stickiness h10 social norms are positively associated with addiction cognitive capital social capital involves a shared understanding and language a shared language is the acronyms subtleties and underlying assumptions that are the staples of daytoday interactions a shared language can be used to convey knowledge essential to information flow in an sns sns users utilize their shared understanding to build their vocabulary thereby increasing the efficiency of communication thus a shared language motivates users to remain involved in social networking activities shared languages may increase stickiness and addiction to snss therefore h11 shared languages are positively associated with stickiness h12 shared languages are positively associated with addiction shared goals are the collective aspirations of organization members shared goals enhance communication and minimize misunderstanding group members with clear shared goals have a greater sense of community and team orientation therefore they are more willing to interact with other members shared goals facilitate the exchange of ideas and mutual understanding h13 shared goals are positively associated with stickiness h14 shared goals are positively associated with addiction stickiness stickiness is the frequency depth and duration of site visits website stickiness is associated with attraction conversion and retention stickiness positively affects users intention to use wechat hsu and lin observed that stickiness positively affects consumers willingness to purchase mobile applications ramayah et al reported that blog stickiness strongly affects retention in addition stickiness positively and significantly influences website loyalty therefore h15 stickiness is positively associated with addiction privacy concerns and perceived security privacy concerns and perceived security a key part of the online experience play a crucial role in the digital world the sharing of individually generated information has increased with the emergence of sns these platforms are used to create and exchange private information in an effortless and seamless manner however when marketers target sns users unexpected consequences could affect perceived privacy and security the growing popularity of sns raise questions surrounding perceived privacy and security for users despite their increasing importance privacy concerns and security issues have not been studied as moderators of sns addiction privacy concerns and perceived security are individual factors that may significantly moderate users acceptance and use of technology the effect of stickiness on addiction may be affected by privacy concerns and perceived security on sns the effect of stickiness on addiction may be stronger for sns with fewer privacy concerns and a high degree of perceived security this study assessed whether privacy concerns and security perceptions moderate stickiness and addiction therefore h16 stronger privacy concerns weaken the relationship between stickiness and addiction h17 weaker perceptions of security weaken the relationship between stickiness and addiction research methodology measurements this studys measurement instrument was based on other studies the surveys pretest was conducted by two researchers to increase the face validity of the questionnaire a total of 54 sns users joined the pilot study before the survey was fully launched in the target population the results of the pilot study indicated that the cronbachs α value for each construct exceeded the criterion of 0735 which is acceptable the measurement instrument involved a sevenpoint likerttype scale with 1 representing total disagreement and 7 representing total agreement the scales that measure social network ties were adapted from tsai and ghoshal the scale items for trust in sns and trust in the members of sns were adapted from dwyer the scales for social identification were adapted from bagozzi and dholakia and nahapiet and ghoshal the scales measuring social norms were adapted from fishbein and ajzen items for shared language and shared goals were adapted from nahapiet and ghoshal and tsai and ghoshal items for stickiness were adapted from lin and li et al the scales for addiction were adapted from xu et al and chou and ting the scales for privacy concerns were adapted from buchanan et al and metzger the scales for perceived security were adapted from yenisey et al data collection to gather empirical data this study conducted field surveys of sns users by creating accounts on popular sns and posting invitations to participate in public forums and groups a total of 242 questionnaires were collected after removing duplicates invalid submissions and those with missing values 227 valid questionnaires were included in the analysis the demographics of the participants are presented in table 1 with 467 male and 533 female in terms of age 247 were younger than 18 years 661 were between 20 and 40 years and 92 were older than 40 years furthermore most respondents had five or more years of general internet experience with 278 having less than three years of sns experience 722 having more than three years of experience and 388 having between three and five years of experience data analysis and results measurement model to avoid the impact of common method bias this study adopted harmans singlefactor analysis the cumulative variance of the first factor tested was 47639 which was less than the recommended cutoff of 50 this finding suggests that cmb was not a concern in this study the kaisermeyerolkin test and bartletts test were conducted to assess the suitability of factor analysis a kmo value 05 indicates adequate sample size the ideal value is 08 the kmo values obtained in this study indicated that the sampling adequacy was excellent the results of bartletts test of sphericity were significant indicating that the measurement approach was valid all the constructs were assessed for potential multicollinearity by using variance inflation factors the vif values of all constructs were below 10 indicating that multicollinearity was not a problem the study used partial least squares structural equation modeling to analyze the hypotheses a confirmatory factor analysis was conducted to examine the measurement model with all constructs the reliability of the items internal consistency between items and convergent and discriminant validity of the model were used to assess the acceptability of the measurement model table 3 presents the number of items means standard deviations composite reliability average variance extracted square root of the ave and correlations between the constructs the composite reliability for all constructs was greater than 084 which is above the suggested value of 070 this indicates acceptable internal consistency the ave values of all the constructs were above 050 indicating convergent validity the square roots of the ave values of each construct were greater than the corresponding correlation coefficients indicating discriminant validity structural model assessment and hypotheses testing the standardized pls path coefficients used to examine the structural model are presented in figure 2 these results support all the hypotheses the paths from social network ties to stickiness and addiction were statistically significant therefore h1 and h2 are supported trust in sns significantly affected stickiness and addiction therefore h3 and h4 are supported trust in members of sns significantly affected stickiness and addiction therefore h5 and h6 are supported the paths from social identification to stickiness and addiction were statistically significant therefore h7 and h8 are supported the paths from social norms to stickiness and addiction were statistically significant therefore h9 and h10 are supported the existence of a shared language was positively related to stickiness and addiction therefore h11 and h12 are supported shared goals were sns providers can hold facetoface meetings and provide rewards to encourage users to share their experiences and enhance their social network ties sns providers can provide interactive features to enhance online communication and interaction among members in addition they can implement attractive online activities to increase interactivity social identification significantly affects stickiness and addiction to sns a sense of group membership increases motivation to continue using sns the desire to belong is analogous to the desire to gain recognition from other members when sns members have a strong sense of belonging to a group and desire to maintain close ties with the members they are willing to spend time using sns membership can also increase willingness to contribute sns usually attract a large group of members because they are a conduit for information sharing and socialization sns can provide members with opportunities to meet others with common goals and interests sns members build relationships through constant communication and have positive experiences members are drawn to sns by a strong sense of belonging online relationships can develop in sns due to low levels of perceived trust and few privacy protections sns users who felt stronger trust had a stronger intention to share their personal information this study divided trust into trust in sns and trust in members of sns it determined that the effect of trust in members of sns on stickiness and addiction to sns is stronger than that of trust in sns sns providers can foster trust among members by enhancing social communication and interaction and encouraging users to share personal information on sns shared languages and goals are stronger predictors of stickiness than trust studies have noted that trust is crucial to any business transaction however the studys results indicate that the path coefficient from shared language and shared goals to stickiness and addiction is higher than that of the path from trust to stickiness and addiction this indicates that sns users value a sense of community more than bilateral relationships like trust these findings elucidate several key points associated with critical determinants of users addiction to sns that have not been addressed in other studies stickiness was identified as a factor that can be used to predict sns addiction when a user develops an addiction to sns sns use becomes more compulsive than volitional from a business standpoint the line between stickiness and addiction is crucial if time spent on sns is long stickiness is stronger and leads to addiction therefore sns should encourage users to revisit for long periods this study proposed that sns addiction is a critical factor that directly contributes to stickiness the causal relationship between stickiness and addiction is vital to both sns users and providers addiction is the ultimate form of loyalty therefore sns providers must master the process of creating stickiness to create loyal sns users in sum this is one of the first studies to evaluate the moderating effect of privacy concerns and perceived security in the context of sns results reveal that privacy concerns significantly and negatively moderate the effects of stickiness on addiction the moderating effect of perceived security in the relationship between stickiness on addiction is significantly positive the findings provide snss providers with information regarding how privacy concerns and perceived security affect stickiness and addiction helping to design security controls to assuage privacy concerns sns generally prioritize traffic over privacy and security in addition sns cannot monitor content in most parts of the world controlling speech from international users is difficult which has resulted in a loss of users sns providers should thus prioritize privacy and security to attract users they can also inform users that they value and consider their security and privacy sns users should avoid unnecessarily sharing private data on sns install antivirus and antispyware software on their devices and uninstall unnecessary thirdparty applications to protect their login credentials in addition sns must enable users worldwide to be online at the same time to create a sense of immersion sns providers can provide augmented reality glasses to enable users to stay in the real world provide virtual reality glasses to fully immerse users in snss and provide mixed reality glasses to combine real and virtual worlds as it creates a new environment and enhances user experience overall the findings provide empirical evidence for sns marketers sns operators sns developers and other parties to manage their businesses and formulate privacy and security policies and regulations with the widespread use of sns the problem of sns addiction has started to receive attention theoretically this study has contributed to the subject of sns addiction in several aspects first although many studies have explored the antecedents of sns addiction according to different theories or perspectives no study has explored the antecedents of sns addiction from the perspective of social capital therefore the researchers conceptualized a research model of the antecedents of sns addiction based on social capital theory second in addition to exploring the antecedent causes of sns addiction through the social capital theory this study analyzed the mediating effect and moderating effect on the association between social capital and sns addiction studies have focused on the direct impact of security and privacy considerations on sns user behavior the application of moderating variables in this study can enhance understanding of the influence of social capital on sns addiction this study has several limitations that should be addressed in future research first this study did not explore the consequences of addiction second studies should identify additional antecedents of addiction in other fields third for researchers examining addiction additional topics remain to be investigated finally analysis of longitudinal data and interviews may be conducted to obtain more reliable results conclusion by using the social capital theory this study explored the influence of structural capital relational capital and cognitive capital on stickiness these factors in turn affect addiction this study revealed that constructs like social network ties trust in sns trust in members of sns social identification social norms shared language and shared goals affect both stickiness and addiction furthermore this study found that privacy concerns and perceived security were key moderators of the relationship between stickiness and addiction these findings can be used as a reference by stakeholders in the sns ecosystem competing interests the authors of this publication declare there are no competing interests appendix measurement items social network ties i maintain close social relationships with some members of sns i spend a lot of time interacting with some members of sns i know some members of sns on a personal level i have frequent communication with some members of sns trust in social network sites i feel that the privacy of my personal information is protected by sns i trust that sns will not use my personal information for any other purpose trust in members of social network sites i believe that most of the profiles i view on sns are exaggerated to make the person look more appealing i worry that i will be embarrassed by wrong information others post about me on sns privacy concerns i am concerned that i do not know the parties who collect the information i provide on sns i am aware of the exact nature of information that will be collected during the use of sns i am concerned that the information i submitted on the sns could be misused i am concerned that there is no effective mechanism to address any violation of the information i provide to the sns social identification security i believe the information i provide to the sns will not be manipulated by inappropriate parties i am confident that the private information i provide to the sns will be secure i believe inappropriate parties may deliberately view the information i provide to this sns

the popularity of social networking sites snss has increased rapidly snss are a key part of daily life for many people around the world the use of snss is already a global phenomenon drawing on social capital theory this research empirically explored how structural capital social network ties relational capital trust in snss trust in members of snss social identification and social norms and cognitive capital shared language and shared goals influence stickiness which in turn affects addiction this study introduced key moderators privacy concerns and perceived security to the relationship between stickiness and addiction the authors empirically evaluated the proposed model by using survey data collected from sns users structural equation modeling was applied to test the model this study can provide a deeper understanding of sns users addiction behavior by focusing on social capital theory privacy concerns and perceived security and therefore contribute to both research and practice

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introduction if we the developers want to provide actionable insight into the human interplay among signbased world and digital technologies as part of processes of organizational transformation it is essential that they the users get insight in what is needed to realize the transformations and can share their experiences with their coworkers this insight requires that each of the actors is afforded to have an idea of the situation he is acting in and that those ideas are shared where needed here we face two alignment issues at once the first may be termed vertical alignment hoppenbrouwers directs the attention to the human side of information systems building with the distinction between business stakeholders and it stakeholders the former being primarily occupied with running the business the latter with designing building and maintaining information systems with the risk of misunderstanding and bad performance due to differing goals and conceptual habits in the design stage 1 stamper looks at it from a systems side when he proposes his semiotic ladder to distinguish the different levels that must be considered when designing an information system 2 the second may be termed horizontal alignment its concern is interoperability across organizations liu li and liu following stampers semiotic framework state that we have semiotic interoperability if signs among systems are successfully communicated in all the six levels stamper distinguishes thus every sign aspect is covered 3 4 their interest concentrates on five of the six levels physical world empirics and syntactics taken together under the label technical semantic and pragmatic interoperability this grouping relates their work to the shannon weaver distinction in three levels 5 of which the stamper framework is a refinement from a semiotic perspective the technical level being formally covered by shannons mathematical theory of communication from there their research climbs the ladder layer by layer leaving the social layer for the moment unexploited goldkuhl and ǻgerfalk remark that it is difficult to distinguish between the pragmatic and social levels on the semiotic ladder because in both signs are produced and such actions are in most cases social actions 6 it appears that they forget that all levels of the ladder contribute in social actions stampers ladder levels are objectifications of sign aspects involved in signs a word has its qualities its form and existence its combinatory properties its meaning its usability and its habitat so all levels of the ladder are involved in the social world just as shannons theory on the technical level is involved in the meaning and effectiveness level the crux being that it is possible to pay attention to the technical level without taking care of the other levels but it is not possible when designing information systems to pay due attention to the social level without taking account of the involved levels as the information revolution makes clear this leaves us with the question what if any the distinguishing characteristics are of the social level of stampers ladder oppl and hoppenbrouwers provide a good vantage point for an answer with their plea for stakeholdercentric modelling in 7 they assert that involving business stakeholders in enterprise modelling also helps them to articulate and align their views on their organization this requires so they state that stakeholders must be able to understand and perform conceptual modelling for representing their views on enterprise structure and behavior i regard this to be part of the vertical view on alignment due to its reliance on the semantical layer and its modelling techniques at least partly the business stakeholders are drawn into the it stakeholders role and must go from their more familiar informal way of looking at their working situation to a less familiar and more formal approach below we suggest a method that professes to model the social layer it rests on the assumption that sign processing actors are unquestionably to be classified as information systems while iss are information systems from some perspectives but also can be viewed as affordances for actors that are acting in and between organizations that also can be looked at as actors for which iss are affordances since the goal is actionable insight for business stakeholders we keep our exposition of the method short in section two we present what we the developers could communicate with the project leader who is supposed to be familiar with ontology charts in section three we describe the kifdiagram we use with the help of the cynefin and sensemaker approach of snowden in section four we describe an experimental case study actualism ontology charts and interpretation processes our general model of the social layer for a company starts with the two assumptions of stampers actualism 1 no reality without a knowing agent 2 no knowledge of the world without action from this we construct the interpretation process agent or state action or effect knowledge or response the symbol is shorthand for the interpretation process that runs from the event of an effect on an agent in a certain state to its resulting conclusion or response the agent can be relatively simple like a tire responding with a flat when undergoing the effect of a nail leaving room for a causal explanation but it can also be complex like a whole company responding to market changes with a reorganization plan the action likewise can be simple like a nail or itself a manifestation of an agent and complex like another business in b to b transactions the goal can be concrete like a flat tire or abstract like business objectives abstract goals have their reality in that they tend to codetermine the agents response on an action in instances of interpretation processes abstract goals turn a mechanical process of cause and effect into a triadic relation in which actor action and goal are the corner stones of a complex process for three reasons we will hook our diagrammatic representation of company processes see below on the ontology charts of the semantic analysis method see fig 1 1 its definition of an agent as a special kind of affordance that can be defined as something that performs responsible behavior and can be as diverse as an individual a organization a language group … 2 the dependency relation that is assumed and expressed by taking society as the root node of which all other agents are ontological depended specifications both points paraphrased from 8 3 the correspondence between these notions in our respective approaches enables the connection of the ontology charts of the semantical level with our diagrams on the social level this suggests the possibility to connect our proposed technical solution with an existing information system in the ontology chart of figure 1 the ontological dependencies are pictured for person employed by an organization for a department and assigned to a project in the semantic layer we want to picture the relations between concepts in the social layer our interest goes to the interactions between the different responsible agents in the execution of their duties the process definition points the way for a first crude approximation lets say also as a first introduction of our experimental case below organization is a company that produces complex tools materials needed in the operation of the tools and some accessories used in the branch they are in the department in focus is the sales department populated with sales representatives each working a rayon the project aims at improving the sales to that end we want insight in the training needs of the sales representatives or in terms of the ontology chart the persondepartment combination to that end we define the process sales representative customer sales by tracing back to the root node we find organizationcompany as the node on which the sales department ontologically depends if we take the management team as the responsible agents for this node we get the process mt business processes performance since the goals of the sales department are subservient to the overall business goals the sales process is an embedded process before we show how this can be captured in a meaningful diagram a few words on the node person and the reason why it appears on the same level as organization suppose that instead of a chart for project management we want to make an ontology chart for the different organizations a given person contributes to besides company family is an obvious candidate but also sportive religious and political organizations are candidates each organization has goals the person tries to contribute to in one way or another and lets not forget the persons selfinterest as a goal pursued relevant conflicts of interest may result and responsibility of agents becomes a subject 3 the cynefin framework kifdiagrams and sensemaker the cynefin framework see fig 2 left originates with kurz and snowden the framework offers five contexts in which persons that must make decisions can find themselves to be it is used primarily … to consider the dynamics of situations decisions perspectives conflicts and changes in order to come to a consensus for decisionmaking under uncertainty it does not aim to categorize a situation but assists in making sense by sharing perceptions 9 the main division is between ordered and unordered domains each domain is characterized according to the causeeffect relationships as they appear to the actors the cause we sense is familiar 1 we can categorize the cause and respond according to the habit or wellstructured set of habits it activates  complicated in the complicated domain the relation between cause and effect may not be fully known or known only by a small group of people we must analyze the cause we sense in order to be able to arrange a set of habits for a suitable response  complex in this domain there are causeeffect relations but we have insufficient actionable insight in their relationships the contingencies of history and unintended consequences of previous actions place us in this domain we must probe the cause from the different perspectives of the involved stake holders and eventually readjust our habits or device new ones for our responses safe to fail strategies are advisable  chaotic disaster happens the best course of action is to start acting in order to stabilize the situation sense the consequences and decide further along the way  disorder this is the domain of conflict between the different stakeholders about what domain we are in with a given cause organizational transformations may suffer from neglect for the deep roots of this domain it is the locus of cognitive dissonance and a source for conflict about the strategy to follow 2the cynefin framework facilitates and stimulates dynamical interpretations a organization firmly located in the simple domain for instance may slide into chaotic if a novelty is recognized not at all to late or met with a strategy pertaining to a wrong domain but it does not have a welldefined notion of interpretation processes the isomorphic kifmodel first introduced by farkas and sarbo 10 contributes one in fig 2 the kifprocessing scheme is represented with the peircean semiotic terms that indicate the factors involved in reaching a conclusion on a sign that offers itself for interpretation to an interpreting system for details the reader is referred to 11 here we only mention some points relevant for our experimental case first it is important to remark that the kifdiagram gives an analytical reconstruction of interpretation processes in a dependency structure it indicates what is involved and does not provide a mechanical bottom up procedure we suppose the inputoutput relation to be on a line orthogonal to the index position next we explicate the state and effect below the qualisign position and the goal of the process above the argument position finally we start to fill in the diagram like a sudoku see fig 3 right for an example of the first approximation explications of cynefin as a rule start in media res with the domain obvious or what is first for us in the order of knowledge kif in contradistinction starts with the first in the order of nature from a cosmic evolutionary perspective ie the primordial soup 3 semiotically the primordial soup is the confluence of all qualities regarded as aspects of signs present to the mind for a process of interpretation that ends with a response in actual practice habits take a shortcut to a response the semiotic analysis explicates what we assume to be involved in those habits of interpretation applying the semiotic notions to cynefin we get a reconstruction of interpretation processes in the most general terms at the event of an interaction the state of the agent and the effect are sorted out of the primordial soup if both fail to be abstracted we are in a chaotic state in which the only course for action is to act sense and respond without any guarantee if only the state succeeds we are in a complex situation since there is no best practice that fits the token we are confronted with we must probe and sense to familiarize with the effect before an adequate response is possible if the effect can be abstracted into a type but the novelty does not fit in with the state the state fails in the complementation state and a suitable response is not found again we find ourselves in the complex domain with the risk of sliding into chaos getting an expert might prove this to be a complicated case enabling sense analyze and respond if both succeed and can be complemented without the emergence of disorder and an adequate response results we have a best practice and reside in the domain simple if both can be abstracted but disorder prevents an adequate response we are in the complicated domain we must sense and analyze before we respond this is where sensemaker fits in quantitative data are excellent means to generalize and categorize but weak in finding the dynamics in individual cases qualitative data like narratives and suggestions derived from stakeholders are good probes of individual cases sensemaker combines quantitative with qualitative data for analytical purposes since the reader will be familiar with quantitative data we concentrate on sensemakers dealing with narratives a typical question for sensemaker is to pose a subject ask people to tell their story and have them signify the stories with the help of triads see for an example fig 4 the left triad a triad is a triangular shape with at each corner a term the trick is to find three terms that are related and allow for graduation as in our example the question posed was what are your training needs the score indicates in what amount product knowledge sales skills and market knowledge are whished for in a training of course in itself the scores on triads can mean almost anything but since the scores are connected to the narratives in the database by making selections on the scores the accompanying narratives are retrieved providing the experiences behind the scores if whished together with gathered qualitative data thus offering handles for interpretation of the scores on the triads and by that supporting policy making and detecting weak signals use of the triads in kifdiagrams differs from their use together with cynefin used together with kif the triads must be distributed over the four domains question and terms on the corners must fit the domain and we ask to provide reasons for the score given the sign definition a sign is something that presents some object to an interpreting thought delivers the format for the terms to choose on the corners see 12 for the peircean background if disorder is an intrinsic feat of the research domain the cynefin approach is suited to find weak signals and patterns if like in an organization it is feasible and desirable to resolve disorder the kifdiagrams offer a uniform model for all processes and a means to order and distinguish them in dependency structures an experimental business case at some point nieuwenhuijsen a trainer in social and commercial skills and interim manager was asked by a company vending highly technical tools to improve the sales of the sales representatives results deteriorating over time markets being lost with van breemen he decided that this was a good opportunity to probe the possibilities of the sensemaking approach for an assessment of the training needs the goal of this paper is to propose a diagrammatic method for the social layer not to analyze a case for that reason we will use case data only where it serves the exposition the actual order of development was first the left diagram of fig 3 next the trikons4 left in fig 4 the information we got from the sales representatives set us to diagram the remaining two figures for consultation of the mt next time we probably will try to follow the order suggested here we start with a diagram of the responsible root agent and define the process from the perspective of the goal pursued mt events sales results see fig 3 right ontologically dependent agents are embedded processes that reside in the index position a sale is an exchange of goods andor services in exchange for money the company has a technical department in which the tools sold are prepared for sale and adapted to the house style our focus is on the sales representatives we indicate both subprocesses as primordial soups with the agent tag below regarding each other the processes are parallel processes goal and effect are determined in relation to each other and must fall within the goal of the root process for feed back to the mt we added marketing and td the left diagram of fig 3 presents the sales process after the state effect and goal are abstracted from the primordial soup at the semantical level our interest goes to concepts and their relations that being covered by the ontology charts the social layer can be reserved for an interest in the social fabric ie the attitudes that codetermine the outcome of interactions the characteristics of the agents their set goals and the characteristics of interactions between agents in the sr customer sales process the domain simple is reserved for the effect the other domains pertain to the state5 in the mirror process customer sr acquiring production tools simple would be reserved for sr the reason being that the only thing we can do in any concrete interaction is trying to categorize the effect as good as possible which includes the possibility of a modification of the selfcategorization of the effect and adjust our state in the chaos domain we ask for attitudes that steers the interpretation process of the agent in a state in complex we ask for the characteristics that determine the relation of the state to the effect and in complicated we try to find out characteristics of the interactions with this general scheme ready we started to design the trikons see fig 4 left experience with interim management and training did help a lot besides the swot analysis that had been made the urgency behind the innovation process determined our question in the chaos domain we asked for the individual perceptions of the business attitude is it a sense of survival profit or growth that reigns the atmosphere in the complex domain we probed the desired kind of training as perceived by the sr product knowledge market knowledge or sales skills in simple we wanted to find out the customers needs in what degree do they need technical solutions product service combinations or best price and delivery conditions in complicated finally our interest went to the social organization of work do the sr work on their own in a hierarchical structure or networked in two days we interviewed all sr for an hour each van breemen asked the sr to score on the trikons after that nieuwenhuijsen had an unstructured in debt conversation about the reasons for the scores while van breemen acted as scribe in fig 4 only part of the scores is given analyzing the results of the conversation our conclusion is that we have a promising tool for the mt member responsible for guidance of sr personnel four types of issues surfaced first we found strict individual issues to be handled on a personal base one sr for instance felt very insecure but he proved to be very helpful for srs with technical questions they didnt get answered by the technical department out of lack of time and started calling him for advice eventually he went to td second on group level we found issues that ask for a meeting to straighten out the diversity of opinion as well on social as on business issues look for example at the diversity of opinions at the attitude question such issues ought to be policy driven third the responsible manager of the srs can use this method for progress interviews with personnel to check goals eg in a next interview concerning the trainings needs question what did you learn what is your current score on the trikon why fourth we found structural issues the srs fell apart in three groups on the question who is your responsible manager sometimes srs had to call their manager during price negotiation the bottom price differed giving rise to uneasiness since part of the wages consisted in a percentage of turn over this instigated us to design fig 3 conclusion in order to actually facilitate actionable insight into the human interplay among signbased world and digital technologies as part of processes of organizational transformation in and between organizations we have to facilitate horizontal alignment at the social layer level and we have to facilitate vertical alignment between the social and the semantic layer for the social layer alignment issues we propose our narrative sense making approach for the vertical alignment issues in our opinion the most promising way to proceed is to systematically work out the connections between our approach for the social layer and the ontology charts of the semantic layer the pragmatic layer in between consists in the interactions between all those involved in the transformation process

the social layer of stampers ladder addresses the problem of responsible agents interacting with each other it is the layer at which in organizations decisions are made and transformations negotiated the method we present supports this human interplay it combines principles of actualism ontology charts the knowledge in formation process model and the cynefin framework to gather and combine quantitative data with qualitative data expressing attitudes and perceptions in meaningful diagrammatic representations of business processes the analytic tool sensemaker can be used to support decision making

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open access nelson mandela bay district of the eastern cape an estimated 20 of adolescents discontinued their treatment regime in 20162017 7 a systematic review by millard et al found evidence that selfmanagement programmes for people living with hiv result in shortterm improvements in knowledge physical and psychosocial health and behaviour 8 targeted selfmanagement interventions informed by thorough needs assessments could improve healthrelated outcomes for plhiv 8 another systematic review found that selfmanagement interventions for young people that focused on improving adherence or dealing with the chronic condition are effective irrespective of the chronic condition involved 9 bernardin et al report in their scoping review of selfmanagement interventions for plhiv that selfmanagement interventions need to address a range of needs and should be tailored to a specific group and context 10 globally alhiv tend to have poor treatment outcomes compared to adults and viral suppression rates are concerning 11 a study that was done in clinics in gauteng and mpumalanga south africa found that alhiv and young adults aged between 15 and 24 years receiving art tended to be virologically unsuppressed have high loss to followup rates and have high virological failure rates compared to adults 12 there is therefore a need to support adolescents with selfmanagement only one south african study has specifically explored selfmanagement amongst alhiv this study was conducted amongst 13to 18yearold alhiv in cape town and identified several aspects of selfmanagement with which adolescents needed support the selfmanagement aspects identified were coping with disclosure and stigma participating in healthcare decisions and community activities communicating about sensitive issues such as missing a dose of art and sexual behaviours knowledge of their viral load and names of antiretroviral drugs and remembering to take treatment 13 higher levels of selfmanagement were associated with treatment adherence viral suppression and better healthrelated quality of life 14 little is known about selfmanagement amongst alhiv in the context of the eastern cape south africa therefore the selfmanagement needs of adolescents in the context of the eastern cape were explored to make recommendations that can be used in further research to develop a programme to support adolescents with selfmanagement theoretical framework the individual and family selfmanagement theory is a middlerange theory that describes selfmanagement in the socioecological context of the family and the individual considering the physical and social environment as well as the characteristics that is unique to the family members according to the ifsmt selfmanagement can be improved by facilitating knowledge and beliefs enhancing selfregulation skills and fostering social facilitation or selfmanagement resources 2 it is hypothesised that improvement in selfmanagement processes leads to healthy behaviours and subsequently better health outcomes 3 the ifsmt provides a conceptual basis for the development of selfmanagement interventions and was therefore used as an organising framework to identify the selfmanagement needs of adolescents there are other selfmanagement theories and frameworks such as the paediatric selfmanagement framework 1 and the self and family management framework 15 however the ifsmt was selected as it had been applied in the south african context to develop an instrument to measure adolescents hiv selfmanagement 16 aim the aim of the research was to explore the selfmanagement needs of alhiv in the nelson mandela bay area of the eastern cape in order to make recommendations that can be used in further research to develop a programme to support adolescents with selfmanagement the specific objectives were to explore adolescents knowledge and beliefs describe ecological context factors individual age gender perinatally behaviourally infected illnessrelated medicaɵon regimen ɵme on art comorbidiɵes environment health care access family environment health outcomes ↓viral load ↑cd4 ↑wellbeing selfmanagement processes knowledge and beliefs selfregulaɵon skills social facilitaɵon selfmanagement intervenɵons selfmanagement behaviours researchers position the researcher is the first author and is a professional nurse working in the primary healthcare services of a clinic in the nmbd the researcher has not worked at the two clinics where the study was conducted population and sampling the researcher conducted the research at two clinics the clinics are situated in the northern areas of the nmbd and fall under the subdistrict c area the clinics were selected based on the number of adolescents accessing art and accessibility to the researcher the focus of this study was on older adolescents in the age group of 1419 years older adolescents were chosen as opposed to younger adolescents because based on their cognitive developmental stage they are more capable of selfmanagement skills such as selfmonitoring planning goal setting and evaluation 5 it is also the age at which parents tend to transfer responsibility of care to the adolescent 17 at the time of the study 30 alhiv of this age group attended the one clinic and 35 alhiv attended the second clinic in order to keep alhivs personal details confidential participants were recruited by asking the healthcare workers rendering art services to refer potential participants inclusion criteria included the age group of 1419 years and awareness of their hiv status healthcare workers confirmed whether the adolescent was aware of their hiv status to avoid accidental disclosure the adolescents were recruited at the clinic appointments scheduled and contact details obtained purposive sampling was used to sample participants across different ages languages and genders twenty adolescents were approached two needed to be excluded because they were already 20 years old and for five participants parental consent could not be obtained or they did not return for interviews after several attempts to contact them the sample size was determined by the emerging themes in the interviews and data saturation thirteen interviews were conducted inclusive of the pilot interview data collection thirteen individual interviews were conducted by the researcher in a private place and at a time selected by the participants a semistructured interview guide was used interview questions started with building rapport for example tell me a bit about yourself this was followed by questions about their experiences at the clinics when they had learned about their hivpositive status and how they take care of themselves questions included for example tell me more about why you come to the clinic tell me more about your future plans and who supports you to take your treatment probing questions were asked interviews were recorded on an audiorecorder interviews were conducted in afrikaans or english the researcher is fluent in afrikaans and english some of the participants were isixhosaspeaking but preferred to communicate in english even though they were provided with the option of using an isixhosaspeaking interpreter the researcher conducted one pilot interview with an adolescent living with hiv to test the interview guide questions the data of the pilot interview were included in the main study the researcher received training in conducting qualitative interviews prior to commencing the pilot interview and received continuous feedback regarding her interview technique from the study supervisor who listened to the audio recordings data analysis interviews were transcribed verbatim and checked by the first author the six steps suggested by creswell were used to analyse the data 18 this included organising and preparing data by checking the transcripts and labelling them followed by reading the data and reflecting on the overall meaning both authors listened to the audio recordings and read the transcripts the transcripts were coded by the first author and the codes were checked by the second author by applying the eight steps described by tesch an iterative process occurred for each new transcript until a complete set of codes were developed both authors then rechecked the coding of the transcripts categories or subthemes were generated by grouping related codes and themes by grouping subthemes after reaching agreement on the themes and subthemes the results were presented in a narrative by illustrating how the various themes are interconnected and interpreted by considering the context and identifying the lessons learned trustworthiness to enhance credibility the principles of prolonged engagement reflexivity recording of information and member checking were applied the researcher has experience in providing services to alhiv and thus had prior knowledge of their experiences field notes were taken whilst conducting the interviews and a reflective diary was used to bracket the researchers personal feelings and experiences about the phenomenon as well as the data collection process although the researcher was a female and older than the adolescents she did not experience difficulty in interviewing the adolescents boys and girls equally verbalised their experiences however older participants aged 17 to 19 years were more open and answered the questions in detail whilst the younger participants aged 14 to 16 years had to be probed to answer questions member checking was performed through probing to ensure that the true meaning of the participants experiences was understood the researcher regularly spoke to the study supervisor and peers who are experts outside the study transferability was applied by providing thick descriptions of the participants and their context an audit trail was kept of the data analysis as well as all communication between the supervisor and researcher the supervisor checked the coding and themes ethical considerations ethical approval was obtained from the health research ethics at the university of stellenbosch reference number s1801004 permission was obtained from the eastern cape department of health reference number ec201803013 during the recruitment of participants gatekeepers such as caregivers were used to ensure that participants did not feel forced to participate informed consent forms were available in the home language of the potential participants adolescents under 18 years gave written informed assent and parental or guardian consent was obtained those who are 18 years and older provided their own consent no participant needed referral because of becoming distressed during the interviews and travel costs were reimbursed if incurred to ensure confidentiality no personal identifying information was recorded or transcribed results participant characteristics two participants were behaviourally infected with hiv and 11 participants were perinatally infected four participants were 14 years old two participants were 16 years old one participant was 17 years old two participants were 18 years old and four participants were 19 years old themes the themes and subthemes are presented in table 1 three main themes were identified that encompassed the selfmanagement processes as described in the ifsmt knowledge and beliefs knowledge and beliefs include views and ideas about ones illness the future and confidence to selfmanage 2 this study is concerned with what the participants knew and understood about hiv and sexual reproductive health as well as their feelings about living with hiv knowledge of human immunodeficiency virus and sexual reproductive health the participants lacked knowledge about hiv and sexual reproductive health this included knowledge of how they acquired hiv certain adolescents demonstrated an understanding of safe sexual practices such as how to protect their partner from acquiring hiv however some participants who were already sexually active mentioned that they were pressurised by their boyfriendsgirlfriends to have sex without condoms or found it challenging to negotiate condom use because of nondisclosure you must use a condom when you sleeping with a boy i feel uncomfortable around my boyfriend and he always ask why dont we do it without a condom because we are first lovers and i always have excuses sources of information several participants verbalised that they are scared or uncomfortable to talk to caregivers or guardians about hiv sex or matters regarding life they therefore accessed information about hiv by using the internet on their mobile phones or at home a few participants mentioned that they received information from a family member or a close friend and others mentioned getting information from the teachers or library at school i go to google mostly i used google most of the time but i also go to the library sometimes to study things that i found in google to study in depth i get information from the teachers at my school the adolescents preferred to obtain information in a way with which they were comfortable they were more comfortable searching for information on the internet than asking healthcare workers or caregivers reaction to living with human immunodeficiency virus the participants verbalised a range of reactions about living with hiv these ranged from negative to positive feelings or a combination of both some of the negative feelings such as anger and sadness related to how they acquired hiv or the way in which the diagnosis was disclosed to them for example if their diagnosis was not communicated openly and honestly i felt so hurt because i didnt know i felt very hateful at first positive feelings such as hope emanated from their acceptance of the illness one participant found hope in believing that scientists are still researching for an hiv cure other participants viewed their illness as something they have no agency to change i feel like i have it theres nothing i can do about it selfesteem selfesteem relates to the participants identity and concerns how the participants view themselves several participants were of the viewpoint that they can reach their potential in life despite living with hiv the secrecy of their illness contributed to their good selfesteem as it gave them confidence that people will not perceive them as being different i dont really look at myself as different i see myself as the same person i was 5 years back before i discovered selfregulation skills in this study we identified selfregulation skills and abilities such as decisions about disclosure managing stigma taking treatment managing emotions communicating and setting goals as key selfregulation skills decisions about disclosure one of the skills an adolescent needs is the ability to know to whom and when to disclose their hiv status ones hiv status was viewed as being a personal issue and handled with extreme caution it was apparent that the hiv status of the participants was not shared outside the family about first i was very cautious i was small when she told me and said i shouldnt tell anyone and so at that time all i felt was that i should not tell anyone because it is no ones business that is all i felt that i have to keep it secret its mine noone elses and i never felt the need to tell anyone the participants made decisions about disclosure in the context of relationships they wanted to confirm trust and their longterm intentions for the relationship before taking the steps to disclose i will hide it for a bit until i trust the person then i will tell him or her that i am hiv positive in other instances disclosure was unplanned but related to obtaining information resources and support from others such as teachers i asked teacher is there no one staying with you with hiv then she say no i ask about hiv and aids what it is about then she told me she asked who have hiv and i say me managing stigma one of the more difficult selfmanagement tasks is dealing or coping with stigma participants verbalised that stigma persists in communities yes they talk a lot especially about my boyfriend the one that gave me the virus people talk about him there were times when people used to ask me if i am not scared to be with him i felt very bad it will hurt if other people know they will joke about it the participants managed stigma differently some chose to ignore negative comments or interactions whilst others found comfort and security in the fact that their hivpositive status is confidential taking treatment taking art is an important part in managing the hiv infection treatment adherence leads to good health and control of the illness managing treatment included taking treatment daily and integrating it with other routines and activities i have a phone then i look at the phone what is the time when i see it is 12 oclock then i go fetch water and drink it to prevent accidental disclosure when taking treatment when the participants are with friends they derived ways of taking their treatment to preserve their secret this included taking treatment before going to their friends or excusing themselves from the group ya this one that was last year it was in grahamstown then there were lots of us i made sure they are not seeing me going to the toilet to drink them and come back managing emotions participants had to manage emotions emanating from the lived realities of disclosure hivrelated stigma and taking treatment daily emotional management varied from person to person avoidance and suppression of emotions were often used participants demonstrated resilience by viewing hiv as only one aspect of their lives thereby preventing negative emotions from taking over they found comfort in talking to open access family or friends or their religion when they experienced feelings of sadness and needed encouragement people used to think i am arrogant i never felt that people looking at me different because i was never that kid that sits in the corner feel sorry for themselves i dont allow myself to do that communication young people with a chronic illness must communicate with caregivers peers and healthcare workers communication between some participants family and guardians and healthcare workers was challenging because of various reasons such as the generational gap and emotional discomfort to speak about hiv and related matters setting goals setting goals is an important component of selfmanagement the participants verbalised several goals these were focused on obtaining an education pursuing a specific career and having families of their own after school i want to go to wits university to study social work the majority of these goals were longterm goals and several of the adolescents did not have a specific plan in place to attain these they also did not have specific goals related to their own health and wellbeing selfmanagement resources the resources that the participants used for social facilitation included health facilities healthcare workers and family and friends health facilities not adolescentfriendly the health facilities did not provide a conducive environment for the participants to attend because of long queues and the lack of dedicated adolescent services the participants expressed the need for a designated area for adolescents collecting treatment interrupted their school routine and led to lost school time when my mom is unavailable to come i come myself i just find that the queues are really annoying the lines are long cant they organise a place where we can get our treatment you lose a whole day from school then you have to make up the next day relationships with healthcare workers adolescents experiences of healthcare workers varied from experiencing them as supportive to reporting that they provide limited information and support adolescents did not know what to expect from their interaction with healthcare workers and did not think that it was important for healthcare workers to engage with them interactions were focused on obtaining blood samples giving blood results and dispensing treatment they just tell me about my viral load thats it that it is high support from family and friends having support and encouragement from friends and family allowed adolescents to continue taking their treatment even at times when they become discouraged my friend is my confidante we are a closeknit family that support each other through everything one of the key support roles of the family is reminding the adolescent to take treatment it appeared that if the participants received support from their family in taking their treatment they were more conscientious in doing so some family members come to the facilities to collect the treatment for the participants my granny reminds me to take the treatment and she come to the clinic to get the treatment discussion the study identified a range of selfmanagement needs in the domains of knowledge and beliefs selfregulation skills and selfmanagement resources knowledge and beliefs knowledge and beliefs influence behaviour specifically selfefficacy outcome expectancy and the integration of goals 2 some of the participants demonstrated limited hiv and sexual reproductive health knowledge even though they regularly access healthcare services this is similar to a study conducted in the united states amongst youths that found alhiv had limited understanding about their viral load and cd4 count 19 diseasespecific knowledge could assist adolescents to better monitor their illness the findings emphasise that alhiv need continuous counselling on hiv sexual matters family planning and treatment for sexually transmitted infections services 20 open access the internet was identified as a frequently used source of information the south african national youth health policy recommends the use of technology in communicating with adolescents 21 technology that particularly appeals to adolescents includes smartphones apps social and sexual networking services and games these technologies are appropriate in the context of hiv because of the focus on anonymity social support real time assessment and feedback 22 the participants in the present study generally experienced positive feelings about living with hiv and had a good selfesteem good selfesteem was related to the perception that one will not be viewed as being different as long as your hivpositive status is a secret one of the reasons for a good selfesteem despite having a highly stigmatised illness may be good social support through social support from others individuals can receive positive appraisal and manage negative feedback which assures a positive evaluation of the self 23 the findings of this study resonate with a study conducted in canada that found that adolescents saw themselves as being healthy human beings and that they had positive views of themselves and the future the authors attributed this to access to art few side effects or problems with medication and medical and social support from a young age 24 selfregulation in order to encourage alhiv to selfmanage their illness they have to be taught skills like selfmonitoring planning goalsetting and evaluation 5 in the present study selfregulation abilities included decisions about disclosure taking treatment managing stigma and emotions communication and setting goals human immunodeficiency virus disclosure was limited to the immediate family similar disclosure practices have been reported in zambia and south africa 2025 and may be because of anticipating hivrelated stigma learning how to manage hivrelated stigma is crucial as various forms of stigma in families communities and healthcare settings have been identified in our study and in other studies conducted amongst alhiv in africa 262728 integrating treatment into daily routines is an important selfregulation skill and participants were able to set reminders and developed strategies for taking their treatment when they were with friends to prevent accidental disclosure a study that was done in zambia reported that the youth often delayed taking their medication for several hours when playing with friends or did not use art when travelling away from home to prevent unintended disclosure like the present study the majority of adolescents had to be reminded by their families to take their treatment 25 managing emotions can be complex for an adolescent strategies to manage emotions ranged from avoidance to engaging the support of others specifically family members adolescents living with hiv are at greater risk of internalising symptoms if they experience hivrelated stigma and tend to use avoidance to manage negative emotions 26 in a study done in kampala it was found that adolescents found comfort in the knowledge that they were not the only persons living with hiv 29 in general the participants found it challenging to communicate with parents or guardians and especially grandparents about their feelings hiv and sex the poor communication between the participants and caregivers or parents also led to ineffective disclosure practices such as late disclosure adolescents appreciate open and truthful communication from parents and caregivers 30 long queues or not feeling comfortable enough to ask questions prevented communication with healthcare workers similarly in a study done in the united kingdom ireland uganda and the united states the majority of adolescents reported not feeling comfortable to ask healthcare workers questions and relied on fragmented information from the internet to make sense of their situations 31 the participants in the study had a positive outlook that included career and family goals however it was mostly the older participants who had thought of how they might go about achieving their goals programmes that assist adolescents with selfmanagement should include career planning 5 adolescents also need to set health goals and healthcare providers must engage the youth so they understand the current status of their illness 19 adolescents need to participate in their own care by for example drawing up action plans that focus on illness needs accessing resources dealing with symptoms and asking for support when needed 32 selfmanagement resources people are more likely to engage in recommended health behaviours if they experience social facilitation social facilitation includes social influence social support and collaboration between the individual family and healthcare providers 5 from the perspective of the participants the health facilities and services are not conducive to keeping appointments because of the lack of dedicated adolescent services long waiting times and clashes with school schedules in a study that was done in the eastern cape it was found that the waiting times and adolescents experiences at the clinic had an impact on retention in care 33 the participants experienced limited communication and support from healthcare workers a study that was done in the eastern cape of south africa found that if adolescents perceived healthcare providers as being kind and having time for them the odds of retaining them in care increased 25 times 33 several participants had support from their family family members supported adolescents by reminding them to take open access their treatment or went to the clinic to collect treatment on their behalf living with an adult who provides daily support for hiv treatment and who is also living with hiv helped to normalise the lives of alhiv in canada 24 in a study that was done in zambia it was found that in addition to verbal reminders many participants families provided them with emotional support 20 being accompanied to the clinic was associated with retention in care in a study in the eastern cape 33 recommendations recommendations for selfmanagement were identified based on the study findings and according to the selfmanagement components limitations a limitation was that some of the adolescents who needed the consent of their guardians or parents did not return for the interview with the consent forms or did not return at all and consequently could not participate there were adolescents who did not know their hiv status and therefore had to be excluded from participating and were not referred to the researcher although some of the participants were isixhosaspeaking they indicated that they were comfortable with communicating in english this could have led to possible bias or lack of indepth understanding on the part of the researcher however the researcher continued with interviews until data saturation was reached conclusion a range of selfmanagement needs of alhiv were identified in the domains of knowledge and beliefs selfregulation skills and selfmanagement resources to address the selfmanagement needs selfmanagement programmes for adolescents should be comprehensive and focus on strategies to enhance hiv and sexual reproductive health knowledge acceptance of the disease and positive selfesteem information should preferably be communicated via informationcommunicationstechnology platforms it is important to implement strategies focused on improving selfregulation skills as well as providing adolescentfriendly services moreover it is necessary to train healthcare providers to work with adolescents and provide selfmanagement support whilst encouraging family and peer involvement data availability data sharing is not applicable to this article competing interests the authors have declared that no competing interest exists authors contribution la wrote the proposal conducted the study as part of her master of nursing degree and reviewed the article providing substantial feedback tc supervised the study developed the initial draft of the article and involved in further revision of the article drafts disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors

human immunodeficiency virus hiv is a chronic condition and there is an increased focus on supporting patients with selfmanagement selfmanagement can be described as the interaction of health behaviours and related processes that patients and families engage in to take care of a chronic condition 1 to selfmanage means to handle direct and control ones chronic illness it includes components such as knowledge and beliefs selfregulation and social facilitation or the utilisation of resources 2 adolescents living with hiv alhiv need the support of the whole family to selfmanage their chronic illness when the individuals and their families acquire selfmanagement skills they become responsible for the management of their chronic condition are able to control the illness and acquire healthy behaviours by purposefully engaging in the performance of learned behaviour 23 an increased number of children living with the hiv are progressing to adolescence and beyond because of increased access to antiretroviral treatment art 4 the world health organization who defines adolescents as individuals in the 1019 years age group early adolescents are between 10 and 14 years old and middle to late adolescents are 1519 years old 5 globally 17 million adolescents aged between 10 and 19 years were living with hiv in 2019 6 at the time of the study 455 adolescents in the age group of 1419 years were on art in the background human immunodeficiency virus hiv is a chronic illness and adolescents living with hiv alhiv need the support of the whole family to selfmanage handle direct and control their chronic illness little is known about selfmanagement amongst alhiv in the context of the eastern cape south africa aim this study explored the selfmanagement needs of alhiv in the nelson mandela bay area of the eastern cape to make recommendations that can be used in further research to develop a programme to support adolescents with selfmanagementthe study was conducted at two primary healthcare clinics in the nelson mandela bay area of the eastern cape methods a qualitative descriptive design was applied thirteen adolescents between the age of 14 and 19 years were interviewed the data were collected through individual interviews data analysis was done using the six steps described by creswell results adolescents living with hiv have limited knowledge and understanding about hiv and sexual reproductive health some alhiv lack selfregulation skills related to decisions about disclosure managing stigma and emotions taking treatment effective communication and setting goals human immunodeficiency virus services were not adolescentfriendly with long queues and no dedicated services for adolescents family and friends were a key selfmanagement resource for alhivadolescents living with hiv have several selfmanagement needs in the domains of knowledge and beliefs selfregulation skills and abilities and selfmanagement resources healthcare workers should support adolescents and their caregivers to acquire selfmanagement skills as this may lead to better treatment and health outcomes

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introduction 1csr in sport settings commercial entities have performed social contribution activities in the context of corporate social responsibility since the 1960s 1 regardless of sports research on the effects of social contribution activities of commercial entities on consumers attitudes and behaviours has been conducted in business fields positive relationships have also been established between social contribution activities and positive attitude toward companies for example ricks 2 documented that a proactive condition of corporate philanthropy has an overall positive effect on consumer perceptions of corporate associations in the sports field sutton et al 3 claimed that professional sports teams and their players played a significant role in building fan identification through communitybased activities in addition babiak and wolfe 4 suggested in the case of the national football league in the united states that csr in sports might help in building the image of a professional sports league while there were numerous documentations between csr and consumers attitudes and behaviours it has been claimed that there were less significant relationships between csr and consumers attitudes and behaviours sen and bhattacharya 5 for instance noted that the efficacy of csr depends on both the csr issues a company that chooses to focus on and individualspecific factors walzel et al 6 reviewed 69 articles published from 2008 to 2017 and written in english of csr in professional team sports organizations and documented several findings first of all soccer was the most investigated single sports context for csr research in ptsos secondly 55 studies adopted the instrumental citizenship perspective that conceptualizes csr in functional terms as a mean to achieve organizational goals thirdly 53 articles predominately came from north american and european countries these findings indicate that it needs to address more asian cases of csr and ptsos with regard to predominant sport such as soccer positively csr in football settings in japan as mentioned above taking asia being a rising sporting continent into consideration it would be important to demonstrate relationship between csr and ptsos as dolles and söderman 7 mentioned the jleague is a professional football league in japan with a history of 30 years which was established with 10 clubs in 1991 and started with an opening match in 1993 currently 60 professional football clubs based in 41 prefectures in japan are members of the jleague as of 2023 eighteen clubs belong to j1 22 clubs belong to j2 and 20 clubs belong to j3 thus the jleague has grown rapidly in the past 30 years before the jleague began the football league in japan was an amateur league constructed with company teams therefore compared to baseball which has a long history in japan football held a minor position in japanese sports scenes following the commencement of the jleague each of its clubs makes efforts to gain widespread acceptance among the communitys residents in fact the league contract obligates each club to make a social contribution to their communities as previously noted studies have documented that the social activities of professional sports clubs have intangible and material benefits for the club and community research on the social contribution of professional sports clubs however has been limited since the jleague commencement matsumura and tohi 8 conducted one of the few studies on the social contribution of professional sports clubs in japan which examined the effects of community activities in a professional sports club among visiting schools attitudes towards teams and athletes there was a significant relationship between community activities and team loyalty and no significant relationship between community activities and attendance behaviour at the stadium during a short period moreover they concluded that grassroots activities such as school visits by professional sports clubs were important to enhance team loyalty among participants especially for children this viewpoint was emphasised as vital for the initial development of loyalty by iwasaki and havitz 9 and james 10 iwasaki and havitz 9 offered a conceptual model to explain the relationships among involvement psychological commitment and loyalty in addition to the conceptual model of iwasaki and havitz james 10 examined when children first begin to demonstrate team loyalty based on piagets 11 theory of cognitive development he interviewed and tested children aged 56 and 89 and concluded that children demonstrated psychological and behavioural loyalty to their favourite team although it depended on their level of cognitive development according to piagets theory 11 cognitive development is divided into four phases sensorimotor development preoperational thought concrete operations and formal operations james tested children between ages five and nine they were positioned in preoperational thought and concrete operations based on piagets theory however james added a new category called the transitional phase between preoperational thought and concrete operations for piagets cognitive development framework children positioned in concrete thought demonstrated complete loyalty to their favourite team but children in preoperational thought and transitional phase were not able to demonstrate loyalty to their favourite team this research result indicated that the age of subjects for research including children should be considered soccer otodoketai jef united ichihara chiba which belongs to the jleague has continued its unique activity named soccer otodoketai as one of the social contribution activities for their community soccer otodoketai activity was initially proposed by the general manager in 2002 and was intended for infants kindergartners and pupils this activity involved visiting the football coaching of kindergartens and primary schools the general manager stated the methodological difference between japan and europe in football coaching in his book 12 players do not try to take a risk and do not try to take responsibility this may be because there is a cause of coaching that confined the thoughts and actions of individuals he pointed out the poor independence of japanese football players as a matter of sport education from early childhood and claimed that soccer otodoketai activity attempted to change the coaching trend in japanese football this activity has been distinct from a business strategy to attract customers on a shortterm basis such as the distribution of free tickets and has also been clearly distinct from the player development system in terms of talent discovery the staffs of soccer otodoketai expected children to make friends play fair as well as exhibit independence through this activity this activity has been characterised as human education a general football coaching in japan usually focuses on progress of skills such as ways of ball kicking and controlling through program on the other hand soccer otodoketai method focuses on ways of communication as fexpressing childrens their independence through football practice for example one soccer otodoketai staff mentioned in the interview survey that we recognise teachers are overwhelmed with quite a few things what they must do in the current school settings of elementary education therefore they do not have time enough to wait for students to find their solutions in a lot of situations we try to supplement a part of these situations through our program of course we are careful of our program not to be selfrighteous 13 it seems that soccer otodoketai method is the antithesis of the coaching that focuses on skills and tactics according to nakayama 13 the expense of this activity has been recorded in the annual budget of the board of education since 2004 over twenty years have passed since the commencement of soccer otodoketai it has continued as of 2023 although soccer otodoketai was initially recognised as passive csr and an obligation in the clubs jleague contract it was gradually accepted as strategic csr that is it seems that the recognition of soccer otodoketai in the club changed from passive to strategic csr therefore it is important to examine the impact of the social contribution activities such as soccer otodoketai on participants including children purpose the purpose of this study is to clarify the influence of the social contribution of a professional sports club on team loyalty more specifically of soccer otodoketai by jef united ichihara chiba this study adopts one of windsors four conceptual approaches for csrthe instrumental citizenship perspective that conceptualizes csr in functional terms as a mean to achieve organizational goals 14 research questions according to sutton et al 3 and babiak and wolfe 4 social contribution activities in sports have a positive impact on the organisations that carry them out in addition matsumura and tohi 8 reported that a professional sports clubs social activities had a significant positive relationship with team loyalty but not a significant positive relationship with attendance behaviour at the stadium over a short period based on the above arguments it poses that the following four research questions rq1 the experience of attending social contribution activities of a professional sports club in the past affects participants team loyalty rq2 the experience of attending social contribution activities of a professional sports club in the past affects participants stadium attendance for watching games rq3 the experience of attending social contribution activities of a professional sports club in the past affects the watching intentions of participants in the stadium rq4 there is a relationship between team loyalty and watching intentions in games at home stadiums among those who previously attended social contribution activities of a professional sports club materials and methods subjects data were obtained from 634 samples of elementary school and junior high school students who had prior experience of participating in a soccer otodoketai class before collecting data researcher confirmed informed consent for survey participants through the board of education at that city conducted survey a questionnaire survey was conducted from 13 to 22 december 2011 measurement items the measurement items comprised 10 items in total measurement items were 1 participation experiences in soccer otodoketai class 2 team loyalty 3 experience of watching games at home stadiums 4 watching intentions at home stadium of jef united ichihara chiba and 5 age and gender wakefield and sloan 15 defined team loyalty as an allegiance or devotion to a particular team and developed a team loyalty scale composed of 3 items the reliability coefficient of that scale they had developed was 91 that scale estimated the attitudinal aspect of individuals to a particular team to assess loyalty or identification to a particular team there are scale constructed aspects both attitudinal and behavioural 16 james 10 however documented that it was difficult to evaluate behavioural aspect of loyalty to their favourite team of children therefore i focused on measuring attitudinal aspect of team loyalty i organised three items to measure team loyalty based on wakefield and sloan 15 to measure respondents attitude to the team these were 1 i am a devoted fan of jef united ichihara chiba 2 i want to inform others that i am a fan of jef united ichihara chiba and 3 i cheer for jef united regardless of the teams success or failure one item under watching intentions at home stadium was would you like to watch the games of jef united ichihara chiba at home stadium team loyalty and watching intentions at home stadium were measured on a fivepoint scale from completely disagree to completely agree analytical procedure as a first step of analysis the independent variable was divided into groups by the participation experience in a soccer otodoketai class the dependent variables were team loyalty number of games watched at home stadium and watching intentions for home games at home stadium next a significant difference test using analysis of variance was performed anova is a statistical method that determines whether there is a statistically significant difference between the mean values of multiple data groups obtained in a study or whether it is an error in this study a oneway anova was used to examine statistical significance between the independent variable and dependent variables team loyalty numbers of watching games and watching intentions finally the correlation coefficient was calculated between the sum score of team loyalty and watching intentions of games at home stadiums results sample characteristics there were 326 males and 308 females the mean age was 132 and the age range was eleven to fifteen there were 478 yes responses for otodoketai class experience 40 no responses and 116 do not remember responses the mean attendance for the otodoketai activity was 433 there were 118 yes responses for experience of watching games at the home stadium of jef united ichihara chiba the mean number of games watched at home stadium was 068 among a total sample in addition among those who responded yes to the experience of watching games at the home stadium of jef united ichihara chiba the mean number was 348 the mean number of watching intentions at home stadium was 279 team loyalty mean and standard deviation for each team loyalty item among total sample was 1 i am a devoted fan of jef united ichihara chiba 175 2 i want to inform others that i am a fan of jef united ichihara chiba 162 3 i cheer for jef united regardless of the success or failure of the team 285 the reliability of scale was 737 table 1 shows the result of a oneway anova for team loyalty by participation experiences in soccer otodoketai classes it shows significant differences in three items measuring team loyalty among three groups and in the case of sum score as well as a result of multiple comparisons in items 1 3 and sum score those who responded yes showed high scores and appeared highly loyal to the team experiences of watching games at home stadium table 2 shows the results of a oneway anova for experiences of watching games at the home stadium by participation experience in soccer otodoketai those who responded yes for the question showed high scores while the number of games they had watched at home stadium was under 1 time as a result of multiple comparisons those who responded yes showed significantly high numbers scores compared with the no and do not remember groups watching intentions at home stadium table 3 shows the results of a oneway anova for watching intentions at home stadium by participation experience in soccer otodoketai as a result of multiple comparisons those who responded yes to the question of participation for the soccer otodoketai class indicated a significantly high value compared with the no and do not remember groups relationship between team loyalty and watching intentions of games the correlation coefficient was calculated between the sum score of team loyalty and watching intentions of games at home stadiums the coefficient was 619 showing a significant positive relationship between them discussion based on piagets cognitive theory james 10 tested the relationship between cognitive development and demonstrating loyalty to a favourite sport team among children and discovered that children positioned in concrete thought demonstrated complete loyalty to their favourite team whereas children positioned in preoperational thought and the transitional phase were unable to do so jamess findings made us sensitive to research including children in this study we collected data from adolescents aged 1115 years who did not refrain from demonstrating loyalty to their favourite things as table 1 indicates team loyalty scores of participants for social contribution activities showed higher values than those who did not participate in and did not remember some participants were questioned three years after attending otodoketai classes these findings would lead teams to engage in grassroots activities such as soccer otodoketai these activities have the potential to increase participant team loyalty which in turn has the potential to influence stadium viewing intentions because those who answered yes to the question about otodoketai experiences had significantly higher scores for watching intentions at the home stadium at jef united ichihara chiba as shown in table 3 brink et al 17 found that strategic causerelated marketing significantly enhanced brand loyalty for consumers additionally the relationship between team loyalty and watching intention of games showed a high correlation coefficient this result indicates that activities that enhance someones team loyalty could drive their intention to watch games at home stadiums on the other hand table 2 shows a lower majority of individuals watching games at home stadiums despite the fact that those who answered yes to the question about soccer otodoketai class experience watched a significantly higher number of games at home stadiums it seems to be difficult for children to manage their money when they visit stadiums to watch games however this point is contingent upon their guardian purchasing tickets however as sociologists and consumer behaviour researchers refer to socalled reverse socialisation hyatt et al 18 reported the possibility that children could be agents for their parents sports fandom the social contribution activities of professional sports clubs at schools might encourage team loyalty in child participants therefore all of the research questions i listed were accepted although this research applied a crosssectional research design these results indicated a close relationship between the social contribution activities of a professional sports club and team loyalty in the case of asian ptsos hence this relationship should be tested using a longitudinal research design conclusions the results of this study quantitatively clarified the relationship between the social contribution of a professional sports club and team loyalty those who remembered their past activities with the staff of a professional sports club could become loyal fans in their community these results might provide evidence for grassroots activities implemented by professional sports clubs future research based on longitudinal research design is required to comprehend the relationship between social contribution activities of professional sports clubs and team loyalty conflicts of interest there is no conflict to declare

research on the effects of social contribution activities of commercial entities on consumers attitudes and behaviours has been conducted in business fields including sport fields while there were numerous documentations between csr and consumers attitudes and behaviours some researches have claimed that there were less significant relationships between csr and consumers attitudes and behaviours this study aims to clarify the influence of social contribution activities of a professional sports club on team loyalty among child participants this study focused on soccer otodoketai the original coaching method used for jef united ichihara chiba which belongs to the j league this activity which was intended for infants kindergartners and pupils was characterised as an educational activity that accompanied football coaching a questionnaire survey was conducted for elementary school and junior high school students who have previously participated in the soccer otodoketai class a total of 789 questionnaires were distributed out of 636 806 responses 634 804 were valid four research questions derived from the results of previous studies were examined as a result of a oneway analysis of variance participants who remembered participating in the soccer otodoketai class scored significantly higher in all the team loyalty items related to the experience of watching games and intentions at home stadiums than those who did not furthermore the sum score of team loyalty showed a significant correlation coefficient with watching intentions at home stadiums the results of this study quantitatively clarified the relationship between the social contribution of a professional sports club and the formation of team loyalty among children those who remembered their past activities with the staff of a professional sports club could become loyal fans in their community these results might provide evidence for grassroots activities implemented by professional sports clubs

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introduction the new global definition of social work 2014 places greater emphasis on the academic and scientific underpinning of the profession the need for collective solutions and the recognition of macro and structural influences on societal functioning whilst understanding that social work is contextually driven the global importance of the profession and its definition has been underpinned by the global agenda and by the recently revised global definition we propose that the revised definition offers a renewed transition towards a profession that seeks to reengage the social in social work although recognising the complexity vastness and contentiousness of this endeavour we seek to highlight the need for a more critical and participatory discourse on the implications of the revised global definition at the local and international level we believe that this includes three critical areas of transition micro versus macro frameworks individual versus collective approaches and the importance of academic scientific and indigenous knowledge the nature and context of indigenous knowledge has been the subject of substantial debate within the profession however although these debates are critical they fall outside the remit of this article therefore whilst recognising the need to further evaluate and critically discuss indigenous knowledge development the impact of linguistic imperialism and the existence of western dominance within social work theory the authors of this article will focus on an analysis of the new global definition through primarily western and englishbased theory and ontological frameworks thus certain arguments in this article may be more directly relevant to the english speaking and european social work context and the need to develop this analysis further through contextualised and indigenous frameworks is both recognised and strongly encouraged that being said we do believe that this analysis holds significance for international social work knowledge development furthermore recognising that the social work profession faces new challenges in the 21st century the authors will reflect upon the current global economic paradigm of neoliberalism and its implications and challenges for the profession and its future within the context of the revised global definition new global challenges in human conditions propel us into a search for new global responses and thus the significance of these recognised shifts in the global definition is understood alongside critical reflection and a reinvigorated profession the new global definition of social work the previous international social work definition highlighted the professions commitment to social justice and human rights however this definition was subject to considerable professional criticism social work professionals regionally took positions against the impact of neoliberalism the perceived western bias of the definition its emphasis on individualism its lack of recognition of collectivism social stability and social cohesion its omission of a strong theoretical underpinning and finally its failure to recognise the importance of indigenous knowledge along with redress for historical cultural and political western scientific colonialism and hegemony in light of these criticisms a joint ifsw and international schools of social work group undertook a fresh review of the international definition with representation by over 110 country members which was a significant shift in comparison to the 63country member participation of the 2000 definition thus whilst some regions may still feel that the new definition needs to be further developed we acknowledge the significant change from the previous position demonstrating some shift in geopolitical and economic power away from traditional western dominance and the start of a debate for the future the new global definition of social work reads as follows social work is a practicebased profession and an academic discipline that promotes social change and development social cohesion and the empowerment and liberation of people principles of social justice human rights collective responsibility and respect for diversities are central to social work underpinned by theories of social work social sciences humanities and indigenous knowledge social work engages people and structures to address life challenges and enhance wellbeing ornellas et al 3 the primary areas where a transition can be recognised include the strengthening of theory and knowledge the movement from individual to collective approaches and in the increased emphasis on macro concepts and structural sources of inequality strengthening of theory and knowledge the new definition more strongly promotes the theoretical base of the social work profession from being a profession which utilises theories of human behaviour and social systems to one that is an academic discipline underpinned by theories of social work social sciences humanities and indigenous knowledge therefore whilst the theoretical underpinning of the social work profession was acknowledged in the previous definition it is evident that the significance scientific origin and the scope of theory is now more strongly advocated with a transition to a more theory based academic and scientific framework in the detailed ifsw commentary on the new definition the social work profession is recognised as drawing on a wide array of scientific theories which include but are not limited to community development social pedagogy administration anthropology ecology economics education management nursing psychiatry psychology public health and sociology previously only theories of human development behaviour and social systems were emphasised predominantly as a means of developing an understanding of the personinenvironment perspective the new definition now advocates for both the recognition and development of a social work specific and scientific knowledge that goes beyond human behaviour approaches what is more the revised definition acknowledges that social work is informed not only by specific practice environments and western theories but also by indigenous knowledge ideas and frameworks there is thus a dual recognition for the profession to engage more broadly within global discourse while increasingly acknowledging and integrating the values knowledge and contributions of indigenous peoples in each region country or area moving from the individual towards the collective the previous 2010 international definition remained predominantly focused on the individual advocating for service delivery that worked from the inside outward empowering individuals to function within their environments and recognising the social worker as a change agent that worked closely with individuals to enable them to achieve wellbeing this focus on individualism was critiqued by many as being in direct opposition to social works commitment to social and economic justice and the expansion of peoples capacity to address their own needs rankopo and oseihwedie highlight that north american and european social organisations emphasise individualism and competition whilst other societies promote collectivism communism and cooperation hopps and lowe identified the master narrative of the previous definition as being one that emphasised the more likely attainment of social work intervention goals by supporting individuals to address personal challenges enabling them to move out of poverty as a result of their improved moral physical capacities whilst the new definition continues to recognise the significance of the individual and keeps some emphasis on the personinenvironment perspective within intervention there is a notable transition towards a more collective stance over that of the previous purely individualistic focus this is particularly evident in the utilisation of the term collective responsibility which did not appear in the previous definition hence a shift which recognises capacity of people to be both affected by and influential over the range of influencing aspects within their environment meeting human needs and developing human potential to one where it is recognised that advocating and upholding human rights and social justice is the motivation and justification for social work and that individual human rights can only be achieved and realised through collective responsibility thus an emphasis upon an increasingly collective social work approach is evident where individual problems are seen as being solved through cooperative solutions and collective action it is imperative to reflect upon the implications of such a shift the use of more collective approaches will require the social work professional to be more critically engaged in policy development implementation and evaluation as well as to engage authoritatively and critically with the media national and international politicians officials policy makers citizens and users of services this will require a wider skills development as well as more specific training in social policy development service evaluation social justice critical reflection and professional selfconfidence micro versus macro perspectives of inequality finally in the new definition there is a greater call to engage with structural sources of oppression with a shift in emphasis from a micro to a more macro approach implicating a movement towards a collective vision in order to address macro and structural changes that impact upon a greater collection of people and thus demonstrate a collective nature with an understanding that whatever happens to the individual happens to the whole group and what happens to the whole group happens to the individual this shift in emphasis can be seen through the advocacy of the social work role in the new definition as being one that participates in and influences macro aspects of society and functioning such as social cohesion social development the empowerment and liberation of people and the call to engage with people and structures although social change was recognised as a social work role in the previous definition this was in a more microfocused manner emphasising problemsolving human relationships human behaviour social systems the engagement with people at the points where people interact with their environments the shift in the new definition to a greater macro focus can be seen in the change of the social work role from what was a mission of enabling all individuals to develop their full potential enrich their lives and prevent dysfunction focusing on aspects of problem solving to a significant need within the social work profession for the development of a critical consciousness this is achieved through the reflection on and understanding of the sources of such structural barriers this transition reflects the critique offered by reisch and jani and webb where they argue that an emphasis on the effectiveness of interventions rather than addressing the structural roots of social problems indicate a subtle assumption that social problems are conditions to be managed rather than eliminated not only is the need for greater consideration of how macro structures impact on society advocated but the need for social workers to recognise their role in the removal andor rethinking of such structural challenges is highlighted ifsw defines this mandate of social development as strategies that transcend the micromacro divide aimed at sustainable development this is viewed as being done through intersectorial and interprofessional collaboration with the primary priority of such interventions being sociostructural and economic development which does not subscribe to conventional wisdom that economic growth is a prerequisite for social development these core shifts as discussed above indicate both a renewed recognition and a transition in how the role of the social worker within society is to be understood and enacted the significance and implications of the changes in the new definition and the direction of this suggested professional transition can only be properly understood when measured against existing social work ontological frameworks that being said the existence of western bias within the professions ontology and the need for further debate and integration of indigenous frameworks into this ontology is recognised ontological frameworks social work practice is based on theorising and it remains a fallacy to refer to theoryless practice theory and practice are considered to be two sides of the same coin it is vital therefore to reflect upon the new global definition against an ontological backdrop towards an understanding of the implications of the definitional changes ontological social work perspectives are essential particularly when discussing broad terms such as collectivism macro versus micro and individualism these values such as collectivism whilst mainstream in nonwestern societies may be considered less mainstream in western societies who value individualism four key predominant western ontological frameworks have been identified within international social work theory as been significant in structuring social work and its role within society although these frameworks predate the indigenisation debates to some degree they reflect the consideration of the deliberation of individualism versus collectivism within the profession these four frameworks can be found within the works of dominelli garrett howe and payne it is important to recognise here once again the dominance of westernbased knowledge and the need for increased indigenous contributions within social work ontological frameworks as is indicated within the new global definition and the continued debate on indigenisation as much as these perspectives are identified as being key international theoretical frameworks for the social work profession as reflected in the sage handbook of international social work their use is not uncontroversial within the indigenous knowledge debate questions have been raised regarding access to the discourse on international social work being dependent on englishbased literature this raises concerns regarding the capacity to achieve mutual exchange and dialogue within social work practice research and knowledge development gray and fook identify the importance of finding and developing commonalities to fight a common cause yet it needs to be recognised that such commonalities are impacted by linguistic imperialism and western dominance however for the purpose of this article these four western ontological understandings will be utilised to provide context meaning and theoretical support for the transitions within the new definition the authors highlight that these understandings and debates need to be contextualised to locality social historical cultural and political context the key underpinnings of the four ontologies are presented in table 1 howes influential categorisation divides social work into four paradigms payne covers similar territory in his three views of social work dominelli also divides the role and purpose of social work into three types these roughly correspond with paynes categories garrett believes that there are four primary perspectives for the social work profession that serve to shape and determine professional understanding of how society is organised or should be organised and the nature of personal and social change these too reflect similarities to the categorisations of dominelli howe and payne hybridisation of ontological social work frameworks based on the clustered expositions as presented in table 1 four distinct ontological social work frameworks can be consolidated for the purposes of an analysis as a hybridisation of frameworks these hybrid frameworks are classified as the interpretivisttherapeutic framework the individualreformist framework the neoliberalmanagerialist framework and the socialistcollectivist framework adoption of these hybrid frameworks is underpinned by an understanding of how social problems originate how best to achieve aims such as social justice and wellbeing and the nature of the social work role in society thus such ontological understandings will directly impact upon how the global social work journal of social work 0 adapted from dominelli garrett howe and payne definition is understood and enacted these four hybrid ontological social work frameworks will be discussed in greater detail below the interpretivisttherapeutic framework the interpretivisttherapeutic framework aligns with of the views of the interpretivist paradigm the reflexivetherapeutic view the therapeutic helping approach and the therapeutic perspective it is based on the principles of psychoanalysis relationshipbased work and emotional intelligence this framework focuses on individual change and psychological functioning as the basis for intervention with a strong emphasis on the individual and their capacity to cope with personal struggles and suffering independent of the social and economic circumstances in which they are embedded the aims of these interactions are for service users to gain a better understanding of their world and become empowered to overcome or rise above their suffering and situation here the social workers are interpretivists or seekers after meaning and operate upon the assumption that orderly relationships arise through interpersonal negotiations the individualreformist framework the individualistreformist framework represents the functionalist paradigm the maintenance approach and the individualistreformist viewperspective according to garrett this perspective does not seek major social change but gradual improvement in conditions it is derived from fabianism influenced by antioppressive practice as well as some principles of the therapeutic perspective within this framework we find the functionalist social worker also referred to as fixers who emphasise social order within a methodological framework of the natural sciences here the focus is on meeting individual needs and improving services while maintaining a good fit between the individual and the environment this framework does not seek social change but sees social work as contributing towards the maintenance of the dominant social system this is recognised as an approach which reinforces a need for compliance to the dominant status quo according to edmondson the emphasis on the word maintenance is important as it critiques social work as ultimately accepting both the basic structure of society and also of social work as a compliant profession which accepts imposed limits to its role and function neoliberalmanagerialist framework the neoliberalmanagerialist framework represents the views of garrett in his managerialisttechnocratic perspective as well as elements of howes radical humanist paradigm and dominellis maintenance approach within this framework social work is viewed as being a business that aims to provide an excellent and quality range of services to a diverse range of customers social work rendered within this framework can sometimes charge for intervention services and there is a lowered level of professional authority with a blurring of the distinctions between those less trained such as auxiliary workers the focus is on performance measurement individual empowerment and the implementation of managerialist techniques this can be seen to tie in with howes radical humanists paradigm where these raisers of consciousness believe that individuals create their places in an unequal and conflictual world implementing consciousness raising and the gaining of personal control as key methods of intervention ultimately the neoliberalmanagerialist framework sees the individual as being responsible for the fostering and maintenance of their own wellbeing undercurrents of dominellis maintenance approach can be found in terms of the encouragement of social work professionals to maintain the status quo as established by the market system this is often referred to as the social work business and is associated with the introduction of mcdonaldization where tasks are broken down into smaller discrete tasks so that the exact resources required for their delivery can be calculated for production with workers following clear management guidelines and instructions governed by manuals policies and procedures socialistcollectivist framework the socialistcollective framework is based upon the categorisations of howes radical structuralist paradigm paynes and garretts socialistcollectivist viewperspective and dominellis emancipatory approach within this framework the core belief is that seeking personal and social fulfilment is impossible given the constraints that capitalism imposes garrett views the socialistcollectivist understanding as being in complete conflict with the therapeutic and psychodynamic models as it recognises and advocates for the collective the social worker therefore recognises that disadvantaged and oppressed people can gain empowerment only through social transformation according to this view the socialistcollectivist aims to promote greater social equality through individual and collective strategies models of radical social work critical social work resistance social work and developmental social work often fall within this category this is seen as being representative of howes radical structuralist paradigm believing that society has an objective material reality which is then characterised by competing interests and control therefore in this regard the aim of social work is to structurally redistribute wealth and power through mobilising collective action debates on ontological social work frameworks the hybrid ontological frameworks whilst not wholly discrete do have different beliefs in the origins of social problems and the role of the social worker in empowering change while the interpretivisttherapeutic worker focuses on the individual the individualreformist allows for some assessment of environmental impact albeit this may be limited the individual remains the centre of intervention the neoliberalmanagerialist implements social work intervention from a distance it does not exclude environmental impact however it also does not implement relationbased work but rather views individuals as being the primary actors in their narratives and as holding full responsibility for their wellbeing finally the socialistcollectivist worker views macro structural sources of oppression as being key to the development of wellbeing and although the individual is still a significant player in intervention the focus is from the outward in challenging the sources of social problems payne and askeland argue that social work in the west uses all three of his categorised views and social work in any one setting may use a mixture depending on organisational and cultural expectations and societal expectations in contrast garrett proposes that differing perspectives are conflicting in nature and thus cannot be implemented simultaneously but rather are in direct contradiction to one another mary argues that the vast majority of our primarily westerndominated work uses the first two approaches interpretivisttherapeutic and individualreformist neither of which is very relevant to a new transformational vision of social welfare as global collective wellbeing however resistance to the domination of these approaches emerged in the late 1960s and early 1970s through the development of radical social work which challenged the notion that casework was being used to target and pathologise the individual as the source and root of social problems ignoring the effects of structural inequality in analysing the new global social work definition and identifying the ontological frameworks presented earlier it is possible to recognise certain ontological underpinnings of the new global social work definition and implications for social work which will be elucidated in the following discussion the ontological underpinnings of the new global definition in reflecting on the underlying ontology of the new global definition of social work the influence and emergence of increasingly socialistcollectivist ideals can be recognised evidence of this can be found in the shift to a collective discourse and from a microbased to increasingly macrofocused understanding of social action terms utilised in the new definition and the commentary thereof such as promotion of social change and development social cohesion and empowerment liberation of people social justice and collective responsibility indicate these changes the term collective responsibility could be argued as being a socialistcollectivist stance particularly in the commentary of the definition where it is stated that advocating and upholding human rights and social justice is the motivation and justification for social work recognising that human rights need to coexist alongside collective responsibility this resonates with the socialistcollectivists promotion of a greater social equality through collective strategies and dow and mcdonalds acknowledgement of redistribution of wealth and power and the mobilising of collective action the new definitional call for social work to develop a critical consciousness is also evidence of these shifts compared to that of previous international social work definitions with the influence of social and economic conditions more keenly recognised and understood as being significant in this regard however although emerging undercurrents of socialistcollectivism can be found this is not to say that the new definition is a single uniform movement towards a socialistcollectivist approach nor is the definition particularly radical in its intentions rather the new definition seems to embrace socialistcollectivist principles while still maintaining its traditional personinenvironment perspective and consideration of the individual the commentary and analysis of the new definition recognises the role of the social worker as being one of individualfocused interventions supporting the individual to cope with the difficulties and struggles they are experiencing within their environment there is a continued focus on the liberation of people within their economic and social contexts and there are still hints of what one might refer to as a therapeutic aroma equally so the extent of socialistcollectivist implications in the new definition is not clearly articulated for instance how far along the collective path the new definition proposes travel these uncertainties can infer the development of an eclectic definition that could be interpreted in various convenient ways however we believe that certain shifts in thinking and power are clearly apparent and that the extent of these changes is what requires more critical discussion and debate this debate between the individual and collective perspectives of social work focus is not new with social work always being on a continuum between community worksocial change on one end and therapeutic work with individuals families or groups on the other social workers who practice counselling or therapeutic methods as their core functions have been seen by some as having sold out moved away from the roots of social justice while others believe that social justice can still be achieved through individual change and that the social worker has a therapeutic role to play in intervention staniforth fouche and obrien highlight that there has been much written about this debate staniforth fouche and obrien advocate a bothand view with both collective and individual focus being within a systems approach to intervention and wellbeing therefore both sides have a place within the social work practice framework in reflecting on the ontological underpinnings of the new global definition this bothand view is apparent thus although a shift towards a more collective and macrofocused stance is clear it is perhaps more evident when viewed in contrast to the more individual focus of the previous international definition in understanding the shift towards increased socialistcollectivist thinking and ontology in the new definition one needs to reflect upon the context within which and towards what the new definition was developed although we highlighted the western dominance of ontology used in international social work frameworks the new global definition can already be said to be somewhat more indigenous in its underpinnings having increased involvement of latin american asiapacific and african countries it can be suggested therefore that advocating for the importance of collectivism development and interdependence in the new global definition may be largely owing to the influence of these participating countries who have long backed the inclusion of these values equally so the shift to the need for increased collectivism and macrounderstandings can also be understood as being a recognition of the changing socioeconomic political spatial and historical context of individuals and communities in implementing the new definition we believe that the development of stronger academic and critical veracity greater integration of indigenous knowledge development of critical consciousness and an improved understanding of socioeconomic contexts are key within todays global world of social inequality poverty social exclusion violation of human rights and the impact these have on individuals families and communities socioeconomic contexts it is widely recognised that social work is embedded in challenging times as the infiltration of global economic policies market capitalism and neoliberal tenets have fast begun to take hold across europe and beyond harvey refers to this as a neoliberal globalisation a blanket guiding perspective for all economic social political cultural and internationally based interactions and relations the increasing global convergence of economic policies and practices although implementation visibility and discourse may vary across countries has had an international impact upon aspects of wellbeing the widening gap between the rich and poor the retrenchment of the welfare state the power of the market the privatisation of care and the influence of a management agenda in all spheres of service provision furthermore the impact of globalisation and converging economics has seen an increase in macroscale social problems all the while neoliberal principles continue to emphasise the responsibility of the individual while social problems have been exasperated through economic recession heightened further through a reduction in social protection and increased welfare reforms in many countries the theory underpinning neoliberalism proposes that human wellbeing can best be advanced by liberating individual entrepreneurial freedoms and skills social work much like global policies has perhaps overly embraced this concept of individualism in fact it has even been suggested that rather than being a victim of neoliberalism social work has perhaps at times been a willing participant and uncritical of the role it has played in the conscious or unconscious promotion of neoliberal ideals the previous international definition was highly criticised for failing to acknowledge the importance of collectivism and interdependence within an increasingly globalised world the need for a broader contextual and collective understanding within social work and social development initiatives therefore has been increasingly recognised thus it was within this context that the new global social work definition is embedded and thus understood calling social work professionals to expand their contextual understanding and awareness of their role in todays global context with the definitional and ontological evidence of a transition in the social work profession and within a contextual understanding the professions role now lies in critically questioning and debating what these changes mean for social work at a global and national level what are the implications of such a shift for social work education practice and leadership implications and challenges for social work in reflecting on the shifts identified in the new definition the ontological positions it represents and the socioeconomic context of todays world various questions beg to be answered do we as professionals need to make changes to how we see our role in society and how we implement intervention or is it more simply that the lens through which we see social problems and social work needs to be broadened what does this mean for social work training and practice we believe that these are critical questions which need to be developed and debated by the social work fraternity it is however clear that unless social work is able to appropriately identify the nature and causes of social distress it will be unable to recommend and support appropriate interventions a more collective social work with renewed recognition of social justice cohesion development and ontology may have implications for current models of social work furthermore uncritical perspectives of social capital social control and even core concepts such as social justice may be influenced by or have close links to neoliberal concepts such as selfhelp lacking the structural perspectives that restrain personal and social development and further highlighting the need for a more academic and scientific social work development is needed in the areas of macro and collectivist interventionist skills critical review of ideology within social work with the recognition of vested interests critical reflection on and understanding of aspects of social control and cohesion recognising the role of the profession as an agent of social control within the global neoliberal world and our promotion of such ideals the positive and negative influences in ideology the complex interrelationship between ideology and discourse and the differing ideological interests and forms that may exist in policy practice and education for example the current global neoliberal context promotes the principles of individualism and consumerism as being cultural norms while the new definition renews the call for social work to counter such developments with the reaffirmation of core values ethics and knowledge such as collectivism social development social justice and social cohesion therefore social workers need to assess and critically debate the ontological paradigm within which they practice andor understand the role of social work continue to question the existence of western dominance and critically reflect upon what the empowerment and liberation of people might mean in practice professionals need to ensure coherence between theory practice and principles recognising ontological paradigms which would best achieve the development and a collective and empowerment call of the new global definition social workers should embrace the broadening of their ontological understanding and interventions moving beyond blanket terms such as social justice and social development towards a fuller understanding as well as acting to ensure their achievement whilst ensuring they do no harm surely empowering individuals to live in and acclimatise to their present circumstances alone is no longer sufficient the challenge for social work then is to develop practice and research their understanding between the global trends and realities local community and individual needs the global definition was essentially a reevaluation of a journey to respond to the increased global complexity in which social work is embedded a critical implication for the profession is thus to expand its orientation to include wider perspectives such as political economy social policy and research in both practice and education as well as recognising policy development implementation and evaluation as a primary social work function we are indeed obligated to informing and participating in policy development and this requires an active engagement with global and regional political institutions conclusion although this article cannot claim to have captured the vastness and complexity of definitional shifts in social work and its implications and challenges for the profession we hope that the questions and ideas raised in this article will spark further discussion and debate the profession in its global regional and individual context has different views on the future of social work assessments of the problems and how the profession should and can respond to the present challenges however the new global definition requires the profession to redirect and articulate clear approaches to achieve its goals of social justice equality development empowerment and wellbeing and to do so with an increased collective understanding a recognition of the structural sources of oppression and a commitment to bringing about social cohesion through both collective and individual approaches although some may be critical of a more radical social work perspective the need to recognise an interconnected macro portrait of our world cannot be rejected the importance of social economic political spatial individual and historical contexts and the role of political economy are vital to understand social distress policy initiatives social work theorymodels and their impacts there is a need to recognise and challenge these interconnected influences as well as the impacts these have upon individuals communities organisations and the wider social context there is no doubt that neoliberal policy is impacting on individuals communities the profession and nation states social work has a critical role in this debate and should not just acquiesce to priorities premises and policies of current regimes rather it should use research theory pedagogy and critical voice to support it in facilitating social change development cohesion and social stability as well as the empowerment and liberation of people the new global definition recognises this potential by critically reflecting on the significant definitional shifts towards macro understandings of oppression collective solutions and increased academic and indigenous integrity the profession can continue to remain relevant and accountable to its commitment to promote social cohesion and social justice within todays challenging global world ethics secondary data was utilised for the project ethical approval was obtained from coventry university and participating universities as required declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

the revised global definition for social work promotes the professions commitment to social change and development social cohesion and the empowerment and liberation of people by reviewing the implications of this definitional shift and locating this within existing influential social work ontological models the implications for social work within global and national contexts are critically reviewed findings the changes to the global definition along with recognition of the importance of strengthening knowledge and theory encourage critical review of the implications of a shift from an emphasis on individual approaches to the importance of collective and macro perspectives in social work intervention the location and exploration of these debates using existing key ontological frameworks and socioeconomic contexts encourages critical reflection on the purpose role and function of social work in society implications social work must critically review what it means by along with the implications of the professions commitments the profession needs to consider how theory its academic discipline and social work interventions support these commitments the critical examination of ontological frameworks indigenous knowledge and social work interventions is vital to inform social work education and practice to enable a reinvigorated profession able to address the contemporary challenges of both society and individuals

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introduction in the united states racial disparities in the criminal justice system have been widely documented black americans have higher rates of arrests convictions and sentencing compared to white americans 1 furthermore the lifetime risk of incarceration for a black man born today is 1 in 3 compared to 1 in 6 among latino men and 1 in 17 among white men 1 these disparities are rooted in the racist foundation which continues to be perpetuated through the current criminal system and prison industrial complex in the us 2 historians have drawn a through line from the utilization of jails and prisons to reinforce the institution of slavery in the southern us to the use of police forces to quell the civil right movement protests in the 1960s to the war on drugs and gangs in the 1980s and 1990s to the police brutality cases that precipitated the present contemporary black lives matter movement 3 while the national discourse on criminal justice has centered the disproportionate injustices experienced by racial and ethnic minority groups sexual and gender minority groups have received less attention however studies have shown that sexual minority communities experience high levels of involvement with the criminal justice system for example a national study found that the incarceration rate of individuals who identify as lesbian gay or bisexual was three times that of the general us population and these communities were more likely to be sexually victimized while incarcerated experience solitary confinement and have psychological distress 4 however the focus on a singular axis of oppression and social marginalization erases the lived experiences of people who exist at the intersection of multiple marginalized and minoritized identities intersectionality theory asserts that identities are not merely independent and additive but interlocking and mutually constitutive 56 specifically black sexual minority men exist at the intersection of racism homophobia and heterosexism which might significantly increase their chances of coming in contact with the us criminal justice system for example a national study of black smm in 6 cities across the us found that 61 reported being incarcerated at least once in their lifetime 7 another study of black smm in the deep south found that 36 of participant had a history of incarceration 8 additionally individuals with a history of incarceration may have limited economic opportunities such as barriers to employment which may contribute to recidivism various studies have documented that smm with a history of incarceration are more likely to report lower income engage in transactional sex and substance use 9 10 11 12 these limited data suggest that black smm might be disproportionally represented in the criminal justice system which has implications for the health and wellbeing of this marginalized group many of the negative impacts of incarceration are downstream effects attributed to stress stigma and limited socioeconomic resources and opportunities 13 14 15 16 past studies of incarceration among smm have been within the context of hiv specifically as an indicator of underlying risk for hiv seroconversion or lapses in the hiv care continuum for example a study of young smm in chicago il found that 41 had a prior history of criminal justice involvement 35 were living with hiv and among those living with hiv having a history of criminal justice involvement was associated with better hivrelated health outcomes compared to those with no prior history of criminal justice involvement 17 another study found no association between incarceration and new cases of hiv among a cohort of black smm 18 while these studies have contributed to our knowledge base on the relationship between incarceration and hiv we also recognize that black smm are confronted with other challenges beyond hiv there is a dearth of research on the nonhiv health impacts of incarceration on black smm recent qualitative research with young black smm found that incarceration negatively impacted employment and economic security 19 another study found that economic hardship prior incarceration and substance use were associated with incident incarceration among young black smm and transgender women 20 more research is needed on the relationship between incarceration and the reentry needs among sexual and gender minorities specifically employment housing and access to health care among black smm with a history of incarceration 142122 to address this research gap we conducted secondary analysis of data from a large multiyear survey of young black smm in houston and dallas texas the objective of the current work was to assess the association between unmet socioeconomic needs structural discrimination and history of incarceration among young black smm in the us south we hypothesized that having a history of incarceration would be associated with higher current socioeconomic and structural needs this analysis will help provide additional insights into the potential services and programs that may be needed to assist young black smm after release from correctional facilities or those at risk for incarceration the survey took about 30 minutes to complete and participants were reimbursed 30 for their time all data were self reported to facilitate identification of duplicate participants across the three study waves several timeinvariant personal characteristics were checked while performing data merging procedures each participant was assigned a unique alphanumeric identifier constructed by combining those characteristics we retained the first observation for participants who completed the surveys at multiple waves after removing duplicates more details on the study methodology have been published elsewhere in publicly available manuscripts 23 24 25 26 methods participants and procedures measures sociodemographic characteristics participants reported their age and location for analysis participants educational level was categorized as having completed high school ged versus not having completed high school ged hiv status was coded as hivnegative hivpositive or unsureunknown serostatus for analysis sexual orientation was measured as gay homosexual same gender loving etc bisexual heterosexual or straight other the latter two categories were collapsed for analysis based on cell sizes socioeconomic needs we collected information about current employment status history of homelessness history of exchange sex in the previous 60 days whether the participant had run out of money during one or more months in the previous year whether the participant needed to borrow money in the previous year whether the participant had a primary care provider and history of testing for an std in previous year structural discrimination experienced racism we measured experienced racism using an 11item scale developed by díaz et al 27 items assessed a range of potential experiences in the past year a racially offensive comment or joke and in the past year how often have your civil rights been violated participants responded using a 5point scale ranging from never to very often and items were summed to create a total score where a higher score indicates greater experiences of racism in the past year experienced homophobia we measured experienced homophobia using a 7item scale developed by díaz et al 27 items assessed a range of potential experiences in the past year or for being attracted to other men participants responded using a 5point scale ranging from never to very often and items were summed to create a total score where a higher score indicates greater experiences of homophobia in the past year mental health we utilized a shortened 8item version of the center for epidemiologic studies depression scale 28 scale to measure depressive symptoms responses are summed and a higher score indicates greater depressive symptoms resilience we utilized the wagnild and young 14item psychological resilience scale 29 to measure resilience participants responded to items using a sixpoint likert scale from disagree strongly to agree strongly greater scores indicate greater psychological resilience substance use to assess binge drinking participants were asked during the past 60 days on how many days did you have 5 or more drinks on the same occasion and we created a none versus any dichotomous variable for analysis stimulant use was also measured with a 60day recall period for analysis we combined responses for ecstasymdma crack cocaine and methamphetamine to create a single none versus any stimulant use variable smoking status was derived from an item asking the number of days in the past 60 days that the respondent had smoked cigarettes from this we created a trichotomous variable history of incarceration participants were asked were you ever in juvenile jail or prison and response categories included no i have never been in juvenile jail or prison yes in the last 2 months yes more than 2 months ago but within the last year yes more than a year ago respondents were only allowed to choose one answer and the question did not instruct participants how to respond if they had experienced multiple incarcerations given this lack of specificity and the ambiguity it would introduce to the interpretation of results we created a collapsed dichotomous variable reflecting any lifetime incarceration experience data analysis variables that had theoretical and domain relevance to incarceration history based on the scientific literature were included for analysis bivariate and multivariable logistic regression models were constructed to examine the unadjusted and adjusted relationship between each variable and history of incarceration variables that had theoretical and domain relevance based on the scientific literature were retained in the multivariable models assessing these outcomes we constructed four multivariable models to test incremental associations between the independent variables and any lifetime on history of incarceration this included model 1 model 2 model 3 and the full model model 4 we utilized this forward stepwise approach to examine which factors remained significant or became insignificant with each addition of covariates category to the model data was analyzed using stata mp 17 results sociodemographic socioeconomic and structural discrimination variables are presented in table 1 over a quarter of the sample had any lifetime experience of incarceration the sample was evenly split between dallas and houston a majority of the sample identified as gayhomosexual same gender loving and selfreported being hiv negative only 15 reported not having a high school diploma or ged and 9 were out of work almost half of the sample reported having run out of money in at least one month in the previous year 38 reported needing to borrow money to get by in the previous year and 9 reported having experienced homelessness in the previous year a quarter reported having no longterm primary care provider and about twothirds had tested for a sexually transmitted disease in the previous year nearly twothirds reported binge drinking in the previous 2 months 44 were current smokers and 24 had used stimulants in the previous 2 months bivariate associations between sociodemographic characteristics socioeconomic and structural needs and history of incarceration are presented in table 2 in the first adjusted regression model history of incarceration was regressed onto socioeconomic needs and structural discrimination and participants with a history of incarceration had increased odds of multiple correlates these correlates included being unsure of their hiv status not having a high school diploma or ged being out of work having experienced homelessness in the previous year and having run out of money for basic needs in the previous year participants with a history of incarceration had decreased odds of reporting having tested for a sexually transmitted disease in the previous year table 3 in the second adjusted regression model history of incarceration was regressed onto socioeconomic needs structural discrimination mental health several variables remained significant from model 1 these variables were being unsure of their hiv status not having a high school diplomaged joblessness history of homelessness having run out of money and history of std testing in this model individuals who identified as bisexual and heterosexualother compared to gayhomosexualsame gender loving and those who experienced greater racism was associated with a higher likelihood of reporting having a history of incarceration in the third adjusted regression model history of incarceration was regressed onto socioeconomic needs structural discrimination substance use and several variables remained significant from model 1 these variables were being unsure of their hiv status not having a high school diploma joblessness having run out of money and history of std testing in this model individuals who identified as heterosexualother compared to gayhomosexualsamegender and being a nondaily smoker or who indicated being a daily smoker compared to being a nonsmoker was associated with a higher likelihood of reporting having a history of incarceration in the fourth adjusted regression model history of incarceration adjusting was regressed onto socioeconomic needs structural discrimination mental health substance use hiv status several variables again remained significant from model 1 these variables were not having a high school diploma ged joblessness having run of money and history of std testing in this model higher level of racism and being a nondaily smoker or daily smoker compared to being a nonsmoker were more likely to report a history of incarceration discussion this study examined the association between socioeconomic needs structural discrimination and history of incarceration among a sample of young black smm in houston and dallas texas we found that more than a quarter of the sample reported a lifetime experience of incarceration additionally participants with unmet socioeconomic and structural needs were more likely to have a history of incarceration these findings reinforce the need for intervention development for young black smm who are at risk for incarceration are currently or have been recently incarcerated together these results suggest heightened vulnerability that could result in recidivism and perpetuate a cycle of social and economic disenfranchisement we found that history of incarceration was associated with several socioeconomic and structural needs including lack of employment homelessness financial insecurity and lower educational attainment these findings are in line with a longitudinal study of young black smm in chicago il that found that economic hardship previous criminal justice involvement and substance was associated with incident criminal justice involvement over 18months of followup 30 these various social and economic positions can be mutually reinforcing such that the possibility for upward mobility becomes almost impossible for example not having a high school diploma or ged can limit employment opportunities potentially compounding the stigma of having been previously incarcerated as a barrier to employment furthermore an individual without stable employment is at higher risk for homelessness which can also impede employment a potential pathway to improved economic security homelessness can also increase risk for incarceration 31 either due to individuals resorting to survival strategies through policies quality of life policing that arrests homeless persons for trespassing or sleeping on public property consequently it is imperative that interventions are developed to address the basic social and economic needs of young black smm with a history of incarceration or who are at risk of incarceration an intervention that provides resources around housing assistance cash assistance food resources and job placement and is facilitated by a dedicated case worker experienced in navigating local and state government safety net programs could address these overlapping and p 005 p 001 p 0001 participants who had a history of incarceration were also more likely to report experiences of racism it is important to note that young black smm are situated at the intersection of multiple minoritized identities on the basis on race and sexual orientation 32 33 34 35 additionally the racialized public perception of the criminal justice system might put young black smm with a history of incarceration at higher risk for experiencing racism it is important to note that after adjusting for other variables experiencing of homophobia was not significantly associated with having been incarcerated providing more evidence about the critical role race plays in the experiences of young black smm with a history of incarceration it is also possible that racist prejudices toward black men who have been involved with the criminal justice system might be more pervasive than homophobic prejudices associating smm with criminality this phenomenon illuminates the need for larger public discourse on the structure and functioning of the criminal justice especially related to how it is overly punitive toward young black men 3637 reform of the criminal justice system especially as it relates to sentencing laws bail reform ban the box policies and juvenile justice reform are desperately needed specifically ban the box reform which posits that employers should first consider a potential job candidates qualification without the stigma of a prior conviction or arrest could result in more economic opportunities of black smm with a history of incarceration it is important to note that the state of texas which is where this study was conducted does not have a ban the box statute at this time while depressive symptoms and resilience were initially significantly associated with history of incarceration those effects became nonsignificant in the multivariable models this provides further evidence about the need to address the underlying socioeconomic and structural needs which also have implication for mental health as we described earlier there is a need for structural intervention and safety net services to support reentry for formerly incarcerated young black smm both socially and economically social cognitive and behavioral interventions are individualistic and in isolation are insufficient for addressing these socioeconomic needs one such model is the louisiana integrated center for care supportive services and community health recently described by brewer et al 18 within the demonstration project that brought together a range of stakeholders and service providers to address social and structural drivers of hiv disparities among black men three priority areas were 1 reducing barriers to hiv care during reentry for incarcerationinvolved young black men 2 addressing socioeconomic disparities among young black smm and 3 an assessment of and communications campaign to address housing discrimination experienced by young black smm 18 our study had some limitations first the selfreported nature of the data could have resulted in social desirability bias and possibly due to fear of experiencing stigma and discrimination especially for participants with a history of incarceration who experience societallevel prejudice this bias may have resulted in an underestimation of prevalence of incarceration history and other pertinent variables second we did not collect data on the reason for incarceration length of time or number of times incarcerated in a similar sample of young black smm reasons for incarceration included substance use or substance dealing intimate partner violence physical altercations sex work and financial fraud 19 consequently there could be different antecedents or outcomes associated with different reasons for incarceration that is not captured in our data or analysis next it is plausible that these independent variables are antecedents of incarceration andor outcomes of incarceration existing longitudinal datasets including those with an original focus on hiv outcomes may have captured enough socioeconomic indicators to support a new secondary analysis that sheds more light on the temporality of these relationships and most critical points for intervention our present findings can provide insight into relevant factors to incorporate finally our data do not include the number of incarcerations experienced the length of these incarceration experiences the setting of incarceration or the recency of incarceration this contextual information could be addressed in future primary data collection or secondary data analysis conclusions a vast majority of research examining incarceration among young black smm have been related to hiv disparities thereby telling an incomplete story housing instability unemployment and limited educational advancement are structural inequities found to be associated with incarceration among young black smm currently programs are warranted that address these factors as part of a more holistic response to the social and structural disadvantage that young black smm navigate daily to date there are few if any reentry programs for formerly incarcerated young black smm that address housing education and employment needs and they are desperately needed future research should 1 examine the mechanisms and pathways underlying the associations between socioeconomic needs and incarceration among young black smm 2 test the cultural appropriateness and relevance of existing reentry programs for the general population and whether these programs adequately reach young black smm or need tailoring and 3 investigate whether experiences of racism may differ for young black smm who have experienced incarceration versus those who have not to shed further light on the most potent sources of disadvantage and discrimination that exacerbate incarceration disparities and incarceration sequalae for young black smm data availability data is available upon request open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit 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there is a dearth of research on incarceration among young black sexual minority men smm the current study aimed to assess the prevalence and association between unmet socioeconomic and structural needs and history of incarceration among young black smm between 2009 and 2015 young black smm n 1774 in dallas and houston texas were recruited to participate in an annual venuebased crosssectional survey we found that 26 of the sample reported any lifetime history of incarceration additionally participants with unmet socioeconomic and structural needs unemployment homelessness financial insecurity and limited educational attainment were more likely to have a history of incarceration it is imperative that interventions are developed to address the basic social and economic needs of young black smm with a history of incarceration or who are at risk for incarceration

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resumo o estudo tem como objetivo descrever como a violência se revela na produção do grupo de pesquisa gênero saúde e enfermagem tratase de pesquisa histórica de abordagem qualitativa que avaliou a produção do grupo de pesquisa por meio de análise de conteúdo os resultados apontam gênero como categoria central na determinação da violência e das práticas em saúde esse aspecto determina limitações nas práticas profissionais de enfrentamento a exemplo da invisibilidade do problema a autonomia feminina o uso de álcool e drogas e a vulnerabilidade social assumem importante relação com o fenômeno e o vínculo é revelado enquanto potencialidade das práticas em saúde para o enfrentamento do problema conclusão a perspectiva de gênero na pesquisa em enfermagem constitui um campo inovador e contrahegemônico com possibilidade assumir um significado práxico pelo potencial transformador da compreensão e dos modos de intervenção no fenômeno da violência de gênero descritores pesquisa enfermagem violência contra a mulher feminismo abstract the study aimed to describe how violence is revealed in the production of the research group on gender health and nursing this is a historical research of qualitative approach which evaluated the production of the research group through content analysis the results show gender as a central category in determining violence and health practices this aspect determines limitations on professional practices of coping such as the invisibility of the problem the female autonomy the use of alcohol and drugs and social vulnerability play an important relation with the phenomenon and the bond is revealed as potentiality of health practices to address the problem conclusion the gender perspective in nursing research is an innovative field and counterhegemonic a possibility to assume a meaning of praxis by transforming potential of understanding and modes of intervention in the phenomenon of gender violence descriptors research nursing violence against women feminism health knowledge resumen el estudio tiene como objetivo describir cómo la violencia se manifiesta en la producción del grupo de investigación de género salud y enfermería se trata de investigación histórica enfoque cualitativo que evaluó la producción del grupo de investigación mediante análisis de contenido los resultados indican el género como una categoría central en la determinación de las prácticas de salud y violencia este aspecto determina limitaciones en las prácticas de afrontamiento profesionales como la invisibilidad del problema la autonomía de la mujer el uso de alcohol y drogas y la vulnerabilidad social desempeñan una importante relación con el fenómeno y el enlace se revela como una potencialidad de las prácticas de salud para abordar el problema la perspectiva de género en la investigación en enfermería es un campo innovador y contrahegemónica con la posibilidad de asumir una práxis con potencial transformador de la comprensión y modos de intervención en el fenómeno de la violencia de género from the 1990s the category gender was appropriated by the health care field and has been used as an important tool for analyzing the determination of the phenomena of life of women and men as a proposed category by feminism then aggregate to the scientific field this category carries intrinsically the political nature and the commitment to social transformations related to women as well as a new view at the power relations established between women and men men and men and women and women the discussion about the relevance of gender as a central category for understanding and intervening on violence against women is based on the assumption that in the hierarchy of power in this society woman has always been inferior to men social position due to built inequalities which are historically naturalized thus although power relations have become modified throughout history in the social and state spheres the structural reality is still far from equality between genders what concerns the private space inequalities remain reproduced as small practices of power in everyday life remains such as domestic violence gender inequality has greatly compromised the quality of life for girls and women presenting across all aspects of reality empowering and legitimizing the oppression that manifests itself in different gender violence translated into physical emotional and social violence materialized in different ways in opposition to this reality equal rights between genders is a very recent possibility being constant presence in the struggles for emancipation and the recognition of women´s rights as human rights aspirations that even today is still largely utopia the dominant mode of explaining gender relations is based on the historicity of institutions and modes of social life that allowed the explanation of the feminine universe by addressing primarily a biological approach in an interpretation that satisfies dominant social interests this discourse is opposed to the one that says that humanity of the human being is socially constructed in social relations such understanding of the world assumes that all social phenomena are products of human action and can be transformed by it the gender perspective has allowed researchers to face the challenge of rethinking the inequalities produced in relations between genders in the light of production and reproduction of different social and historical contexts in which submission and inequality contribute to establishment and maintenance of gender violence the research group on gender health and nursing from the university of são paulo is the first of the field of nursing and perhaps health to take gender as specific field of studies to analyze the phenomena of womens lives the work of nursing the healthdisease process of women and genderbased violence against women and adolescents are themes that have outlined the research history of the group especially from the year 2005 when gender violence became the specific object of research studies the production of new research projects and intervention has allowed the researchers to observe a panorama of the studies regarding the phenomenon of violence in the light of gender it is time to ask whether the conceptual field built and consolidated by the research group open to researchers and society important elements to an established theoretical base that actually subsidize the intervention for the prevention and facing genderbased violence against girls and women thus this research paper aims to reflect from the scientific production of this research group on a gender perspective in the search for understanding and intervening in the phenomenon of violence and describing how the phenomenon of violence reveals the realities studied methods this is a historical research conducted through production review of the research group on gender health and nursing registered at cnpq the data consisted of the theses and dissertations produced by the research group defended since the time of our research group formation until the present day as inclusion criteria we considered all theses and dissertations produced by professors and students of the graduate program participants of the research group from the period 1990 to 2014 which had the phenomenon of violence as a specific research object as exclusion criteria studies that mentioned violence as one of the findings of the research but whose object of research was another information was obtained from reading the material and organizing into instrument containing general data abstract we searched for the original volumes available in the library wanda de aguiar horta at eeusp in order to enable a qualitative analysis in depth studies were accessed in full and submitted to content analysis results in 25 years of existence the production of the group was 17 doctoral theses one of full professor and 9 masters dissertations all of these were produced in the context of graduate program in the two existing graduate programs at school of nursing university of sao paulo namely interunits graduate program in nursing of the campuses of sao paulo and ribeirao preto and nursing graduate program area of concentration in community health nursing among the 27 studies produced by the research group only since 2005 genderbased violence has become the specific object of research studies so that by 2014 10 studies on the subject have been completed as specified in table 1 however since the first thesis produced in the group violence against women was presented as a recurring phenomenon even when not constituted the object of specific research the same occurred in other paper works until the first specific study of violence against women was completed in 2005 the analysis of studies on violence revealed a predominance of studies on genderbased violence against women and two studies was under investigation of violence in adolescence most research chose the qualitative approach data analysis from the standpoint of content analysis and criticalemancipatory workshops as data production strategy regarding research settings there was a predominance of studies in primary health care more specifically in the family health strategy as shown in table 1 a empirical categories 1violence is never alone the determination and experience of violence as a complex and multifaceted twoway street in all studies the findings confirm that violence is a phenomenon that involves in its determination coping and complexity the social construction of male and female and the relations of dominationsubordination established with regard to the definition of violence revealed in several studies it is noteworthy that gender violence may manifest in various ways and in varying degrees of severity having the family institution as its privileged locus violence affects women in its various manifestations being in most cases overlapped being the private sphere the one which predominantly expresses gender violence in the public sphere gender violence also takes various forms of expression such as workplace and society violence thus gender violence are presented in studies as a phenomenon that is never alone as it is manifested in contexts listed by problems related to structural violence and social exclusion furthermore studies have revealed gender violence experienced in adulthood most often in the marital relationship accompanied by a prior history of violence in childhood or adolescence a study on violence against adolescents seen by adolescents themselves is overwhelming by the combination of various types and intensities of violence on marginalized groups and the awareness that this is a serious problem for their life girls as sexual violence was revealed in all studies even though only one of them specifically addresses this classification when practiced against women who are married sexual violence takes the meaning of consensual violence because it is legitimized by marriage few studies reveal findings of sexual violence committed by an unknown aggressor so that in most cases violence is revealed as a phenomenon in the marital or family relationship committed by partner or male relative which makes it socially legitimized naturalized and invisibly gender violence is a phenomenon that also occurs in relationships permeated with affection in which are deposited expectations that revolve around the ideal of family and marriage being the aggressor in general a person with whom the victim shares her life divides and constitutes home it makes the violence a contradictory phenomenon even more important since it involves feelings of helplessness disappointment disaffection and hopelessness this aspect was a common finding in all studies studies found idealization of meanings related to the family in society as they relate to the construction of the home as an institutional space where values of different types of society are internalized providing the basis for the reproduction of learned cultural and social model thus violence appears in the social imaginary but it is in fact a consequence of an ideological mechanism to the ideological maintenance and reproduction of male power and its hegemony as direct consequences of gender relations the social production materialized in a paid work was revealed in this study as an important determinant of potential for facing violence however entry into the labor market has not decreased for example the social responsibility of women for the care of the home and with family which results in double or triple shifts generating overload and constituting more potential stress for the healthdisease process of women making them subaltern and vulnerable studies revealed consequences of violence experienced in various aspects of life and health of women stress resulting from genderbased violence such as high blood pressure epilepsy diffuse pain aggravation of mental order and vulnerability to sexually transmitted diseases are presented in the studies among the repercussions of violence in womens lives several studies revealed the reproduction of violence by women as a result determined by their experience showing women as perpetrators of violence against the spouse children and other people in their social relations nevertheless the interviewees understand this behavior as arising from an emotional state given by experienced violence 2silenced and invisibilized gender violence is concrete in health services and in the lives of women the spaces searched for care by women are also spaces to capture the implicit violence that comes between the demands they bring since care and gender violence are brought and experienced constructs which are historically much more experienced by women in studies 9 violence is presented in health services always implicitly that is it is not the specific situation the reason that led women to seek health services there are spontaneous expressions of women about experiences but these hardly are placed in terms of demands for health care or by professionals these manifestations are understood as both the presence of possible communication channels identified by women in relation to the service that represents the understanding of users and professionals about the possibility of caring and facing gender violence by the health service although they have the knowledge for compulsory notification of violence studies reveal that services often do not notify nor registry confusing notification with police complaint this finding reveals the production of invisibility of violence as a health problem in the investigated scenarios far from being the exception this reflects a common gap to most health services 9 health professionals are able to identify users who experience violence by marks or physical symptoms or associated symptoms such as somatization unfounded complaints and diffuse discomfort anxiety depression not located pain among other manifestations another element that contributes to the identification of violence is a report produced by women when asked about the theme we talk about invisibility but the findings reveal that gender violence is visible in health services is part of reality however because it appears submerged in the complaints that women bring it is invisibilized or even not recognized by services as an inherent problem to their attention as potential aspect of invisibility studies 9 identified significant construction marks of gender identity practices and concepts of health professionals men and women at the same time some women health professionals also experience violence and pointed to this aspect as influencing their attitude towards its problematic 9 it is observed that under the fhs on one hand women do not speak on the other hand the professionals do not ask about violence the medicalization logic limits the development of tools that enhance the uptake of violence which makes women also unaware of the health services as a possibility for support 3autonomy of women as a possibility for overcoming violence the achievement of financial independence and work in the public world proved in studies of women as a necessity for its transformation and liberation from oppression and violence this was a converging point for all studies the social production translated by paid work appears as a necessity intrinsically related to autonomy and facing the situation of oppression that marks their social reproduction the achievement of greater autonomy presupposes the liberation of women from the shackles determined by gender and that include gender violence the overload for exclusivity in reproductive responsibilities and care and have been excluded from productive activities and therefore financially dependent social inequality is a concrete reality of excluded individuals from work and when added to gender inequality that pervades the relationship of conjugal violence compromises social reproduction through the intercession of inequities produced by two categories class and gender both producing barriers to autonomy to health and to the existence of women understanding that individuals are responsible for their choices and living conditions permeates health services also being the focus found in many programs this aspect is a strategy that denies the construction of a collective project of social transformation the ability of subjects to make their choices has the fundamental assumption to guarantee the autonomy and equality needs that could not be fulfilled without a transformation of the existing social structure nonetheless the recovery of possible autonomy is an urgent need critical to health and puts into question both the way it medicates and institutionalizes the lives of individuals as the disregard of this dimension for the services it is impossible to speak in absolute autonomy since it is not possible to deny the difficult driving forces to control and the spaces of freedom are nearly privileges however it is important to rescue this need to restore a degree of human autonomy since disease and related destructive processes are also determined by the alienation of men the achievement of autonomy understood as control over ones own life and body and the right to an independent identity and selfrespect is preceded by two conditions one is the consideration of the needs and interests of men and women by policies and programs to achieve gender equality the other is to support strategies that aim to female strengthening and empowerment facing the challenge for the achievement of gender equality and autonomy of women requires an overview with care and caution of the situation of thousands of women who suffer inequities in daily life being indignant with it and moving to transformation rather than the unattainable idealization of individual and collective happiness decontextualized and ahistorical women citizenworkers should be attended according to the needs of their health and disease profile understanding them in the light of their gender class status generation profile and other analytical approaches 4limitations of professional practices on violence impotence and medicalization studies reveal the impotence that health professionals refer to when they verbalize their coping with violence pointed out by professionals in all studies of which were subject 9 impotence is called in one study as paralyzing and fueled by misinformation and lack of specific professional qualification the issues identified in the studies that composes this category reflect the medicalization of health care for victimized women and girls which is related to the technical impossibilities of professionals towards the problem and also with service limitations referred by professionals as overload of demands and responsibilities it seems like medicalization logic prevails in services even when addressing situations of violence with predetermined prioritization of needs with regard to victimized women they also seek health services from physical demands since they transform the violence experienced in demands for health care in an attempt to be cared by the service regarding professionals violence is not understood as a problem that is related to health when there is not physical visibility in their body studies point for a reduced recognition of womens needs to reproductive health in an individual cutout and limited to reproductive and biological aspects of the female body when not reduced to the body attention is translated into actions related to referrals to psychiatric or psychological attention even revealing the fragmented and factorial public health approach in the perspective of health services although violence has an intrinsic relationship with physical and mental health that is with all aspects that make womens health the criticism that is made is related to the limitation of attention to aggravation disregarding its determination that involves oppression violence gender relations and all relations that permeate their way of life it is important to take care of health problems and we do not intend here dismiss the health area of this assignment as it shall but should go far beyond them health services should be constituted as local care and support and no longer a barrier in an attempt undertaken by women to transform their situation of oppression the studies in general point to the need that violence is recognized as a problem and as a demand whose attention is inherent to health services considering the subordination of gender as a determinant of this process this recognition is essential for the creation of practical possibilities to overcome the limitation to the dominant logic of medicalization furthermore violence appears in a gender free and naturalized understanding this reality is the result of a complete historical process of construction of health care in our society and therefore a further scientific training in biomedical and androcentric molds 5potentialities hearing and the bond as possibilities of care studies pointed to the hearing in the relationship between professionals and users mediated by creating bonds such powerful aspect of care given in experience related to gender violence this theme seems related to the recognition of both health professionals as the victimized women when referring to confront violence and the support of health services nevertheless it is important that the listener does not translate practice into a simple dialogue that permeates the assistance a qualified hearing implies full attention the close look in the care for women who experience violence it must be mediated by a gendered instrumental which learn the needs of users recognized as subjects of their existence and inserted into a society that determines subordination and violence hearing must stimulate talks not being limited to it paying attention to details also omitted beneath the discourse considering the importance of the relational aspects and the conversations network that permeate fhs practices the phenomenon of gender violence needs specific conditions to be spoken from the perspective of strength and emancipation the limits should overcome a personal conversation and advices that the personal friendship or sympathy would conduct those aspects that were identified in the discourses from the bonds established between professionals and users as determined by continuous service and the proximity that enables fhs possibilities emerge to capture the violence the dialogue and hearing established in this relationship enclose power to overcome trauma and womens strength the possibility of an expanded health care for women implies considering the healthdisease dynamic process related to different universes of meaning in addition to its gendering and valuing of qualities such as solidarity trust transformation of hegemonically defended values egalitarian social relations and recognition of differences so that professional practices are instruments with potential to contribute to social emancipation 6violence and the abuse of alcohol and drugs a complex relationship all studies analised indicated a significant relationship among the abuse of alcohol and drugs and violence the problem appears both in the meanings produced by health professionals as the experiences reported by women the problematic use of alcohol by aggressors in the studies seems as a phenomenon that precedes violent behavior the use of alcohol and other drugs by victimized women is shown in studies as an escape mechanism to escape the physical and emotional effects caused by violence several national and international studies have investigated the association between domestic violence and the abuse of alcohol however a direct causal relationship has not been established excessive alcohol consumption is still one of the biggest controversies between the theories that try to explain violence it is not yet consensus that there is a causal relationship between alcohol and violência with regard to gender violence domestic aggression associated with alcohol use remains mostly perpetrated by men against women consequently assuming that the problematic use of psychoactive substances as a cause of social and complex phenomena as violence would fall into the same unicausal positivist reductionism that has for a long time understood the determinism of healthdisease process the use of alcohol and drugs as violence is a complex social phenomena that have an important relationship observed in several studies mentioned assuming a complex association whose determination involves several other social psychological and biological aspects 7criticalemancipatory workshops as a possibility of professional qualification for facing violence in researches in general there is a significant use of wce as a methodological strategy the method development was an important contribution of the group to use the workshops to collect and analyze data concomitant to reflection and empowerment of participants it was shown that these techniques came to the scientific area as a pedagogical and knowledge production instrument being adapted to objects of research in the social area seeking qualitative transformation of learning spaces 79 studies revealed the fertility of this methodological process that enables the integration of research and social intervention it can be stated that in gender studies workshops constitute a method of feminist episteme based on the theoretical foundations of criticalemancipatory education and in the emotions as constructions of knowledge 69 conclusion violence is a perverse form of power relations based on gender which translates into domination where women are often disadvantaged the analyzed studies bring violence as an object of research in the field of public health practice more specifically in the family health strategy this strategy enables the bond and the approach of professionals with social reality revealing problems before they are invisible and not considered amenable to health intervention and research in general violence is seen as a problem less of health care than others and professionals consider themselves powerless and unprepared to deal with it the concepts are based on the knowledge of common sense and do not take into account the historicity of the imbalance in power relations between men and women in determining the gender violence this area has received a large concentration of studies nowadays driven by increasing contribution of womens movements in uncovering problems which were naturalized before and of little interest to the scientific production it has gradually being constituted an important item in health area which has also stimulated the emergence of research the production of the research group on gender health and nursing reveals that deepening understanding of social phenomena among them violence under the view of gender has brought advances not only in the field of research but also for interventions the field of health practices have been shown to reveal the limits and potential that it permeates the use of gender perspective can be seen as guiding praxis of health care transforming the view on realities and interventions to overcome its contradictions the analysis of the scientific production on gender and violence of the research group on gender health and nursing revealed categories that evidence even among studies with very different methodological designs common findings that enable the consolidation of a powerful conceptual framework to support further research on interventions and policies to prevent and combat gender violence this finding opens a new phase in the scenario of studies interventions in reality aimed at focusing on preventing and facing violence it is these advances that have strengthened the constitution of a field of innovative studies which are counterhegemonic and sometimes contradictory to others at the same time this field is a fertile soil to produce studies that support nursing and womens place in the sun that both seek and deserve

a violência como objeto de pesquisa e intervenção no campo da saúde uma análise a partir da produção do grupo de pesquisa gênero saúde e enfermagem la violencia como un tema de investigación e intervención en salud un análisis de la producción del grupo de investigación de género salud y enfermagem research group of the department of community health nursing school of nursing university of são paulo eeusp registered in the national directory of research groups of the national center for scientific and technological development cnpq research based in the work of fonseca rmgsf oliveira rng gender as fertile ground for research in violence oral presentation 3o congresso ibero americano em investigação qualitativa 1517 july 2014 badajoz es 1 nurse phd in science university of são paulo postdoctoral student nursing departament school of nursing eeusp fapesp scholarship process no 2013067961 são paulo brazil 2 nurse full professor department of community health nursing school of nursing university of são paulo productivity grant 1d of cnpq

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introduction a key tenet of the united kingdoms national health service is that access to healthcare should be fair and equal for all 1 whilst direct financial barriers to healthcare are mostly absorbed by the nhs in the uk 2 barriers presented by indirect and intangible costs still persist studies dating back to 1968 3 report significant socioeconomic and sociodemographic inequalities in access to medical treatment these inequalities have endured through time with those of higher socioeconomic status still receiving better surgical provisions and outcomes relative to need 1 inequalities faced by ethnic minorities need to be acknowledged as they have poorer access relative to white patients 4 a recent review 5 also highlighted ethnic minority patients increased vulnerability to patient safety events including surgical complications and hospitalacquired infections since 2010 government spending on critical social determinants of health has declined by 7 6 these reductions have disproportionately impacted the clinical commissioning groups responsible for ensuring access to healthcare for the most deprived communities of the uk consequently there is a need to determine which patients face the greatest inequalities to help ccgs plan how to distribute their limited financial resources to those in greatest need hip replacement is one of the most frequently performed surgeries in the uk 7 making it a strong case for exploring access inequalities hip replacement is costeffective 8 and improves the quality of life of elderly patients 9 given the ageing population of the uk 10 the healthcare burden placed on the nhs is growing in 2015 it was predicted that the nhs will need to conduct an estimated 439097 hip replacement surgeries by 2035 11 in addition to this figure almost 100000 patients are waiting for delayed joint replacement surgery due to covid19 12 upper estimates from the british medical association suggest that clearing the backlog of elective surgery will cost the nhs £54 billion 13 delayed hip replacements have a detrimental impact on patients 14 including worse postoperative outcomes depression 15 and increased reliance on opioid painkillers 16 the direct and indirect costs associated with delayed surgery increase the financial strain on patients and the nhs 14 the nhs long term plan 17 aims to improve healthcare access with an estimated £1 billion spend in areas with the greatest inequalities previous financial incentives to promote healthcare equality such as payforperformance schemes have been criticised for their inability to tackle prorich inequalities in hip replacement surgery 18 furthermore evidence suggests that adding this competitive element to healthcare leads to a fading of ethics in how performance goals are achieved 19 this ethical fading in the pursuit of achieving greater funding risks exacerbating inequalities in the social determinants of health by providing a breakdown of factors affecting access to hip replacement surgery this systematic review aims to provide evidence to inform policy decisions the objectives will be to 1 determine which patients experience inequalities in access to hip replacement surgery 2 determine where these patients are located in the uk and 3 explore other variables that influence the observations such as differences between hospitals this review will take a multifaceted approach by exploring surgical access need provision and outcome to achieve a wider picture of which areas drive access inequalities inequalities in healthcare access have been reviewed previously 20 but no review has focused explicitly on hip replacement surgery a phd thesis 21 containing a systematic review exploring equality in access was identified however the scope differed from this review as it included multiple countries and knee replacement surgery methods a systematic search of published literature was performed on 4th february 2021 the search strategy followed the population phenomena of interest and context framework pico is explicitly designed 22 for qualitative research and is adapted from the population intervention control outcome framework relevant medical subject headings keywords were extracted from the previous review 21 and organised into pico subheadings the search was performed in the following databases medline pubmed and web of science the complete search strategy is described table 9 in appendix 1 eligibility criteria search records were eligible for inclusion provided specific criteria were met identified articles were reviewed as specified by the preferred reporting items for systematic review and metaanalyses 2020 guidelines 23 articles were organised screened and deduplicated using rayyan 24 a semiautomated webtool that assists with exclusion and inclusion decisions while automatically detecting duplicate studies assessment of risk of bias the risk of bias of the included studies was assessed using a checklist adapted from mújicamota et al 25 this checklist assesses the impact of selection bias and confounding two significant challenges for observational studies 26 the checklist questions determine patient characteristics patient wellbeing disease severity detail of hip surgery and hospitalrelated confounders the presence of confidence intervals was used to determine whether random error was accounted for in study data a score was calculated as a sum of the criteria met by each study to facilitate comparison between them data extraction published data from the included studies were extracted under the following categories study design year of publication study population study timeframe source of study data and measurement domains this data is presented in table 3 these categories were adapted from the study overview presented in a previous paper 21 results search results over the three databases searched 482 articles were identified of which 382 were removed in the deduplication process with duplicates removed 120 articles were screened against the inclusion criteria sixtysix papers published before december 2005 and those without ukbased cohorts were removed the remaining 54 articles were screened against the exclusion criteria using fulltext copies resulting in the removal of a further 38 papers reasons for removal are shown figure 1 in appendix 2 the most prevalent reasons for removal were studies that discussed an unrelated pathology such as shoulder arthroplasty and studies relating to patients postoperative return to work the 16 remaining studies were included in this systematic review study characteristics the 16 studies included in this review are of varying characteristics and demographics table 3 shows an overview of the study characteristics the year of publication for the included studies ranged from 2007 to 2016 the largest study 27 explored 406253 patients over 10 years and the smallest study 28 explored 282 patients over a single year of the included studies 8 were crosssectional studies 12 28 29 30 31 32 33 7 were ecological studies 427 34 35 36 37 38 and one was a longitudinal study 39 the shortest timeframe of the included studies was 1 year 2 28 29 30 32 and the longest was 10 years 2731 the datasets used by studies ranged in age from 1991 31 to 2012 4 in terms of patientlevel datasets used seven studies incorporated hospital episode statistics data 124 30 31 32 33 an englandwide database of all nhs hospital activity one study used the scottish morbidity record 36 which provides similar patientlevel data to hes but for scotland four studies used internal hospital data 28293739 and two studies used unspecified national patientlevel data 2738 two studies used a combination of localscale and nationalscale patientlevel data from the somerset and avon survey of health and the english longitudinal study of ageing respectively 134 english indices of multiple deprivation were used by 10 studies to assess ses 1 2 4 2830 3234 38 7 of which used the 2004 edition 1 2830 32 34 38 2 used the 2007 edition 233 and one used the 2010 edition 4 scottish imd were used by two studies both of which used the 2006 edition 3637 two studies used the carstairs index 2739 one study used the townsend index 31 an unknown quintilebased deprivation index was used by one study 35 a complete list of assessed domains is provided in table 3 risk of bias the risk of bias checklist for assessing the quality of the included studies is shown in table 4 with the number of questions answered by each study for comparison all studies recorded the age and gender of the study population of the 16 studies only one included data from private hospital admissions 29 two reported the distance travelled by patients to receive hip replacement surgery 132 three studies had information on the rurality of patients residences 12732 four studies had information on patients quality of life 4 37 38 39 or their body mass index scores 4343739 two studies met the most quality criteria answering 12 out of 16 questions 14 one study met the fewest quality criteria answering only five questions 31 on average the included studies answered nine questions for quality criteria 36 31 32 4 37 28 39 33 38 were the following study characteristics reported study population • • • • • • • • • • • • • age • • • • • • • • • • • • • • • • gender • • • • • • • • • • • • • • • • ethnicity • • • • • • • primary diagnosis • • • • • • • • • • bmi • • • • rurality of residence • • • distance travelled for care • • were patientrecorded outcome measures assessed • • • • • • • was patientrecorded quality of life assessed • • • • was the type of hip surgery reported • • • • • • • • • • • • • • was a distinction made between primary and revision surgeries • • • • • • • • • • • • • were hospitalrelated factors assessed • • • • • • did the study assess data from more than one hospital • • • • • • • • • • • • • was data from private hospitals included • were confidence intervals presented with data analysis • • • • • • • • • • • • • outcome score need for hip replacement surgery table 5 shows the results for the three included studies that explored the need for hip replacement surgery 22934 judge et al 34 reported that 319 per 1000 english residents over 50 years old were in need of a hip replacement need was greatest for patients living in the mostdeprived areas a stronger linear relationship was found between occupational social class and need with the lowest social class having the greatest surgical need neuburger et al 2 showed that before surgery mean oxford hip score was 36 points lower in the leastdeprived patients than the mostdeprived soljak et al 29 reported a similar trend in ohs with mean ohs 35 points lower in the leastdeprived patients than the mostdeprived however adjusting for age sex general health comorbidities and patientreported quality of life lowered the level of significance increasing the pvalue from p 0001 to p 002 neuburger et al 2 showed the mostdeprived patients experienced hip problems for a longer duration than the leastdeprived longerterm hip problems were also associated with patients younger than 50 years old compared to patients aged 71 to 80 despite this judge et al 34 found that rates of need increased with age with patients aged over 85 years experiencing the greatest need after adjustment for obesity patient bmi scores above 30 were a strong predictor for surgical need women have a greater reported need for surgery than men with neuburger et al 2 reporting a mean presurgical ohs 23 points lower than for men despite this women had a lower likelihood of reporting longterm hip problems than men south asian and black patients had lower mean ohs than white patients south asian patients had mean ohs 27 points lower than white patients and black patients had mean ohs scores 09 points lower however when comparing the mean ohs of black and white patients the adjusted differences were not statistically significant at the 5 level judge et al 34 found that whilst univariable analyses suggested nonwhite patients had a greater surgical need this effect was due to confounding from areabased deprivation and social class furthermore no association was found between the ethnic mix of patients residence and surgical need neither was any association found between the rurality of patient residence and surgical need access to hip replacement surgery table 6 shows the results for the five included studies that explored overall access to surgery 127303536 judge et al 1 reported 70 less provision relative to need in the lowest ses patients for england cookson et al 35 showed that the ratio between provision and need increased by 12 from 2002 to 2009 judge et al 1 reported that for every 1000 english people in need of hip replacement only 44 will undergo the operation cookson et al 35 report that the average rate of hip replacement across england in 2009 was 202 per 10000 people over 35 years of age when adjusted for age and sex hip replacement rates were higher in the leastdeprived quintile than the mostdeprived with a q5q1 ratio of 135 that isq1 patients were 35 more likely to undergo surgery than q5 patients kirkwood et al 36 reported that while geographical inequality significantly improved in scotland from 1998 to 2008 socioeconomic inequality did not change significantly judge et al 1 also noted greater access inequality in the west midlands london and the north of england with patients in the south of england experiencing greater provision relative to need increased rurality in england was associated with greater provision relative to need as were longer road travel times for care kirkwood et al 36 reported that hip replacement rates were significantly lower in the mostdeprived simd quintile than any other quintiles in terms of waiting times laudicella et al 30 showed that the most educated patients waiting times for surgery were 165 shorter than for less educated patients the same trend applied to patient income as patients with the lowest income waited 75 longer than patients with the highest income from 1997 to 2000 cooper et al 27 reported that each decreasing quintile below q1 was associated with an additional 12 week wait for surgery despite this by 2007 they reported almost uniformly distributed waiting times across the deprivation quintiles cooper et al 27 was the only accessrelated study to report an overall decrease in waiting time and ses inequality from 1997 to 2007 judge et al 1 reported that people aged 6064 received more surgeries relative to need compared to those aged 5059 those aged over 85 also received less surgery laudicella et al 30 also reported that patients aged 75 years and older waited 1730 less than patients aged 4554 these patients were also more likely to experience a greater number of disabilities cooper et al 27 reported that men received 8 more surgeries relative to need compared to women despite this laudicella et al 30 reported male patients as having to wait 35 longer compared to female patients judge et al 1 reported that the ethnic mix of patients area of residence did not affect access to hip replacement surgery provision of hip replacement surgery table 7 shows the results for the three included studies that explored the provision of hip replacement surgery as determined by the rate of surgery 43132 from 1991 to 2001 cookson et al 31 reported that the rate of hip replacement in england rose from 160 per 100000 to 184 per 100000 an increase in provision was observed among more deprived patients with utilisation rate ratios for the mostdeprived quintile rising from 0804 to 0843 the increase in surgical rate required for the rate of surgery in the mostdeprived patients to match the rate in the leastdeprived patients fell from 41 to 27 in patients aged 50 to 59 years judge et al 32 found the most deprived had the greatest surgical provision despite this an inverse effect was seen in patients over 85 provision decreased with increasing deprivation women received greater provision across all age groups than men however the effect was weakest in the oldest and youngest age groups geography influenced gender variation men in the london borough of lambeth received 28 less provision than women compared to men in wansbeck northeast england who received 20 more provision than women however smith et al 4 reported little difference in provision between men and women cookson et al 31 reported that in both 1991 and 2001 surgical provision was lower than expected for patients in the lowest third of ses smith et al 4 also reported fewer surgical procedures were performed on black and asian patients than expected ethnic minority patients were younger and had greater physiological asa fitness grade but were likely to live in more deprived areas surgeries performed on black patients were more likely to use uncemented hip prostheses instead of cemented prostheses despite this judge et al 32 reported no differences in procedure related to patient ethnicity smith et al 4 also reported that black and asian patients were more likely to receive hip replacements due to osteonecrosis rheumatoid arthritis and congenital dysplasia compared to white patients surgical provision was greater in hospitals with more operating theatres and higher surgical rates despite this hospitals with greater numbers of consultants specifically anaesthetic consultants had lower rates of provision in terms of rurality nonurban patients experienced greater surgical provision as did patients living further from the hospital surgical outcome of hip replacement surgery table 8 shows the results for the five included studies that explored surgical outcomes 2833 37 38 39 preoperatively clement et al 39 reported that the mostdeprived patients depcat scored 58 points lower than the leastdeprived on a scale of selfreported hip condition neuburger et al 33 also reported a mean ohs 40 points lower in the mostdeprived patients versus the leastdeprived jenkins et al 37 reported that more deprived patients had worse selfreported hip condition presurgery at 6 months after surgery and 18 months after surgery at 6 months after surgery neuburger et al 33 reported a mean ohs 50 points lower for the mostdeprived patients versus the leastdeprived the mostdeprived patients were 32 more likely to report no improvement in their hip condition after surgery and were also more likely to report a decline in condition cookson and laudicella 38 reported that the mostdeprived patients remained in hospital after surgery 6 longer in 2001 falling to 2 longer by 2007 at 18 months after surgery jenkins et al 37 reported significantly worse mental and physical wellbeing in more deprived patients neuburger et al 33 identified that 33 of patients living in the mostdeprived areas reported poor general health compared to 18 in the leastdeprived areas more deprived patients also had more comorbidities except for cancer cookson and laudicella 38 reported that patients with seven or more comorbidities stayed in hospital 58 longer than other patients in 2001 increasing to 73 longer by 2007 clement et al 39 reported that the comorbidity that predicted no improvement in condition 12 months after surgery was depression in contrast jenkins et al 37 reported no differences associated with ses and preoperative comorbidities despite this a greater proportion of patients with an asa status grade i were in the lowest deprivation quintile compared to the highest quintile another surgical risk identifier the physiological and operative severity score for the enumeration of mortality and morbidity was used by hollowell et al 28 who showed a modest socioeconomic gradient in possum score with surgical risk significantly decreasing from deprivation quintile q5 to q1 however no evidence was found between ses and postoperative morbidity clement et al 39 also found no significant association between overall postoperative morbidity and ses but did find a significant association with postoperative hip dislocation in the mostdeprived groups no significant difference between patients ses and bmi was found by clement et al 39 and jenkins et al 37 jenkins et al 37 showed a significantly lower proportion of active smokers in the leastdeprived quintile compared to the mostdeprived discussion socioeconomic inequalities in hip replacement surgery socioeconomic inequality was the most widely measured variable affecting access in england the mostdeprived patients received 70 lower surgical provision relative to need compared to the leastdeprived 1 one study reported that some lower ses patients reported worse hip condition after surgery 33 in contrast a dutch study 40 found no evidence of educational levels impacting postoperative patient quality of life as assessed by the sf36 questionnaire a swedish study 41 also investigated educationrelated deprivation but found no association with postoperative mortality risk questioning its applicability as a sole indicator of deprivation interestingly a study 42 focusing only on olderage patients found the only commonly used socioeconomic indicator independently associated with health was income education social class and occupational complexity had no independent effects on health in olderage patients this is an important consideration for future studies investigating hip replacement surgery as osteoarthritis typically starts at around 50 years of age 43 however one study found a stronger relationship between social class and surgical need than english imd and surgical need 34 some study cohorts were not representative of the wider uk population due to fewer patients in more deprived imd quintiles 233 this is a notable sampling bias that can reduce the reliability of deprivation indicators such as the imd none of the included studies provided evidence that authors implemented controls for measuring deprivation in older age groups the income deprivation affecting older people is a supplementary index in the english imd 44 tailored to assess income deprivation for over60yearolds a study that specifically focused on the income index of imd one of seven areas assessed in the imd to show overall deprivation did not use the idaopi 30 increasing the risk of sampling bias both the carstairs and townsend deprivation indices use employment as part of their assessment of deprivation 44 over the timeframes of the studies that used these indices 273139 the uk employment rate of over 65yearolds was only around 55 to 73 45 with a lower employment rate in more elderly patients employment is an inadequate indicator of deprivation for hip replacement patients furthermore hip osteoarthritis has been associated with early retirement 46 which suggests the actual employment rate for hip replacement patients is lower than the uk average future studies must cautiously consider which measure of socioeconomic deprivation to choose ensuring that the outcome will be valid for their studys sociodemographic characteristics ethnicityrelated inequalities in hip replacement surgery three studies exploring ethnic mix found no association between access need or provision of surgery and ethnic mix of patient residence 13234 this contrasts with evidence from the usa where a study in individuals with federal health insurance showed that black patients were 30 less likely to undergo hip replacement surgery than white patients after age and genderstandardisation 47 furthermore black patients were also shown to have worse preoperative and postoperative pain and function scores 48 one of the studies reporting no association between ethnic mix and surgical need also reported that while initial data reported an association this was eliminated by controlling for social class and deprivation 34 through an awareness of the intersectionality between ethnicity and ses studies can explore distinct trends in inequality without conflating the two variables ethnicityrelated inequalities have been shown to be distinct from ses in a study assessing incomebased inequality 47 in this case incomebased inequality was a more suitable indicator for assessing ses as it allows for individuallevel analysis ethnic mix and imd are arealevel ecological measures that are not able to show causation or be extrapolated to the individual level it is essential to recognise this ecological bias as in order for ethnic inequality to be distinctly explored both ethnicity and socioeconomic status need to be individually assessed two studies explored distinct ethnic minority groups 24 one study found black and asian patients are more likely to suffer from rheumatoid arthritis and osteonecrosis as their primary condition before hip replacement 4 both conditions were also associated with shorter waiting times due to their increased severity over osteoarthritis 30 when only osteoarthritis patients were assessed more severe hip condition was shown in black and south asian patients 2 however the minimal clinically important differences in ohs were not met 49 nevertheless the increased urgency of surgery in patients with osteonecrosis and rheumatoid arthritis 30 presents a potential confounding variable also the majority of studies that controlled for primary diagnosis only removed cancer or traumarelated hip replacements 131 3439 which are known to disproportionately affect lower social classes 35 to reduce the impact of primary diagnosis as a confounder future studies might focus on specific preoperative diagnoses however it must be noted that there is strong evidence that the quality of ethnicity data reported by individual hospitals varies 50 studies investigating differences between individual ethnic minorities should consider this potential for misclassification error in their sensitivity analyses furthermore crosssectional studies exploring trends over multiple hospitals should ensure other interand intrahospital variables are not responsible for observed patientlevel trends 303338 in standard regression analysis hypothesised unequal surgical provision in ethnic minorities could be explored using rate of surgery as a dependent variable and the ethnic diversity of hospital staff as a key predictor even if this investigation were able to prove the original hypothesis unobserved variables such as differences in primary diagnosis introduce omitted variable bias 51 hospital fixedeffects models include hospital dummies in the regression analysis to control for observed and unobserved variables such as primary diagnosis diminishing potential omitted variable bias 52 studies performing regression analyses should consider using a hospital fixedeffects model to mitigate the impact of omitted variable bias geographical inequalities in hip replacement surgery scottish geographical inequality in access to hip replacement surgery declined from 1998 to 2008 36 however england has a distinct northsouth divide in surgical access 1 the higher the needtoprovision ratio the greater the gap between high surgical need and low surgical provision with ratios being the highest in southern england and lowest in northern england variations exist within this divide with domains such as male gender having pockets of higher provision in low needtoprovision ratio areas 32 this is despite evidence showing men had lower surgical need and provision compared to women 13234 studies have suggested a postcode lottery effect might be responsible 36 this effect describes certain areas that provide greater provision due to discrepancies in resource allocation by local ccgs no relationship between rurality and need was found by one study 34 however needtoprovision ratios were higher in rural areas 1 this contrasts with findings that urban hospitals with greater surgical capacity have greater surgical provision 132 however higher provision ratios for rural patients provide a potential explanation for studies that found associations between longer travel times for treatment and increased provision 132 differences in rurality also affect arealevel deprivation measures such as the imd a us study showed that arealevel deprivation measures significantly disagreed with individuallevel deprivation measures in ruralurban mix areas 53 a new poverty index is currently under development by the department of work and pensions as an individuallevel alternative to deprivation indices 54 it is hoped future studies may utilise this index to provide more reliable data on healthcare inequalities across the uk one method the uk government has used to attempt to reduce geographic inequality was creating independent sector treatment centres in 2002 55 these are private hospitals contracted by the nhs to conduct elective procedures one included study 36 reported a reduction in nhsfunded private hip replacements in scotland from 2008 to 2011 from 83 to 08 however in england private hospitals conducted 30 of all nhsfunded hip replacements in 201718 56 increases in nhsfunded private surgeries have been associated with the diversion of funds from the nhs to the private sector 57 in scotland this has resulted in significantly reduced direct nhs surgical provision and a wider socioeconomic gap in provision measured using simd while provision inequity between socioeconomic groups is still apparent in the uk evidence shows the gap has fallen over time in england 273138 consequently an increase in nhsfunded private surgeries threatens to weaken past improvements in socioeconomic and geographical inequality with fears regarding the privatisation of the nhs increasing 58 researchers should investigate the relationship between the proportion of nhsfunded surgeries and socioeconomic inequality in the uk lifestyle and comorbidity inequalities in hip replacement surgery increasing numbers of ccgs in the uk have begun implementing rationing measures for smokers and obese patients 59 concerns have been raised over such measures with arguments that obesity and smoking are linked to lower ses and therefore rationing would disproportionately affect lower ses patients significantly fewer current smokers were observed in more deprived quintiles 37 despite this two studies 3739 investigating surgical outcomes showed obesity as having no relationship to ses in addition evidence suggests that other preoperative comorbidities which are more common in lower ses patients 2 are not perceived as an access barrier to hip replacement surgery 60 nevertheless it is vital that regardless of the involvement of ses patients with higher bmi scores do not face discrimination recent evidence 61 from the us shows that while obesity is linked to a greater risk of surgical complication 6month postoperative sf36 physical wellbeing scores were similar between obese and nonobese hip replacement patients furthermore a study 62 investigating smokers exsmokers and nonsmokers found no clinically important difference in postoperative patientreported outcome measures between groups although greater mortality and complication risk were observed this evidence shows that the basis behind smoking and obesityrelated rationing measures is weaker than suggested and such measures should be reviewed to ensure they do not unnecessarily discriminate as of 2009 the nhs has required preoperative and postoperative proms to be collected for all hip replacement surgery patients 63 however completing these questionnaires is not mandatory younger deprived nonwhite men who live alone and have poorer quality of life have been linked to higher nonresponse rates caution should be exercised when interpreting outcomes based solely on proms as nonresponse bias may cause misrepresentation of the groups that face the greatest healthcare inequality another issue faced when assessing proms is what change in score can be considered clinically meaningful for the ohs the mcid was calculated to be a 5point increase or decrease 49 of the four 2293339 included studies that used the ohs two 3339 achieved the mcid necessary to prove their association between deprivation and surgical outcome the other two studies 229 failed to reach the mcid harming the validity of reported access inequalities in age gender ethnicity and deprivation despite their statistical significance despite this one study 29 still reported their findings as statistically highly significant as the reported pvalue was 0001 one included study 37 used the hhs however scores failed to achieve the mcid of between a 7and 10point 64 change no mcid values could be found for the new zealand score used by two included studies researchers must ensure that the clinical importance of findings is not purely based on statistical significance and relevant mcids are used for the intervention being assessed and prom used limitations of review only one study had welsh data and no studies had northern irish data excluding large samples of the uk population introduces selection bias as the missing population data may have changed the pattern of inequalities described consequently a narrower approach individually focussing on england or scotland may have been more suitable while a lack of research may be responsible for the lack of welsh and northern irish data it is also possible that geographical search criteria may have been imprecise a custom uk geographical filter was used for the medline database search 65 it was only effective for that specific database the simplified filter used for other databases may have excluded relevant studies development of an automated internet or softwarebased tool to remap search syntax between different databases would allow the custom filter to work in other databases the risk of bias is challenging to assess for observational studies and is further limited by the included studies data heterogeneity different checklist questions may have different weightings on study bias making interpretation of summary scores challenging there is a need for a standardised methodology to assess the risk of bias in observational studies this methodology must be easy to apply and allow identification of individual risks of bias whilst facilitating quick comparison between the overall risks of bias in different studies conclusion this review summarises the available literature on access inequalities in hip replacement surgery for the uk while the heterogeneity of study outcomes and methodology made drawing conclusive evidence challenging it is clear that access inequality is a major issue in the uk potential inequalities in presurgical patient consultation were not explored in the included studies patient diagnosis and referral to surgery may be impacted by implicit biases present in practitioners such as an ethnic bias in pain evaluation for black patients 66 despite the unknown prevalence of such ethnic biases their potential impact signals the importance of increasing workforce diversity in addition to mandatory implicit bias training for nhs staff this review demonstrates that there is a shortage of studies that assist in understanding the relationship between sociodemographic or socioeconomic variables and health inequalities there is a need for bigger studies with more variables based on routinely gathered healthcare data these studies need to be complemented by proms and ethnographic approaches to gather patient narratives this will assist the development of better services to address inequalities given ongoing protests for racial equality and the impact of the covid19 pandemic now is a crucial time to tackle gaps in equality and prevent their growth appendix 1 table 9 full database search strategy for included studies † to complete the search pico tools were combined as follows population and interest and context i and context ii exp refers to an exploded search whereby more niche mesh keywords relating to the wider concept were captured mp refers to a multipurpose search whereby the specific term is searched for in several fields of the article including the title and abstract tw refers to a text word search whereby the specific term is searched for only in the title and abstract for added specificity mh refers to a mesh specific search which ensures the terms are searched as meshspecific keywords only tiab refers to title and abstract search whereby the specific term is searched for only in the title and abstract ts refers to a topic search whereby the specific term is searched for in several fields of the article including the title and abstract and are truncation symbols allowing for a variety of wordendings to be captured competing interests none • 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 • 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persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the uk consequently a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery database searches were performed using medline pubmed and web of science studies with a focus on surgical need access provision and outcome were of interest inequalities were explored in the context of sociodemographic characteristics socioeconomic status ses geographical location and hospitalrelated variables only studies in the context of the uk were included screening of search and extraction of data were performed and 482 articles were identified in the database search of which 16 were eligible eligible studies consisted of eight crosssectional studies seven ecological studies and one longitudinal study although socioeconomic inequality has somewhat decreased lower ses patients and ethnic minority patients demonstrate increased surgical needs reduced access and poor outcomes lower ses and black minority patients were younger and had more comorbidities surgical need increased with age women had greater surgical need and provision than men geographical inequality had reduced in scotland but a northsouth divide persists in england rural areas received greater provision relative to need despite increased travel for care in all access inequalities remain widespread and policy change driven by research is needed

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there are few related descriptions of contextual and psychological factors experienced by rural elders who anticipate relocation relocation has long been associated with stress although anticipation of relocation has been viewed as a stressor for older adults it has not been labeled as a chronic stressor chronic stressors have been defined as persistent or recurrent difficulties of life the most common chronic stressors include difficulties carrying out roles and role conflicts chronic stress also can arise when persons believe that they have few choices in their daily lives it is evidenced by the perception that a situation is unduly complex however most of the extant work on the nature of chronic stressors pertains to adults who are employed outside the home based on a factor analysis of a measure of home and job stress serido et al discerned four types of chronic stressors work demands home demands lack of home control and lack of work control finding that chronic stressors adversely affected psychological wellbeing serido et al concluded chronic stressors present an ongoing threat to the individual the everpresent potential to erupt in ways both large and small in an individuals daily life exploration of the experience of anticipated relocation could inform a perspective about whether it could be a chronic stressor for some older rural adults who live alone if so such situations could warrant particular interventions to promote health and enhance quality of life for older adults the purpose of this phenomenological study was to describe the personalsocial context of the experience of anticipated relocation for one older rural homebound woman ms berson from a phenomenological perspective natural knowledge begins with experience and remains within experience p 45 context was understood from a phenomenological perspective as the everyday lifeworld the point of reference that one uses to explain the world findings detail the points of reference ms berson used during her frequent spontaneous references to concerns about a longcontemplated move to the nursing home in her rural town it is likely that she perceived anticipated relocation as a chronic stressor method this work emerges from a particular aim of a longitudinal study of the experience of reaching help quickly which was to describe the rhq experience of each woman in the sample and to set the experience in its personalsocial context over the 18month study 4 inhome interviews were to be done with each of 40 women who lived alone were 85 years of age or older and needed personal help a walking device or both to leave home the rhq study was approved by the health sciences institutional review board at the university of missouri the study was publicized by contacts with nearby social service agencies and through newspaper advertisements volunteers contacted the lead researcher by telephone or by mailing a preaddressed stamped postcard volunteers were screened for inclusion criteria during a telephone call and if eligible were invited to learn more about the study during a preliminary home interview the lead researcher read the informed consent aloud and answered questions about the study before inviting the volunteer to participate and to sign the consent sample upon enrollment the 40 participants ranged in age from 85 to 98 the mean age was 896 years because advanced age is considered protected health information according to the health insurance portability and accountability act the precise age of ms berson the subject of this case study cannot be disclosed however she was 90 years or older on enrollment in the study and her age exceeded the mean age of the sample she was one of the 16 rural women in the sample defined as rural by virtue of living in the open countryside or in a place of less than 2500 persons in addition to ms berson other women in the sample referred to the possibility of relocating to a more supervised living situation and several actually did so during the project however ms berson is the focus for this case study because her data were an exemplary illustration of the pragmatic motive basic to lifeworld she struggled with the problem of anticipating relocation but she remained at home because she could repeat her past successful acts she was able to sustain herself at home with help until further notice notice that arrived abruptly after the research project ended porters project staff also contacted each woman for a monthly telephone conversation when an inhome interview was not scheduled during a telephone call if a woman reported a fall a hospitalization or a major health change that could have influenced her need to reach help quickly we asked for an additional inhome interview to discuss the situation ms berson experienced a fall after interview 2 so she had an extra inhome interview in all we had 17 contacts with her over 18 months the author conducted all of ms bersons inhome interviews and most of her monthly telephone interviews a trained research associate did the other telephone interviews each interview was transcribed and uploaded into qsr n6 to enable data management data collection to obtain particular data about rhq from each participant we developed a semistructured interview guide for each inhome interview and used a standard interview guide for telephone calls questions pertained to the experience of rhq and its context including the need for and use of assistive devices and personal help and health concerns we employed an openended interview technique after introducing a question we allowed ms berson to talk at will there were no questions about relocation on the interview guide but she raised that topic during each inhome interview and 8 of her 11 telephone contacts during interviews she often spontaneously mentioned the possibility of relocation during soliloquies about her hope to continue living alone with help during telephone calls she spoke of anticipating relocation in response to routine questions about whether she was still living alone or whether she had fallen thus she created opportunities to reveal the stress she associated with anticipating relocation in addition she revealed important lifehistory and lifecourse migration information that is often neglected in longitudinal studies of relocation such remarks illuminated her lifeworld and enabled understanding of the experience of anticipating relocation data analysis in porters method for describing lifeworld interviews are read and reread to capture data about how participants explain their world those facets of lifeworld are detailed in gerund phrases using everyday language to characterize their empirical nature for example i sketched ms bersons concern about being unable to care for herself in this phrase foreseeing a time when i might not be able to do that lifeworld is to be sketched in objectivated categories or a taxonomy the most basic individualized level is that of the lifeworld element all findings reported here are lifeworld elements finally because lifeworld has intersubjective dimensions engaging in dialogue about lifeworld is essential i discussed findings with ms berson from time to time asking if i had captured what she was conveying i also discussed each interview with coinvestigators to refine ideas findings are presented in concert with the dialectical perspective that is basic to lifeworld that is although facets of lifeworld can be taken for granted as givens lifeworld is surrounded by uncertainty its horizons are indeterminate but dialectical poles such as near and far home ground and foreign ground can be perceived relative to where one stands after presenting a sketch of ms bersons life i report dialectical facets of her lifeworld that are linked to anticipating relocation in data excerpts interviewer remarks are in brackets findings a lifesketch with migration history ms berson lived in missouri in dexter a rural town of less than 1500 people she was born about 100 miles from dexter also in missouri in a rural area that had been home to her parents families for several generations when she was a toddler her parents moved the family about 400 miles to another rural community in another state her parents and several younger siblings died in the flu epidemic of 1918 family members took her and several siblings back to the rural area where she was born she was raised by her grandmother she obtained a teaching certificate when she graduated from high school and took additional credits at a university about 45 miles away she moved to a more urbanized area about 100 miles away to take a teaching job but left teaching for a betterpaying job in a shoe factory she met her future husband a river employee at the place where they were both boarding they were married when she was 21 years old a few years later he was transferred to dexter about 140 miles away where their son was born after renting a home for about 20 years they bought the home where ms berson had lived for more than 40 years when she enrolled in the project after moving to dexter ms berson worked outside the home for about 30 years until she had the first of two mastectomy surgeries she nearly died of cardiac failure at age 50 but she had a successful heart surgery her husband cared for her as she recovered from surgeries after mr berson suffered a brain injury she took care of him at home until the physician advised her that she had no choice but to admit him to the nursing home she was deeply regretful she visited him daily he lived there for several years she arranged for his burial in a rural cemetery in the county where she was born i want to be buried by him i put up a double stone my names on it and when i was born the only thing thats not on it is when i die life circumstances upon project enrollment ms berson had been a widow for nearly 30 years when she enrolled in the project after her husband died she said i was getting pretty lonely here so she starting selling a product doortodoor i had good luck with it and went all over town and knew where everybody lived and got acquainted with them some of them i had worked with and they ordered from me and i liked that she had given up her car at least 15 years before enrolling in the project for at least 5 years she had been unable to leave home without a walking device her son who had health problems lived about 1500 miles away and visited several times a year she had lost close contact with her two granddaughters both of whom lived at least 1000 miles from dexter ms bersons health status was somewhat precarious she took heartrelated medications her status was monitored weekly by homecare nurses and periodically by cardiologists at the urban medical center some 50 miles from dexter where she was also under care for chronic urinary incontinence she could see to get around but she had a medley of visual impairments she frequently used a walking aide indoors and always used one when she went outdoors she had suffered so many falls that she could not remember them all but she took the risk of falling to be out in the garden im gonna go out even if i fall because in the little while ive got left i want to see my flowers as long as i can see and the weather gets warm im going out and try to pick a tomato and get it in the house after she fell outdoors during one of her sons visits he ordered a personal emergency response system despite her opposition im the one apayin for the thing she always wore the pers helpbutton but she had never used it at the outset of interview 1 ms berson revealed her intention to live at home as long as possible when we asked her to explain why she needed help to get out of the house the reason i use this all the time its got a banister on both sides my husband put them banisters in when he was living yet when he owned the place because he said well need it sometime so even he was getting me fixed up for old age so i hold to them when i go up and come down and when im able to take the garbage out i hold to the banister always with one hand and the garbage i carry with this hand but i havent been going out in the snow or the ice my neighbor will bring me my groceries today and pick the trash up tomorrow and i pay him for the groceries and thank god ive had enough to pay my bills so far when my husband was ill i was awonderin how much longer i could keep paying the nursing home and paying to keep this house along for myself later in interview 1 when asked who she would contact if she needed to reach help quickly ms berson mentioned her neighbor and the homecare nurses then she said and different ones that works out here at the nursing home as nurses and things have told me if i ever needed help to call them and they would come you know there are people i know and theyre trying to get me to come to the nursing home i guess im older than people thats out there but i still own my own home and i dont have any bills against it but the homeowners insurance is agettin so high i dont know it goes up at least a hundred every year i might be ahead to go to the nursing home well no i wouldnt be because it would be a hundred and something a day no i wouldnt thus ms bersons lifeworld was characterized by being invited to move to the nursing home and wondering if i would be ahead to go the nursing home over the next 18 months she wondered aloud whether she should act on that invitation factors she associated with anticipated relocation are explained below as dialectical lifeworld elements lifeworld facets linked to anticipated relocation outliving age peers and acknowledging that i do not have that much time left throughout the project ms berson frequently described herself as the only one left of her friends and agemates when you consider im past and other women have died and not as old as i am 10 years younger than i am and theyre all adying i dont have any friends left or any foes either one im alive yet and thats more than they are yet with the lengthening of her days came the knowledge that the remaining time was truncated ms berson frequently said that the surgical heart procedure she had had 40 years earlier had far exceeded its predictable duration physicians had said that at some point the repair would suddenly cease to function due to her age everyone involved had ruled out an attempt at another repair they told me id be unconscious it would be like a stroke but i dont worry about it what is to be will be i just hope i dont suffer nobody can expect to live forever wondering how much longer i can live alone and knowing where i will end up if i cannot wait on myself ms berson described herself as clumsy and stumbly she could not get into the bathtub safely without the aides help she felt so tired that she often napped morning and afternoon in interview 2 she said i dont know how much longer ill be able to live here alone i dont want to go to a nursing home until i have to but thats where im going to end up if i cant wait on myself she had seen that scenario played out with friends including a woman who went to the urban medical center after a light stroke they didnt ask her if she wanted to go home or if she wanted to go to the nursing home they took her to the nursing home shes been there ever since and i guess they will be there the rest of their lives staying out of a nursing home and knowing where i would want to go if i have to leave home initially ms berson offered only one reason why the nursing home would not be her ideal living arrangement i can raise a few tomatoes and things that i like to have i like to eat what i like at the nursing home id have to eat what somebody would tell me to eat yet realizing that she could end up there she voiced that scenario as a plan in interview 2 when i cant wait on myself and do for myself anymore what i plan to do is go to the nursing home she had ruled out any possibility of living with a family member in interview 3 she spoke of other friends who had entered the nursing home from the hospital theyre out here we have a nursing home out here theyre all in the same one then yeah thats the one i would kind of like to go to… id like to stay in dexter where i know people beyond those factors there were still other reasons she had settled on that nursing home if she had to leave home i had had open heart surgery and they was awantin to build a nursing home here they needed it they needed some kind of a place here in dexter they had a hard time raising the money that they had to have to build it a lady that lived out there had the ground on that hill and she gave the ground for the nursing home i think they was 20 or 25 gave money or raised money and gave money and then the rest of it they borrowed and my husband and different people helped my husband could survey being on the river helped survey the ground out and he donated money too so i feel like ive got a little interest in this nursing home it used to be full all the time but it seems like where a lot of them are having the nurses someone in the house with them a wife or someone and they dont go to the nursing home anymore i dont know how much longer theyll be able to keep this operating as a nursing home are you concerned that they might have to stop operating well kind of after all im a stockholder in the thing yes thats the one you would prefer to go to if you had to go then well yeah i think thats where i should go it wouldnt only benefit myself it would be a benefit to everybody that was like bertha and ella and me alivin alone paying in advance for something i hope i do not need and considering whether i would be ahead to go to the nursing home ms berson focused on the finances associated with going to a nursing home or staying at home her lifeworld was featured by two interconnected facets underlying the intention of making the ends meet with ends understood the end of the money and the end of my life first in interview 1 she explained that she was apayin five hundred dollars a month for nursing home insurance … that is supposed to pay a hundred dollars a day on a nursing home ill just have to wait and see if i need it or not i just hope when the time comes i could just go to sleep and i wont wake up she also voiced the conclusion that moving to the nursing home would not be a wise financial decision however she was still considering whether i would be ahead to go to the nursing home and 7 months later her view had changed in interview 3 she explained why relocating might be a wise financial move after all this soliloquy was her response to a standard question to explore what women were trying to do to prevent the need to reach help quickly well i dont know you tell me what would be the sane thing to do if i get to the place that i need to have help in the house this fall when i was here alone i knew i couldnt count on the children for anything i took out a nursing home insurance policy i asked the nurses out there how to do it i was gonna get it for two years and they said a lot of people out here are living past a hundred get it for as long as you can what i took was one that would pay a hundred dollars a day for as long as i live thats as long as it would have to be well what im athinkin when i cant take care of myself anymore and have to hire everything done id better hang onto the little bit ive got yet and go ahead and go to the nursing home and take that the only time i will only get that hundred dollars a day is when im in a nursing home and the doctor needs to say i need to be there then well move what im aliving on here and use that to pay what i have to pay over a hundred dollars a day which im sure it will be ill end up like every other old woman but ill be in april surely i wont live to a hundred or very much past a hundred whatll i do just do like other people that dont have the money to pay for it just stay in the nursing home my son could very well be gone my daughterinlaw could be gone well what do you think try to stay here and beg people to come and do for me and pay them or as soon as the doctors say go to the nursing home go continuing to live at home alone and having reasons for thinking about moving out of this house at each contact we asked ms berson if she was still living alone early on her typical response was yes im still alone but later she offered more tentative responses such as yes and i hope i can make it yet this winter yet i thought i would try and make it and see if i can get to feeling any better by spring yet she also voiced some reasons for thinking about moving theres so many of us old women that want to live in a house alone nobody fools with you i can tell you that other than her neighbor there were few persons other than the homecare nurses to whom she could turn for help no one calls except him all the people i was close with and we neighbored with over the years are all dead its altogether a different generation of people furthermore her neighbor an older man who bought her groceries planted her garden and transported her locally and to the urban medical center was also caring for his spouse who had dementia and his adult son who had learning disabilities foreseeing a time when i might not be able to do that in this house that used to suit us fine and deciding to line up some more help in case ms berson compared herself to other women her age by saying i do more here of my own work she did her own cooking and laundry and sorted the plunder that had accumulated in the house she canned garden vegetables and fruit these tasks involved going upstairs and going into the basement after each of her falls she stayed on the main floor until she felt comfortable on the stairs again but those selfimposed restrictions limited her ability to do necessary tasks in interview 2 she said see this suited us fine my husband and i we was both working and i washed in the basement thats where my washing machine is i dont have room to put it upstairs i need everything on one floor now i dont have it and theres no way i can get it here id have to sell the house and get another house and might get a worse one how are you managing your laundry i have a washing machine and i take it down there and i wash it you take it down there by yourself so far i wear these old clothes and stand at the top of the stairs and throw them down the steps and then when i get down the steps i pick them up and carry them over to this corner where my wash machine is when i explained that the homecare agency might help with laundry ms berson said she already knew that was not the case however the nurses had sent me some names over here and they was about eight nine dollars an hour that price was too steep so she had checked with the woman who helped her neighbor care for his wife she would do it for fivefifteen and housework too if i needed it i thought i would get her when i couldnt do it anymore myself setting my own bar for feeling prepared to go to the nursing home and presuming i would meet the criteria to get in to the nursing home ms berson wanted to have an orderly wellmaintained home that would be salable in dexters glutted housing market at interview 2 she had contacted a handyman to repair the retaining wall in the backyard she wanted the wall fixed before putting the house up for sale in a telephone call prior to interview 4 she said i have to get this house sold before i can do anything different you know go to a nursing home she had set the house sale as a goal before moving to the nursing home but she also viewed herself as able to meet the likely admission criteria surely an old woman x years old could get into a nursing home if they dont get to the bathroom in time and cant hardly walk being urged to move to the nursing home and having reasons to stay at home yet this wintersummer during telephone calls before the final interview ms berson said that one of her physicians had advised relocation to the nursing home having fallen recently she had used a cane to walk into the office she felt that the physician was adversely influenced by the cane i had to have that cane to steady me she said i dont want you to give me any trouble or your son either she said i think you need to go to the nursing home yeah the way i was getting around and walking she was talking about going to the nursing home and i said well i think i can get along im gonna stay here at home as long as i can and im trying to stay this winter all winter long in fact i hope i can stay here forever just go to sleep some night and not wake up another physician later gave the same opinion ms berson recounted a similar response to it although ms berson voiced some reasons for thinking about moving from her home the physicians urgings were not among them in fact being urged to move to the nursing home seemed to intensify her desire to stay at home she had a plethora of reasons to stay at home during any upcoming season in the winter there was reading to do and plunder to sort the garden needed tending in the summer furthermore she was comparing myself favorably to those old women who lived alone she felt better able to care for herself than certain friends who lived alone at home too long she was feeling much stronger now than i did at that time when she was recovering from her surgeries and could do nothing for herself for weeks or months so are you telling me that you really feel youre doing better than you were at those earlier times in your life yes that you feel able to do for yourself yeah staying out of the nursing home for all of those reasons and making sure these study people can find me if they do not find me at home early in the project ms berson made it clear that staying out of the nursing home was a goal but she offered few reasons beyond the fact that her tomatoes would not be on the menu however after being urged to go to the nursing home she mentioned more reasons why it was best not to do so as the spouse of a former resident she was very familiar with the nursing home environment them halls out there are so long and so far apart i dont think i could walk them even to get my dinner and breakfast and supper i know i couldnt without this walker later she said but you cant take anything but a few clothes its a 60bed nursing home and i know that little closet theyve got is just big enough for a coat and maybe two outfits of clothes later she related another reason that i dont want to go to the nursing home im not the most intelligent person in the world but i wouldnt have anyone maybe even to talk to that was … anyone that was able to talk with you yeah and i think that would make me feel bad just to be around those kind of people all the time finally she expressed concern for her safety as a nursing home resident the nurses and you and everybody has been kind and good to me and you get in a nursing home you dont know whats agoin to happen to you i have read articles in the paper where if the patient dont do what they want them to do they put them in a bathroom and beat them up well you know i dont want to go through that id rather lay here in the bed and have a stroke and die alone as the research project neared conclusion ms berson began concluding each contact by expressing a deep concern that project staff might not be able to contact her to set up the next appointment i realize i might have to go to the nursing home anytime she said if im able ill be here and if im not able ill be somewhere in a nursing home and the only way to find that out where id be is through the nurses i guess if she did not answer the telephone she explained it could be because she had gone to the nursing home she elaborated at length explaining that she would want me to contact the homecare nurses the nursing home the police the neighbor or her son to find out what had happened however at our last interview ms berson was still at home alone sustaining herself in the place where she could best be herself epilogue while writing this case study i found ms bersons obituary on the website of the mortuary in the county seat i chose to act on her longstanding invitation to contact someone to find out what had happened to her the homecare nursing supervisor explained that ms berson lived at home alone for a year after my last interview with her when she fell and broke a hip she contacted help using her pers she was hospitalized at the medical center and discharged to the nursing home in dexter where she lived for about 9 months until she died late in the project ms benson voiced her intention to continue living at home but she seemed to envision what might happen to her and even to resign herself to that circumstance and as long as i can as long as i dont break a hip or something which i can do any time i fall i guess ill stay here i dont know what will happen from one day to the next the thing that happens here when an old woman like me falls and cant get up the first thing theyd do if id push this button are the police comes and looks about me or they got some men at the fire department that will come you know what they do they call the ambulance and send me to the hospital youre there a couple of days and they put you in the nursing home and you know the same thing will happen to me because i dont have anybody here to be with me all the time and thats what theyd do with me too okay but in case im never able to call you and tell you that im in the nursing home maybe you can find out by calling this here thing or the nursing home in dexter missouri is where i would want to go discussion this work extends the limited knowledge about a neglected facet of a relatively unexplored topic the role of residential relocation as part of the aging experience in quantitative studies of relocation it can be difficult to capitalize on the strengths of longitudinal designs however in this extended qualitative study with a very reflective participant it was possible to illuminate facets of the experience that have seldom been addressed in addition to sharing scalable data that would have been useful in a longitudinal quantitative study such as the number of times she had moved and the number of years she had lived at her current residence ms berson related that information in a deeply personal geographic and lifecourse context that has implications for further research findings suggest anticipatory relocation is likely unique for each older person and that residential location as a facet of lifeworld plays a key role researchers should explore that supposition in more extensive studies with larger samples findings are discussed first in relation to the overarching dialectical framework of lifeworld and then to specific lifeworld features of older women who live alone finally i discuss the anticipated relocation of ms berson as a chronic stressor comparing findings to polarities in the literature pertaining to relocation lifeworld the context of the anticipatory relocation experience the spatial arrangement of lifeworld played a prominent contextual role in ms bersons experience of anticipating relocation she was situated within her home a world within actual reach as one ages the salience of the community context can become more pronounced as it did for ms berson although researchers tend to emphasize the importance of community context without explaining it data evoke such explanations in the case of ms berson for ms berson the world within actual reach her home and community had changed and not for the better she was a witness to interrelated populationbased changes in dexter the death of her generation and the appearance of the altogether different generation these trends coincided with the plethora of older homes for sale evoking concern that her deteriorating house would not sell before or after her death she struggled to maintain what was once a desirable property in what once was a desirable part of town even as she prepared to let go of it to relocate within that community to age in place in a new but very familiar place the local nursing home the ongoing changes in the community meant that the breadth of ms bersons social network had diminished reduction in number of contacts and an associated decrease in engagement with other people have been identified as attributes of social isolation in older adults although geographic isolation can be associated with rural residence feeling isolated is not necessarily associated with being a rural person like other older rural women living alone ms berson did not refer to herself as isolated or lonely in fact throughout the study she referred to being lonely only once years before immediately after her husbands death in fact data did not support a conclusion that she exhibited the other key attributes of social isolation that nicholson discerned a diminished feeling of belonging lack of fulfilling relationships or problematic quality of network members her identification with dexter was so strong that she would choose to live out her life there regardless of whether she spent her last days at home or in the nursing home although she was saddened by the deaths and relocations of agepeers and the fact that she had lost contact with her granddaughters she had fulfilling relationships with her neighbor his son and the homecare nurses her son initiated regular telephone calls and visits for ms berson daily life at home was set in relief against the lifeworld within potential reach and its two facets both of which were relevant to anticipated relocation first the past world of restorable reach was relevant she had spent hours at the dexter nursing home with her husband to the point that she knew exactly how many beds it had and what it had been like when he lived there the projected future world of attainable reach was pertinent also that is she could envision what it might be like to live at the nursing home to the point of forecasting a scarcity of highquality garden vegetables the constraints and opportunities presented by communities … affect the actualization of preferences for ms berson the lifeworlds within actual reach and potential reach overlapped relative to the dexter nursing home and only that nursing home in her case the lifeworld dialectic of home ground and foreign ground was blurred the dexter nursing home was notsoforeign as to be foreign ground she had been part of the campaign to get a nursing home in town a place where her husband lived a place where she knew employees who also knew her accordingly she could draw upon a special source of social capital data revealed several classic examples of situations in which networks … and social trust facilitate coordination and cooperation for mutual benefit in this rural setting ms berson and the nursing home staff were part of a network she sought the counsel of nursing home staff before she bought a nursing home insurance policy in turn she experienced an individualized form of relocation marketing as have other older women in similar rural communities whose relatives had once lived at a particular facility hence ms berson pondered with angst the invitation to move from home to a particular nursing home from home ground to notsoforeign ground for ms berson the temporal arrangement of lifeworld also played a prominent role in anticipating relocation first although sudden death from cardiac arrest might preclude relocation to the nursing home a gradual deterioration meant that relocation was almost a certainty her remark nobody can expect to live forever is a lay restatement of an observation of the phenomenological sociologists schutz and luckmann i know that there are limits to my duration second because the interfaces across the duration of ones physical being and other seasons of world time … are uncertain the phenomenon of waiting … is an inevitable consequence ms berson often referred to this limbolike state in its broadest sense when she responded to our routine question about whether she was living alone im still here the passage of time was in part a state of waiting for changes that she hoped would not come to pass including relocation to the nursing home a phenomenological framework the lifeworld of older women who live alone set inside that broad philosophical view my prior perspective on lifeworld of older women is the proximate context to which findings are directly related because preliminary phenomenological studies are to be used as grounds for further work to explore experiences in greater depth in an earlier study of the experience of living alone at home for older widows i discerned these broad features of their lifeworld knowing what living is all about being in the position facing vulnerability and living where i can best be myself each lifeworld feature is comprised of descriptors that are directly relevant to the lifeworld descriptors that emerged in this study as shown in table 1 anticipatory relocation as a chronic stressor contrasts between findings and the literature as ms berson grew older while living alone at home her anticipated relocation to a residential facility became a chronic stressor the fact that she mentioned this issue during most of our encounters over 18 months is evidence that it was one of the persistent or recurrent difficulties of her life that chronic stressor revealed itself in a variety of interlaced facets of lifeworld that emerged spontaneously over time it dissipated only after the dexter nursing home became her world within actual reach her home of many years reverted to her world of restorable reach a past world that only memory could restore to her because few studies pertain to anticipatory relocation findings are compared to prior work on relocation and discussed relative to the primary conclusion of this work that the experience of anticipating relocation can become a chronic stressor for older rural persons relocation has been described in relation to at three sets of polarities its voluntary or involuntary nature its advantages and disadvantages and push and pull factors findings of this study set in the dialectics of lifeworld afford commentary on each set of polarities first the concept of voluntariness has long been associated with research on relocation voluntary and involuntary relocation have been contrasted relative to postrelocation adjustment however findings suggest that those two constructs are not necessarily dichotomous ms bersons situation could be viewed as a case of involuntary relocation that is she did not want to leave home until she had to do so however that involuntary admission was preceded by a lengthy period of contemplation about voluntary relocation to a specific nursing home accordingly voluntary and involuntary relocation can be part and parcel of an individuals experience a situation that could contribute to chronic stress over time second although the advantagedisadvantage polarity might be a useful framework to explain the decisionmaking process of relocation advantages and disadvantages per se did not surface in this study instead for ms berson contemplation of anticipated relocation occurred as a comparative perception of self at past present and future ms berson had recovered from three major surgeries and managed to get back to par each time progressing from the point of having a locked arm to getting back an arm after a mastectomy and to tending a garden after spending five months in bed to recover from openheart surgery she had not needed to go to the nursing home during those times when she was much worse off so in her view it was not reasonable to consider nursing home admission now when in spite of difficulties she could be up and about caring for herself and her home with a little help yet although she could still wait on myself she recognized that the time would come when she would no longer be able to do so third data revealed different factors associated with anticipatory relocation than those detailed in previous studies of relocation to explain reasons for relocation among older persons who had moved to independent or assisted living facilities bekhet et al borrowed a pushpull framework from stimson and mccrea as groger and kinney had done pushing factors which were coercing pressing or repelling in nature reflected the involuntary nature of relocation these included health getting rid of responsibilities lack of available helpers closure of another facility and loneliness they also addressed pulling or attracting factors which were location familiarity and reputation of the facility security and joining friends a third category was overlapping a mix of the other two types which in their view constituted a persons singular reason for moving some participants verbalized more than one idea at the same time and described both pushing and pulling factors as their reason for relocation the dialectical findings of the present study suggest that to focus on only one reason for anticipating relocation is to take a very narrow view of that complex experience conclusion in contrast to the polarities used to describe anticipatory relocation in prior research findings of this case study support the conclusion that anticipatory relocation can be understood as a dialectical stagebased process one that can vary depending on the persons lifeworld for ms berson the experience of anticipatory relocation was centered around two places her rural home and a particular rural nursing home there were stages of associated prior experiences facility development while living at home spousal residence in the facility while she was living at home and personal preparation for leaving homemoving to the facility ms berson and her husband worked with other townspeople to establish the nursing home that the town needed years later ms berson reached the stage of regretfully admitting her spouse to the facility and visiting him there daily for years years later the stage of personal preparation began as she conversed with nursing home staff about insurance had invitations to move there and witnessed transitions of agepeers from their homes to that facility each stage engendered a different sort of stress contributing to an experience of chronic stress relative to anticipating relocation this work demonstrates that to learn about the experience of relocation researchers need to study the experience of anticipated relocation rather than simply interviewing persons after they have relocated it is imperative to broaden investigations about chronic stressors to include those faced by very old people and to consider differences depending on urban and rural residence location taking a cue from this work researchers should explore the extent to which other older persons experience the stressor of anticipated relocation elaborate its incidence and describe its health and social implications furthermore if anticipated relocation is a chronic stressor with unique facets for each individual then practitioners must design individualized preventive and restorative interventions to counterbalance it in view of limited mental health services for rural older persons this will be a particular challenge however in keeping with recent models of integrating physical and mental health services in rural areas practitioners should incorporate preventive interventions regarding anticipatory relocation in routine visits with rural older persons well before advising that it is time to go to the nursing home practitioners must take the time to elicit client concerns about anticipatory relocation if and when practitioners deliver such a message they must concurrently offer opportunities to share concerns with nonjudgmental therapeutic listeners this would be a suitable role for registered nurses and advanced practice nurses who could intervene in person and via telephone with older rural elders who are anticipating relocation lifeworld descriptors of anticipating relocation knowing what living is all about mediating about the living of a long life outliving age peers and acknowledging that i do not have that much time left being in the position watching others watch me grow older and holding on and letting go • being invited to move to the nursing home and wondering if i would be ahead to go the nursing home

although rates of residential relocation by older adults have declined slightly in the last decade wolf longino 2005 relocation of residence in late life is nonetheless a prevalent event sergeant ekerdt chapin 2008 researchers have typically studied relocation from the epidemiological perspective of population transitions in living arrangements that is from individual residence at home to coresidence with a family member wilmoth 1998 or a move to an assisted living facility castle sonon 2007 or a nursing home taylor osterman acuff østbey 2005 another focus which has received less attention than the epidemiological thrust is that of understanding the role of residential relocation as part of the aging experience sergeant et al p s96 using qualitative methods some researchers have explored facets of relocation by interviewing older persons who have already relocated bekhet zauszniewski nakhla 2009 a few qualitative studies have involved older persons living at home who were on waiting lists for facilities nakashima chapin macmillan zimmerman 2004rutman freedman 1988 a factor that could influence perceptions about anticipatory relocation thus the relocation event has been the fulcrum of interest in a process that often has a nebulous beginning little is known about what it is like for older adults to contemplate relocation regardless of whether the final impetus for a move is voluntary or involuntary critically few scholars have directly explored the unique experiences of rural older persons relative to relocation if residential relocation is a significant course event sergeant et al 2008 p s97 then it is important to understand situations and circumstances that precede it including aging in place while anticipating relocation in a particular demographic context that thrust was evident in a study involving focus groups of older rural persons in which a strong attachment to place was particularly noteworthy despite identified challenges to aging in place relative to social support transportation and health care dye willoughby battisto 2011 in the relocation transition both contextual and psychological factors are important smider essex ryff 1996 p 362

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palavraschave bemestar coronavírus isolamento social docente introdução the adoption of social distancing as one of the public health measures during the covid19 pandemic was positive and effective it has resulted in proven benefits for reducing the transmission rate of the sarscov2 virus however this restriction interfered in personal and professional life and in interpersonal relationships causing changes in peoples routine education needed to be restructured due to this pandemic and the facetoface model was changed classes in this modality from basic to higher education were suspended in march 2020 and replaced by distance learning authorized by mec ordinance nº 343 of march 17 2020 consequently professors mediation became to occur online even if synchronous teaching has been indicated as one of the most stressful professions and combined with these new challenges imposed during the covid19 pandemic the digital transformation occurred rapidly for the professional education category stangrabrig et al observed that during this period professors faced several challenges and among them they had to rebuild themselves didactically and methodologically for remote teaching from this they analyzed the occupational wellbeing of these professionals and their relationship with personal and work demands and resources other studies have showed that the new social mode imposed by the pandemic have led to negative consequences on professors mental health it was caused by the lack of personal contact high demands for home office work the urgency in the domain of digital technologies the institutional pressures to maintain the functioning of their courses it is important that educators are encouraged and welcomed so that the negative impacts of the pandemic are minimized cliumorg 359 the educational scenario has probably changed permanently given the changes imposed by the pandemic these changes are linked to the personal and professional adaptations of both professor and student as for the professors personal lives padmanabhanunni et al analyzed the relationship between vulnerability and fear of being contaminated by covid19 anxiety and psychological suffering thus they identified that this professional category despite not being on the front line fighting the virus had its life abruptly changed due to the establishment of this disease developing symptoms of anxiety depression and lack of hope under this scenario it was observed the importance of studies focused on the understanding of the changes related to professors lives in the face of the social restriction caused by the pandemic and on public policies at the municipal level in this research we aimed to identify the perception of university professors about their socioeconomic professional social and public health policies conditions in the face of the challenges imposed in the initial period of social distancing for the prevention and control of the covid19 pandemic in the year 2020 methods this research is characterized as transversal analytical with a quantitative approach it was carried out with the faculty of a private university in rio grande do sul whose sponsor has national performance with both facetoface and distance learning education modalities the study population consisted of 1114 professors and the calculated sample size was 340 professors considering a 5 probability of sampling error inclusion criteria were professors who were in the professional framework during the 20201 semester regardless of age and gender those who were away during the research either on health or maternity leave were excluded the sample was for convenience an instrument was created in google forms and sent to professors via institutional email by the universitys communication and marketing sector and was available for a period of 45 days between june and july 2020 the characterization of the participants started with sociodemographic questions to verify the professors perception of living and working conditions during the pandemic sixteen closed questions were prepared we statistically analyzed the data using spss 230 software and the results of the nominal variables were expressed by the analysis of frequency and those of the continuous variables by the measures of position and dispersion to verify the association between gender and the variables the chisquare and fishers exact tests were used in all analyses the significant level p 005 was considered all participants signed the free informed consent form before starting the questionnaire the research was approved by the ethics committee of the lutheran university of brazil results the participants of this research were from different federative units of brazil rio grande do sul contributed to the highest number followed by tocantins goiás amazonas pará and santa catarina both with 1 as for the profile of higher education professors most were female the most prevalent age groups were 50 to 59 years 40 to 49 and 30 to 39 and showed a statistical difference between the sexes regarding color 935 declared themselves white and 5 reported having some type of disability professionally 80 worked in facetoface teaching 185 in both modalities and 15 in distance learning regarding the professors respective area of knowledge health sciences human sciences applied social sciences and exact and earth sciences regarding the level of education 69 worked only in undergraduate 24 in undergraduate and specialization and 7 in undergraduate masters and doctorate the family group was mostly represented by a composition of three two or four people and regarding the economic issue the majority have at least one family member who only studies andor has no paid activity showing a significant difference between the sexes regarding work the majority have at least one family member with formal employment the evaluation of public policies implemented by the municipality of residence regarding the confrontation of the covid19 pandemic carried out by the professors is shown in table 2 most professors evaluated positively and 797 considered it very important to face social and health problems regarding the testing condition and personal or family contagion of covid19 it was possible to verify that most professors have not tested themselves for covid19 and most people in their family circle had not been tested positive for covid19 when the questioning was extended to the circle of friends the configuration changed where 424 tested positive for the disease as for external activities most professors did not work on the front line of the fight against the pandemic showing a statistical difference between the sexes leaving home for nonessential activities remained restricted for 65 of the professors who remained in social isolation in this context the majority did not approve the return to normal presential work and study activities regarding the impacts of the pandemic on life the professors perception is recorded in table 3 about the professors sense of wellbeing and pleasure in living in march april and cliumorg 362 cliumorg 363 may 2020 more than a third were satisfied regarding postpandemic life 797 of this professional category agreed that it will be permanently changed quanto ao impacto da pandemia do covid19 na economia 898 acreditam nesta possibilidade apresentando diferença estatística entre os sexos as atividades de lazer neste período ficaram prejudicadas e isso fica evidente para 667 dos docentes insatisfeitos com diferenças estatísticas entre os sexos ao avaliarem seus relacionamentos familiares 682 registraram satisfação na manutenção dos seus contatos com a família apresentando diferença estatística entre os sexos concerning the impact of the covid19 pandemic on the economy 898 believe in this possibility showing a statistical difference between the sexes leisure activities in this period were impaired and this is evident for 667 of the professors with statistical differences between the sexes when evaluating their family relationships 682 reported satisfaction in maintaining contact with family showing a statistical difference between the sexes discussion the sociodemographic profile of university professors identified in this study is in accordance with those recorded by dumith who found a predominance of female professors and aged over 50 years ali et al observed that variables such as gender age marital status and family group of physical education professors can be affected by stress anxiety sexual satisfaction and social support the authors identified that there is a significant difference between marital status gender and social support when it comes to the pandemic the family profile of participants was analyzed and it was possible to identify the prevalence of families composed of two or three people and with two members who work with a formal contract or similar according to the last national census the resident rate per household cliumorg 365 is 29 people per unit which reinforces the data recorded in this research reflecting the reality of brazilian families regarding the professors professional characteristics the level of undergraduate education the facetoface modality and the area of health sciences were the most predominant sanchez et al identified similar data the prevalence of this modality is justified since most courses in the health area are essentially facetoface through contact with patients hospitals and clinics based on the perspective of information on coping with covid19 alamsyah and zhu found that the quality of government information is vitally important to help citizens to deal with the pandemic as well as to reduce their anxiety these data corroborate the results recorded here where the professors pointed out as positive and very important the social and health public policies implemented by the city governments to avoid the disease transmission brazilian states and municipalities have developed different strategies to fight covid19 according to the needs of each region an example is a health unit in the state of bahia that built a flow of care for symptomatic patients and social orientation for the population regarding protection measures with accessible and efficient language regarding testing for the virus at this early stage of the pandemic most professors as well as their family members did not take the diagnostic test for the disease the justification for not carrying it out is mostly the lack of need to leave the house to work and they did not work on the front line being less exposed to the virus however for the friends circle 424 tested positive for the disease as for nonessential activities such as running walking for example most professors did not practice during social distancing similar results were reported by costa et al especially among nonactive participants in contrast crochemore silva et al when evaluating the practice of physical activity by residents of the municipality of bagérs observed that 24 of them practiced physical and leisure activities during the pandemic in this survey most professors were dissatisfied or very dissatisfied when asked about their leisure activities the change in leisure habits regarding social physicalsports and tourist interests was negative in personal life having less free time for leisure in the period of social isolation may be a consequence of the increased workload and daily tasks in addition public policies of social restrictions promoted changes in the leisure activities that was possible and experienced differently as they became limited to the home environment contributing to this in the analyzed period there was neither vaccine nor medication available for everyone with the measure of social distancing people began to live more with family members and less with friends and coworkers in this survey around 50 are satisfied with social cliumorg 366 relationships and 682 with family relationships this result of satisfaction with family relationships may be associated with the family profile as the families in this sample were mostly composed of two or three residents the feeling of isolation was probably attenuated suggesting that coexistence remained the same prepandemic the feeling of general wellbeing is associated with several factors and its reduction is noticeable with the appearance of psychopathological symptoms making efficient interventions necessary to reduce suffering regarding satisfaction with life the teachers in this research point out that they are not completely satisfied in the period from march to may 2020 teaching strategies for online teaching during the covid19 pandemic and its relation with stress wellbeing and negative emotions were analyzed there was a positive correlation between psychological outcomes and the approach to coping and there was a negative correlation with how to avoid it the occupational wellbeing of german professors and its relationship with coworkers support professional demands and personal resources were investigated support from colleagues in the personal matter was positive and related to job satisfaction but negatively related to stress and exhaustion occupational stress related to covid19 for irish professors was related to the presence of large classes high workload contact outside working hours among others these factors contributed negatively to the professors mental health and wellbeing for south african professors the feeling of fear regarding covid19 resulted in high levels of anxiety and depression aversion to the virus and the possibility of infection were associated with fear and anxiety mental health levels regarding behavioral changes caused by social isolation with symptoms of anxiety and depression were higher among brazilians when compared with the swedish in this context the psychological implications of the transition to digital education in which educators had to adapt quickly the management of virtual classes and teaching materials in addition to the simultaneous routines of caring for children and working in the same physical space lead to situations of difficulties trauma and stress in the face of the pandemic the covid19 pandemic has changed the lives of brazilians in many ways and almost 50 of the teachers in this research believe that life after the pandemic will be partially changed life during the pandemic presented many changes from the decrease in physical activity change in leisure habits food and dynamics of coexistence cliumorg 367 to support professors and prevent burnout and attrition during the pandemic the actions of institutional managers are essential and demonstrate organizational commitment to increasing challenges even if professors faced exhaustion they remained committed to their institutions and profession final considerations the perception of university professors about their socioeconomic and professional conditions and social and health public policies in the face of the impact and confrontation with the covid19 pandemic in its initial period indicated changes in this sense the professors demonstrated the ability to reinvent and transform themselves under impacts in health social economic and professional conditions the lack of leisure activities social interaction changes in habits and teaching methodologies can impact the quality of life as well as represent risk factors for physical and mental illness human wellbeing is linked to maintaining a balance between personal and professional life awareness of the need for professors wellbeing is essential and the establishment of institutional guidelines for the implementation of wellbeing programs in the workplace can reduce health risks and absenteeism of this professional category

the pandemic of the new coronavirus influenced professors social and professional behaviors due to the restrictive measures of social isolation the study aimed to identify the perception of teachers about the feeling of wellbeing socioeconomic conditions professionals and family relationships in the face of the challenges imposed in the initial period of the covid19 pandemic a total of 340 brazilian university professors participated data collection was carried out using a google forms questionnaire consisting of 23 questions as for the profile of professors most were female 565 white 935 and the age group from 50 to 59 years 37 was more prevalent most teachers 549 positively evaluated municipal public policies to face the covid19 pandemic about the feeling of wellbeing and pleasure of living more than a third were satisfied but leisure activities were impaired 667 regarding family relationships 682 reported satisfaction as well as the perception that postpandemic life will be permanently changed 797 the establishment of institutional guidelines for the implementation of wellness programs in the workplace can reduce the health risks and absenteeism of this professional category

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introduction f ew populationbased data are available on overweight and obesity of children in the pacific region and obesity is a major threat to the future health of our population in us data from the 48 contiguous states it has been estimated that approximately 60 of 5to 10yearold overweight children will develop type 2 diabetes at some point in their lives whereas in the total population of those children onethird will develop diabetes 1 obese children are more likely than their peers to experience negative social and psychological consequences including discrimination stigmatization and low selfesteem 2 3 4 5 orthopedic 67 neurological 89 pulmonary 1011 digestive 1213 and endocrine systems 14 15 16 are all negatively affected by obesity in children national data are not provided on obesity of native hawaiians other pacific islanders or asians nor has the state of hawaii been selected for measurement in the national health and nutrition examination surveys 17 a previous study showed that the average bmi and the risk for overweight and obesity in hawaii varied by ethnic group in the preschoolage population using data from the supplemental feeding program for women infants and children 18 the prevalence of obesity among preschoolers was 9 and varied from 2 in asian children to 17 in samoan children a study of children in hawaii based on parent telephone report of weight height health and socioeconomic factors showed a 318 prevalence of overweight and obesity among 10 to 13 year olds 19 in that study native hawaiian and pacific islander children had a greater prevalence of obesity than whites as did children of mixed ethnicity prevalence was higher among children of younger mothers and among children whose mothers had less education overweight and obesity prevalence was higher among children of poorer health than among those of very good health the relationship between socioeconomic status and childhood obesity has been shown to vary among ethnic groups where ses was inversely related to obesity in whites but not in hispanics or african americans 20 in national data the mean prevalence of obesity was 18 among 6 to 11 year olds 21 in a study of the adult hotel worker population in hawaii 22 obesity prevalence among males and females was respectively 51 and 46 among pacific islanders 17 and 13 among filipinos 19 and 8 among other asians and 27 and 19 among whites a study by novotny et al showed that acculturation level of the population accounted for some of the disparity in bmi in adults 2324 hawaiis population has a high rate of intermarriage and 236 of the population reports mixed ethnicity 25 for those reporting at least two ethnic groups the largest mixed ethnic group was a combination of asian with native hawaiian and other pacific islanders comprising 53 of the states population those identifying with three or more ethnic groups totaled 113640 people or 84 of the population a study by albright et al 26 showed that mixedethnicity adults had higher bmi values than would be expected from the mean of the component ethnic groups the objectives of this study are to examine the bmi of 5to 8yearold children from kaiser permanente hawaii electronic medical records for prevalence of overweight and obesity for ethnic differences in bmi and for risk for overweight and obesity with adjustment for important covariates of particular interest is the comparison of the asian and pacific islander ethnic groups prevalent in hawaii and the large native hawaiianasian mixed ethnic group compared to the white population living in the same hawaii environment methods and procedures the study used a crosssectional study design and electronic medical record data from kph the sample included the 8984 5to 8yearold children with a parent who was a member of kph health maintenance organization 145 had a missing weight or height yielding n 8839 available for bmi analyses data include children born between january 1 2002 and december 31 2005 both kph and the university of hawaii reviewed and approved the study for use of human subjects bmi data from the hmo because children visit the hmo at varying ages multiple emr entries were often available for each child thus for this analysis weights and heights from the last emr entry were extracted bmi was calculated as weight in kilograms divided by height in meters squared bmi percentiles and zscores were determined for each child based on age and sex according to cdc methods 27 biologically implausible bmi zscores were determined by the cdc algorithm and excluded from the analyses yielding n 8738 for analyses by the cdc method the following bmi zscore ranges are considered biologically implausible by the cdc method less than 40 and greater than 50 bmi zscores were considered biologically implausible overweight is defined as the ‡85 th 95 th percentile for age and sex and obese as the ‡95 th percentile for age and sex compared to the cdc reference data ethnicity at kph ethnic information is collected from one of three sources inpatient admission via interview personal history sheet completed by the patient used at all clinics and physician notes sometimes used in the tumor registry although the data source is not recorded in the database most ethnic information is captured through the personal history sheet which was implemented in the last decade to capture this information at outpatient visits the kph personal history sheet provides the opportunity to identify 29 ethnic categories the emr data contain up to five ethnic entries per child for children this information is obtained predominantly by parental report ethnic data were available on approximately 60 of the membership we collapsed the different ethnic categories and their combinations into eight categories for the present analysis white asian filipino native hawaiian samoan hawaiianasian other mixed other the asian group included those whose entries were chinese japanese korean asian indianpakistani vietnamese laotian kampuchean other asian a child of a mixed ethnicity involving native hawaiian and asian was assigned to a hawaiianasian mixedethnicity group this group was retained separately because it was the predominant mixed ethnic category all other individuals with mixed ethnicity were combined into one mixed ethnicity group the mixed ethnic group included asianmixed filipinomixed hawaiianmixed othermixed and samoanmixed the other ethnic group included black american indianaleutian eskimo other pacific islander and other in all 4608 of the 8738 children had ethnic data available for analysis which is similar to the overall percentage of kph membership with ethnicity data available neighborhood education level ses data were not collected in the kph emr to understand the extent to which ethnic differences were explained by ses the year 2000 census data were attached to the data to provide information on neighborhood education level based on the zip code of the childs address as an indicator of ses the census data provide the percentage of adults 25 years or older by education category we computed an average number of years of education for zip code using the midpoint of completed years of education for each category category of neighborhood educational level was then assigned based on the average as 1 high school or less 2 some college 3 associate degree 4 greater than associate degree these data were missing for 9 children leaving 4599 for this analysis subsample with vital records data maternal age and maternal education were also available in a subsample of children these variables were included in analysis as more proximal individuallevel indicators of ses these data were made available on a subsample from a special linkage done with vital records from the hawaii state department of health at the request of the kaiser permanente center for health research hawaii the data on maternal education were grouped in the same levels given above and maternal age groups used were 20 years 2130 years 3140 years and 40 years statistical analysis descriptive statistics and regression analyses were calculated using sas v 92 the population of children was first described by age ethnicity and neighborhood education level the younger ages of 5 and 6 years were found to be overrepresented due to younger children being more likely to have visits to kph for recommended wellchild visits than older children because we wished to provide results that are reflective of the child population aged 58 years found in the state of hawaii a weighting scheme was created based on the age distribution of 5 to 8 year olds in the 2000 state census data 25 such that the sum of the weights equals the overall sample size of 4599 the weighting was applied to all analyses except the initial description of the population regression was used to model bmi continuously or as overweight or obese because neighborhood education level was assigned within zip code a correlation structure was imposed on the data that had to be accounted for in the analysis therefore mixed regression models were used to account for the imposed clustering of data into the 83 zip codes via a compound symmetric covariance matrix independent variables in all models included sex age neighborhood education level and ethnic group models on the subsample also included maternal age and maternal education interaction between neighborhood education level and ethnic group was tested using crossproduct terms mixed linear models were used where the outcome was bmi percentiles of children and covariateadjusted means were computed by ethnic group the model assumptions were checked and found generally to be met mixed logistic models were used where the outcome was the category of overweight and obesity with the odds ratio and 95 confidence intervals as the measures of association because data were derived from kaiser permanente records an insurance company to assure an estimate of overweight and obesity that was reflective of the child population found in the state of hawaii a weighting scheme was applied to the data that was based on the age distribution of 5 to 8 year olds in the 2000 state census data 25 and that retained the overall sample size of 4599 results age ethnic group and neighborhood education level distribution by sex frequencies of child age ethnic group and neighborhood education level by sex prior to weighting are ethnic distribution thirtythree percent of children had two or more ethnic groups of which 15 was mixed hawaiianasian ethnicity the distribution by ethnic group was generally unchanged after applying the weighting scheme neighborhood education level the children generally lived in neighborhoods where most adults 25 years and older had an associate of arts or science degree or some college education there were no differences in neighborhood education level by child sex a significant association between ethnic group and neighborhood education level was found of particular note is the lower neighborhood educational level of samoan and filipino children as compared with whites and asians overweight and obesity the estimated prevalence of overweight was 129 and obesity was 197 among this 5to 8yearold sample with ethnic information after weighting to the year 2000 census age distribution the overweight plus obesity prevalence of 326 is similar to the estimate of 30 for children with ethnic data but with no weighting to the census age distribution the prevalence of overweight and obesity among children with no ethnic information was 287 and combining children with and without ethnic information the prevalence was 294 all children except asians were significantly more likely to be overweight or obese in comparison with white children the excess risk varied by ethnic group samoan native hawaiian filipino hawaiianasian mixed other mixed and other children figure 2 shows the mean child bmi by ethnic group and by neighborhood education level adjusted for age and sex the bmis were significantly different for both variables higher neighborhood education level was associated with lower bmi relationships between bmi the ethnic groups and the neighborhood education levels remained the same when not adjusted for age and sex figure 3 shows the ageand sexadjusted odds ratios for overweight and obesity by neighborhood education levels within ethnic group the interaction between these two variables was significant within each group the highest levels of education were associated with lower levels of overweightobesity although the association was not consistent at the lower education levels for samoans and others children living in neighborhoods with the lowest level of education were the most likely to be overweight or obese for all other ethnic groups the children living in neighborhoods with the lowest level of education were generally less likely to be overweightobese compared to children from neighborhoods in the next highest education level subsample with vital records data in the subsample with vital records data mothers averaged 288 63 years of age and 136 22 years of education at the birth of the child the correlation between maternal years of education and neighborhood education level was 026 we found that the older maternal age groups and higher education levels were associated with lower bmis among children compared to children of mothers with less than or equal to high school education children whose mothers had some college education had an increased risk of overweight and obesity those whose mothers had an associate degree had a decreased risk and those whose mothers had more than an associate degree had a further decreased risk when both neighborhood education level and maternal education level were included in one logistic model of child overweight obesity both variables were significant discussion the prevalence of obesity was 197 in this population of 5 to 8 year olds higher than the level found in the 48 contiguous us states among children 219 years old among those 611 years old the prevalence in these national data was 18 21 these national data showed ethnic differences in obesity prevalence with white children at 139 and prevalence among nonhispanic black children at 286 there were significant ethnic differences in the likelihood of overweight and obesity among our 5to 8yearold children most children were more likely to be overweight and obese in comparison with white children except asians samoan risk was notably higher for overweight and obesity as compared with risk among whites another study by stark et al 28 examined 554 randomly selected 2to 10yearold children who received wellchild care at kph in 2003 the prevalence of overweight was 13 and of obesity was 19 for a combined prevalence of 32 close to that of the current study they found more boys to be overweight when compared to girls and more pacific islanders were overweight compared to other ethnic groups followed by native hawaiians place of residence was also related to risk of overweight and obesity in a hawaii preschoolage wic sample from a slightly earlier time period risk for obesity was also significantly elevated for samoan children compared to whites 18 however in that study native hawaiian ethnicity was not associated with increased risk and asian ethnicity was protective whereas in our study native hawaiian children also had increased risk but asians were similar to whites in risk possibly these disparities in risk have increased with age as children moved from preschool to early elementary school and also over time samoans native hawaiians hawaiianasians mixed filipinos and other ethnic groups also had a higher risk of overweight and obesity compared to whites and asians samoans and filipinos are newly acculturated to hawaii which may increase risk the environment and lifestyle in hawaii continues to westernize from traditional native practices which also may increase risk we accounted for mixed ethnicity prevalent especially among native hawaiians which may account for differences in findings as compared to other studies nonetheless both mixed and native hawaiianonly reported ancestry had an increased risk of obesity compared to whites in this older sample of children appropriate reference data and cutoff points to determine overweight and obesity are debated we used the cdc cutoff points for overweight and obesity it has been suggested that ethnicspecific cutoff points would be more appropriate other bmi cutoff points for overweight and obesity could be compared to these cdc cutoff points in further study although lower cutoff points for overweight and obesity have been proposed for asian adults and higher ones for pacific islander adults mixed asian and pacific islander ethnicity in hawaii complicates choice of cutoff points 29 selecting appropriate cutoff points for children also requires further study such as by relating values to health conditions mean bmiforage and sex percentiles for hawaiianasian mixed children were more similar to native hawaiian than to asian percentiles this may reflect a tendency to adopt the host culture or may reflect bicultural adaptation to ethnic mixing which is prevalent in hawaii ethnic mixing would be expected to favor retention of favored cultural attributes such as ceremonial foods that are likely more energy dense 30 and could explain higher bmi percentiles actual proportion of ethnic group for children with mixed ethnicity would require information on parental ethnicity which is currently unavailable there could be important body composition differences between children of different ethnic groups which might partially explain bmi differences and be associated with different health risks 30 31 32 but this is outside the scope of this study there was a monotonic relationship between neighborhood education level and risk of overweightobesity for two ethnic groups with a lower level of neighborhood education level for other ethnic groups an elevated risk was only observed for the second lowest neighborhood education level this may be due to a livelihood and lifestyle based on more physical activity among those with a lower neighborhood education level among ethnic groups other than samoans and others lower ses and education have been found to be associated with greater obesity in other studies and such obesity is expected to be due to poorquality energydense diets among lowerincome children 33 neighborhood educational level was used because we did not have individual data on parents education on all children which could be a limitation of the study however our findings were similar whether using neighborhood education level or maternal education level when available indeed both variables contributed to models suggesting importance of both neighborhood and family ses ideally the 2010 american community survey zip code data would be used in the analysis however zip codelevel information for 2010 was not available at the time of the data extraction nonetheless we found that the association between neighborhood education level from census 2000 zip code data and child overweightobesity differed by ethnic group our power was adequate despite the misclassification because we found that the associations for neighborhood education level explain the findings our study is based on a sample of insured children in hawaii although the ethnic distribution is similar to the state average the sample of insured children may not represent the most underserved children in the state in the subsample analysis we found that younger maternal age was associated with higher child overweight and obesity mothers who are young may still be going to school which may result in a lifestyle for children that is more sedentary and includes more fast food unfortunately we do not have data on maternal occupation household income level might also be expected to explain findings but was not available for our analysis conclusion this study provides new information on littledocumented ethnic disparity in child overweight and obesity and on mixed ethnicity which has behavioral clinical and public health implications samoan native hawaiian hawaiianasian mixed filipino and children of other ethnicity were more overweight and obese than white or asian children in hawaii we found that higher neighborhood education level was associated with lower bmi levels and interacted with ethnic group and that younger maternal age and lower maternal education were associated with child overweight and obesity populations of mixed pacific ethnic groups deserve further study related to acculturation to environment and lifestyle and determination of healthy body size author disclosure statement no competing financial interests exist

background pacific islander asian and mixedethnicity children are not described in national nutrition and health surveys methods data on bmi values of 4608 5to 8yearold children available from kaiser permanente hawaii electronic medical records in 2010 were analyzed for prevalence of overweight and obesity and for ethnic differences in bmi and risk for overweight and obesity controlling for age sex neighborhood education level and on a subset n 2169 that further controlled for maternal education and maternal age kaiser permanente data allow for reporting of multiple ethnicities results data revealed that 33 of this child population was of mixed ethnic ancestry prevalence of overweight and obesity was 326 129 overweight and 197 obese however samoan children and children of native hawaiian filipino and mixed ethnic ancestries had higher levels of overweight and obesity than whites or asians higher neighborhood education level higher maternal education level and older maternal age were associated with decreased risk of overweight and obesity except for children whose mothers were between 21 and 30 years old who had a higher risk for obesity than those whose mothers were under 20 years of age odds ratio 134 conclusions populations of mixed ethnicities in the pacific region deserve further study related to healthy body size and acculturation to environment and lifestyle

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göçmen gastroakişlar ve sosyal ağlar i̇stanbulfati̇h bölgesi̇ndeki̇ suri̇ye mutfaği örneği̇nde göç kültür ve yemek i̇li̇şki̇si̇ öz bu makalenin amacı 2011deki savaş sonrası i̇stanbulda suriyeli göçmenler tarafından yemek kültürü aracılığıyla inşa edilip yeniden üretilen ulusaşırı değişken ve çoklu gastroakışları incelemek ve bölgede göç sonrası meydana gelen toplumsal değişim sürecini anlamaya katkı sağlamaktır bu amaçla suriyeli göçmenlerin en fazla tercih ettiği ilçelerden biri olan fatihte 82 kişi ile yarıyapılandırılmış derinlemesine mülakat ve katılımcı gözlem metodu ile veri toplanmıştır türkiyeye göç eden suriyeli grupların büyük çoğunluğu geçici barınma merkezlerinde kalmak yerine daha iyi yaşam koşullarına erişebilmek amacıyla neredeyse tamamen kendi beşeri sosyal ve finansal sermayelerine güvenereki̇stanbul başta olmak üzere büyük şehirlere göç etmiştir ülkedeki belirsizlikler ve güvencesizlik koşullarında açılan gıda işletmeleri bir anlamda yeni mücadele ve müzakere alanları olarak suriyeli göçmenlerin büyük kentsel merkezlerde kendilerine yeni bir alan açma çabasının somut göstergesi olarak öne çıkmaktadır bir yandan da kültürün introduction this research examines the sociocultural integration process of syrian refugees in türkiye with a focus on 3 how they construct immigrant foodscapes in istanbul as a way of claiming a right to the city and creating a shared sense of belonging in a new country the immigrant foodscapes are built around intricate social networks by syrian refugees at the intersection of kinship relations socioeconomic ties transcultural interactions fellowtownsmenship and postwar solidarity food emerges as one of the most significant cultural symbols for syrian refugees in türkiye for it transfers the collective cultural memory to a new migration culture both metaphorically and physically hence the sociocultural ties shaped around the foodscapes in istanbul serve both to protect the existing culture and to reflourish or transform it in a different cultural setting yet this process is full of various struggles including postwar traumas adaptation to a new culture discrimination and lack of effective policies for migration management the main research question of this paper is to investigate how syrian refugees in istanbul deal with these challenges through constructing immigrant foodscapes in fatih one of istanbuls most densely populated provinces in terms of syrian refugee settlements 3 according to the 6458 numbered law on foreigners and international protection adopted in 2013 by the republic of türkiye ministry of interior syrian people are under the status of temporary protection and not officially given the refugee status this conviction results from türkiyes partition to the 1951 un convention which puts a geographic limitation on the definition of asylum seekers and refugees within international law this convention prevents türkiye to grant asylum to displaced ones who come from countries other than europe this temporary protection status was put into effect in 2013 within the framework of international protection standards to deal with forced mass or acute migration movements including syrian immigrants in this paper the term refugee is used in consideration of syrian peoples forced migration state yet the discussion on their legal status should be kept in mind further info about the temporary protection status can be obtained via methodology and data this research presents a qualitative analysis of the data collected through an ethnographic field work in fatih istanbul from august 2021 to may 2022 throughout the field work i made semistructured facetoface indepth interviews followup interviews focus group discussions with 82 participants from 53 food businesses in aksarayyusufpaşahasekifındıkzade and fatih central districts 4 in addition i visited different venues in the region both as a client and as a researcher usually once a week or once every two weeks for detailed exploration and participant observation of the site 29 of my interviewees are business owners or authorized managers employees were not always available because of the workload and sometimes they had to ask permission from the bosses despite this i was able to interview 27 staff members in addition to 19 customers from different ethnic communities most of my interviewees are syrian and i have also interviewed 16 turkish people in addition to customers and waiters from different communities the age range of participants is 1865 years legal status of the participants is kept confidential but the number of those who got citizenship was only a few in terms of gender the majority of my interviewees were male at this point i should mention that syrian caférestaurants in fatih are gendered places when it comes to labour force in other words it is not a culturally common and accepted norm for women to work at caférestaurants hence the women i 5 interviewed for my research belong to the customer category furthermore doing extensive ethnographic research in the district as a young muslim turkish women had both advantages and disadvantages most of the time it was challenging for me to visit the syrian caférestaurants by myself because of the cultural norms usually articulated by my intervieweesthat would find it awkward when a young woman goes to a restaurant alone and when this genderspecific difficulty combined with the language barrier building a social bond with the interviewees was much more demanding on many occasions however the restaurant owners were very happy to meet and talk to me about their experiences in istanbul often referring to the common cultural and religious notions in terms of being muslim and coming from ottoman roots both during interviews and my observations most of the participants were quite welcoming generous and open for mutual exchange yet as they were triggered by the deep anxiety and fear of intelligence by the syrian regime back in their country it was not surprising to see many participants were shy hesitant and suspicious of my intentions as a researcher in the first place being in the field with a friend with my interpreters or sometimes with my family helped me overcome this difficulty enabled a positive communication and allowed me to gain trust of my interviewees although it was possible to communicate with many syrian migrants at a basic level in turkish the percentage of syrian immigrants who know turkish was very low in general the language barrier constituted a serious limitation both in terms of communication in my research and in terms of the integration processes of syrian immigrants in istanbul another difficulty i experienced in the field so far was the state of uneasiness that we can say stems from the fragile and insecure situation of immigrants the political and social uncertainties regarding the legal status of syrian people in türkiye are reflected upon each realm of life because they expect to be given citizenship yet they are still under temporary protection a further challenge was the difficulty of continuing indepth interviews in a busy environment due to frequent interruption of conversations and constant busyness in cafesrestaurants like customer arrivals food orders management issues and so on additionally covid19 pandemic greatly affected my fieldwork as the businesses were closed for long periods of time in addition to the financial and social hardships experienced by everyone the pandemic made it extremely difficult to visit the field talk to and actively observe people for about six months but the situation gradually returned to normal in time throughout the research and especially during interviews i strictly followed the main ethical principles of voluntary participation protecting the right to privacy and do no harm which are particularly important when working with vulnerable groups such as refugees in the interviews questions about migration histories were asked in the beginning followed by openended questions in line with the research questions related to migration food culture social ties and integration the participants include business owners authorized managers paid employees and customers the food establishments examined in the research are restaurants cafés dessert shops coffee shops herbalists and grocery stores in terms of the restaurants subcategories some features specific to syrias culinary culture are also significant the interviews and observations were coded via nvivo software and analysed using reflexive thematic analysis method as a result of the coding process i specified 5 main themes related to the central theme of my research question which is syrian foodscapes in fatih the five main themes are the transformation of urban space and social life sense of identity and belonging homemaking practices social networks sociocultural integration these themes have both distinct features and interconnected aspects with respect to the formation of syrian foodscapes in istanbul migrant foodscapes in the age of global mobility and precarious hopes the concept of immigrantmigrant foodscapes refers to multiple dimensions of social networks in a transnational multiple and hybrid way that are built and reproduced through food culture for immigrants going beyond immigrants eatingdrinking habits or culinary practices the term is derived from arjun appadurais conceptual framework used for the analysis of global culture and it represents the multidimensional relations evolving around global consumptionproduction chains food and belonging this perspective helps us to understand the emerging alternative modernities in the globalizing world independent of any national borders either physical or metaphorical researchers who adopted a similar approach continued to produce new concepts by applying this framework to different fields including the sociology of migration and food for example silivia ferreros and komarnisky immigrants can import prepare offer for sale share and consume food and beverages that migrated with them from their homeland in their own unique ways in this way immigrants can reconstruct their immigrant identity on their own cultural elements via transnational cultural practices that connect people and places on a global level ajay bailey likewise examines indian foodscapes in the netherlands in terms of maintaining transnational social networks and a sense of belonging through commensality indian immigrants in the netherlands maintain the habit of eating at the same table reproducing the idea of imagined community and the sense of belonging to a shared culture in general belonging homemaking sense of community and sense of integration emerge as the building factors of immigrant foodscapes in the transnational sphere in addition factors that determine the global cultural economy such as technology capital power struggles economy and media also direct or affect the formation of transnational immigrant foodscapes cultural memories and social ties are significant in each immigration story yet they are more vital when it comes to forced migration because refugees and asylum seekers often leave their countries without knowing when or if they will return hence they carry not only their personal belongings but also their memories traditions relationships experiences and cultures from their homeland to maintain a sense of belonging and to transfer their cultural heritance to future generations almost all that comes out of the migrants suitcase help refugees while starting a new life in a new culture living in the memories minds and senses of the refugees food in this case like musicis an indispensable piece of the migrant suitcase making it possible to maintain an integrity of the sense of self home belonging both physically and metaphorically in a way food helps the refugees to struggle with the big losses on the strenuous road of migration reminding them of what is still not lost or what they still preserve to cherish precarious hopes in the face of brutal wars in the context of transnational migration the bond established with food mostly emerges as a resistance tactic in the postmigration process where the sense of transnationality national identity and belonging is shaken a common aspect shared by different international diasporas is that immigrants build on cultures with more plural and mixed identities rather than singular national and cultural identities in this process holding on to the culture of origin which is a resistance tool for international diasporas helps people to maintain their selfesteem in cases where talents and experiences are damaged just like language music rituals clothes and so on food is one of the most important resistance tools in this sense immigrant culinary cultures also inevitably gain a symbolic value in the ideological wars and struggles after migration and cannot be thought separately from the political and ideological struggles food is often instrumentalized in sociopolitical struggles national identities and mechanisms of global cultural production embedded in the receiving society anny gaul presents a good example of ethnographic research on the writing of culinary histories by examining the food memories of three moroccan immigrant women in terms of nationculture ideologies migration memory and the formation of national identities immigrant foodscapes and culinary culture is a constantly evolving and dynamic set of values interwoven with cultural and social networks consumption of the traditional dishes together with the same ethnic or social community and keeping the same eatingdrinking habitsrituals after migration has a unifying affect for migrants who built a new cohesive shared cultural identity senegalese food in italy moroccan food couscous in europe donerkebab in germany chinese food in the us or indian food in england are different examples among many cases where we observe consuming a countryspecific food nurture a sense of belonging and shared cultural identity based on culturally symbolic culinary practices among the immigrants on the other hand immigrant foodscapes mostly lead to multinational and multicultural encounters which sometimes result in the creation of new culinary and cultural practices that brings together the receiving and migrating society we might think of hybrid or fusion foods or culinary practices for immigrant societies by changing adding or omitting some ingredients or ways of cooking for instance it is possible to come across examples of strong symbolic values based on belonging which are attributed to the concept of food by immigrants in other immigrant communities apart from the ones mentioned above for example chapman beagan approaches the relationship between food culturespractices and the formation of transnational identities from an anthropological perspective based on case studies on two families who immigrated to canada from punjab india similar to senegaleseitalian immigrants punjabiindian immigrants blend and continue their food practices in the receiving country while at the same time constructing multinational and multicultural identities that transcend national borders through these new foodbased cultural practices and changing cultural norms as another example we see that bulgarian immigrants who came to türkiye after 1989 also created a hybrid immigrant cuisine and immigrant culture in interaction with the food cultures in the new country similarly as seen in a study on families who immigrated from south asia to england to open restaurants or markets serving south asian dishes the relationship established with food in migration cultures creates a sense of belonging through family and home metaphors traditional food practices which are maintained with the idea of food of home are central to immigrants sense of belonging and common identity syrian foodscapes in fatih istanbul fatih one of the oldest historical districts in istanbul has long been a centre of intense migration flows from different countries coming to istanbul apart from immigrant groups with a large muslim population such as uzbek uyghur and afghan immigrants many immigrants from african and central asian countries also settle and work in fatih simultaneously the district has also been a gastrotourism center for türkiye for local and foreign tourists with its various dining venues bearing the traces of historical ottoman cuisine the syrian migration added a new dimension to the urban structure and now the district of fatih has become a representative of not only the historical ottoman cuisine but also the historical arab cuisine however when talking about syrian cuisine we should not ignore the existence of other immigrant groups in the district in the period before the syrian migration in 2011 food establishments belonging to diverse immigrant groups found a place not only in the central parts of fatih but also in quarters such as aksaray laleli yenikapı samatya and kumkapı the bestknown examples among these are the uzbek uyghur and georgian restaurants most of which are in aksaray laleli and kumkapı districts other migrant foodscapes include iraqi afghan yemeni lebanese palestinian somalian ghanaian moroccan senegal and so on in other words we are faced with a multilayered cultural diversity that nurtures the cosmopolitan structure of fatih today which flourished even more after the syrian migration having said that when we look at the construction of foodscapes in fatih after the syrian refugee influx to istanbul we initially realize that there are different layers of urban and social structure within the district that is when you go from aksaray towards fatihs headquarter and the famous malta bazaar you realize the multicultural diversity manifested in aksaray leaves its place to more syriandominated spheres the food venues preferred by syrian families are in the majority in the malta bazaar and around there are restaurants that are relatively decent setting higher standards in terms of taste and quality appealing to both the middle and uppermiddle classes in malta bazaar and surrounding main streets in the venues in aksaray and yusufpaşa however restaurants for the lower or middle classes are high in number and the qualityprice is considered lower by most of my interviewees the criterion of being a place you can visit with family is also very important for example a graduate student from aleppo i interviewed says i live in üsküdar with my older brother sometimes we come to fatih to eat homecooked meals that we miss i usually dont prefer to eat downstairs referring to yusufpaşa the quality there is a bit low it hurts my stomach i always bring my friends here too or there are a couple of other places these dishes are unique to aleppo talking about kibbeh and mensef not everyone can do it well in addition the prices are generally more affordable than the turkish restaurants or restaurants in the vicinity i asked one of the managers why the prices were more affordable than other places and this is a public restaurant anyone who has no money can come and eat for 1520 tl he replied evidently there is no clearcut boundaries and the city has multiple layers however the socioeconomic differentiations between districts of istanbul also affects the syrian foodscapes for instance istanbuls başakşehir district which gained popularity among islamist conservative elites in istanbul in the last two decades is now also emerging as another prominent urban center for elite migrants due to the increasing syrian refugee settlements fatih is usually the point of entry for uppermiddle and highclass syrian population with enough financial capital on condition that they thrive at business and are part of social upward mobility in time they usually prefer to move from fatih to başakşehir to settle and do business as well i learned from my manager interviewees that the entrepreneurs who generated profit opened new officesbranches in başakşehir and moved their headquarters there business owners also moved their houses to başakşehir as well fatih province is currently far from being a place to live for them they list security as the primary reason for this internal migration trend neighbourhoods such as aksaray kumkapı yusufpaşa and haseki are seen as uncanny because it hosts illegal immigrants from many different ethnicities mostly belonging to poor or lower classes a syrian restaurant owner near the yusufpaşa tram station said you cannot safely walk alone on this tram street after evening even i hesitate in the daytime everywhere is full of beggars in the evening there are drugs women meaning sex workers whatever you look for but the police dont say anything to anyone during our meeting beggars came to our table several times while sitting at the tables outside the restaurant during the interview my interviewee warned me as well to protect my bag and phone sense of community and social networks in syrian foodscapes social ties have always been crucial in migration studies literature in various aspects ranging from migration decision to the integration of immigrants or to economic and political relations among countries the network theory is one of the significant theories which emphasize the importance of social networks in shaping the migration decision of individuals immigrants establish strong or weak interpersonal ties between the sending and receiving countries both before and after they migrate in time these interpersonal social ties also lead to chain migration movements as social networks or bonds evolve over time and are not broken easily once they are established the immigrant networks have functions such as providing information flow that will shape the decision to migrate adaptation to life after migration helping each other find employment accommodation socialization and fostering solidarity against discriminationhardships premigration kinship or compatriot relations also play a significant role in shaping social networks most importantly social networks have always played a key role in integration and social cohesion practices whether positive or negative from the very beginning when the network theory was first put forward the focus was on the role of social networks in shaping the decisions to migrate and the migration chains in time the research focused on the multinational multidimensional and deeper immigrant networks that connect the sending and receiving countries and go beyond national identities transnationalism approach gained more importance in migration studies numerous studies have been conducted on the international turkish diaspora especially in the context of turks in europe with a transnational approach there is also research on transnational immigrant ties such as family business friendship networks based on qualitative and quantitative data analyses utilizing social network analysis method during the last decade since the civil war there has been a rapid increase in the number of cafésrestaurants serving syrian cuisine in istanbul especially in fatih esenyurt and başakşehir the foodscape here consists of a variety of food establishments ranging from finedining restaurants to fastfood chains charcuteries butchers shops patisseries bakeries grocery stores herbalists so on and so forth these foodscapes are also surrounded by other businesses run by syrian migrants in any branch what distinguishes the fatih province is the high demand for and domination of syrian food establishments in the area one of my interviewees who is a famous restaurant owner being among the first syrian refugee entrepreneurs coming to istanbul said there are more than 100 syrian restaurants on this street wherever you look in the beginning there was no one but me on this street i am the only one then everybody came here now to those who call me and say we want to come and open a place what do you think i say dont come there were also those who opened different restaurants but they couldnt survive for example iraqi lebanese etc restaurants were opened but its not happening here there is no demand they all closed the shops or went back to syrian food in this period syrian businessman paid almost double for shops in fatih and syrian restaurants were popping up everywhere many turkish restaurants transformed their menus and began serving syrian foods even other local business owners closed their old shops and opened cafés and restaurants serving syrian cuisine initially syrian businessmen and investors bought turkish restaurants and kiosks in the malta bazaar for higher prices than usual later on with the help of transnational social networks and chain migration the number of investors who came to the region increased and spread to the districts outside the main headquarter there are some pioneering restaurants that started the chain migration these wellknown restaurant owners then functioned as locomotives for other restaurant owners and paid workers who would want to migrate to istanbul for example there are some chefs who initially worked in these established restaurants learned the job saved some money and then opened their own new restaurants in fatih likewise there are partnerships in the beginning and later on partners go their separate ways and open new branches while keeping their first restaurants among the syrian investors who initially went to other countries during the war in syria there are also people who have recently immigrated to türkiye and are planning to open new restaurants in istanbul for example in one of my most recent interviews i met two investors who stayed in saudi arabia for a few years and came to istanbulaksaray to open a dönerkebab shop in the same week i learned one of their friends from saudi arabia was also trying to make an agreement with a jeweller owned by a turkish operator next door and they would come here to open a new restaurant too friendship ties like this make it possible for the refugees to easily find contacts accommodation operate business plans etc and such cases are among the good examples whereby we see the positive effects of social networks on refugees migration and integration processes in a new country in addition to these kinds of smallscale or individual social ties the syrian restaurant owners also have an organized social network called ziyafet association which brings together almost 200 food establishment owners in istanbul mainly fatih to meet and support each other in business management i interviewed two board members of this association and learned that they mostly use social media channels to support each other but they also gather in person frequently one of the board members tells now we have 184 members all of whom are restaurant owners in our whatsapp group syrian yemeni doesnt matter generally arabs mostly syrians egyptians iraqi palestinian most yemeni restaurants are in şirinevler whoever is egyptian they go there whoever is syrian comes to either fatih or başakşehir whatever problem we have we talk about it in the group the board members underlined that while it is good to be part of such a helpful organization they also need to be more involved in other local or national gatherings so as to be more cohesive with the receiving society plus they told there is sometimes competition among the owners and the solidarity is not so intense as told by g59 there is of course a solidarity to some extent but there is also jealousy you know who has more customers etc aside from this association social media networks are very crucial for the syrian foodscapes in istanbul it is mostly through social media that the investors and customers connect to each other and get organized as some famous and wellestablished brands in the syrian foodscapes make more profit here they expand their businesses at a transnational level and becomes their headquarters in this expansion they open their own factories in the city rather than buying the ingredients from other suppliers and some of them also open new branches in and out of türkiye such as european or gulf countries plus most migrant workers in my research stated that they settled in istanbul and were employed here with the help of their acquaintances or previous relationships here it is possible to see the effect of social ties and solidarity networks as also presented by the network theory of migration although solidarity networks among immigrants have generally positive effects in facilitating migration decision and postmigration adaptation social networks do not always have a positive function in addition to rivalry among the businesses kinship ties or previous hostilities might continue in the new country in the case of two kunefe selling syrian shops in malta bazaar in fatih we see an example of the negative effects of kinship ties one of the relatives tells me the story we are in fact relatives with them but we dont see each other our families fell out with each other back in syria now here i was going to buy a larger place in this bazaar but they learnt it and paid more money to buy it before me just to make me go out of business i had very difficult times trying to find this small shop to continue working social networks initially establish an environment in which immigrants can feel more secure economically and culturally but the negative effects of these networks appear in two areas in particular first the strong social ties and the social circles organized around these ties can create a barrier to the integration and interaction of immigrant societies with the society in the receiving country ghettoization and social detachment may become much more pronounced as we see in the comments below by a syrian youngmale restaurant chef working in yusufpaşa living in such a dense and crowded community in somewhere as immigrants like we do here in aksaray for instance is too bad for integration thats why we have a bad image in the society we have to change this ghetto mindset in order to close the cultural gap between the turkish and syrian communities we need a complete mentality transformation secondly the fact that immigrants build a cultural economic and social life only around their own social networks and the lack of equipment to survive outside this social environment can push immigrants to stay in the same social environment all the time almost like a prison in the face of any negative experience in the social environment ingroup discrimination conflict or being pushed out of the group for any reason it can make immigrants vulnerable as part of the subject of this article attention has been drawn to the positive and negative effects of ties in syrian refugees social networks in addition in the field research i conducted there are discussions about both positive and negative effects of social networks in the context of culinary culture different studies on effective social networks in the international syrian diaspora also draw attention to the functions of social networks in the integration processes of syrian immigrants can syrian foodscapes be a starting point for sociocultural integration and transculturation as cultures close in on themselves in todays world where the fear of foreigners is high the gap between us and them is getting bigger and bigger this gap will continue to increase as individuals imprison themselves within culturescommunities which is seen as a fortress under siege and todays societies live in an allencompassing ambiguity fluidity insecurity and fear in which time and space are lost refugees including syrianswho are deterritorialized because of war are the most wellknown foreigners of the age of liquid modernity due to the insecurity and fear of foreigners prevailing in both refugees and settled societies social orders are formed in the multicommunitarianism approach which alain touraine points out instead of multiculturalism as a result individuals who claim to belong to a culture are also obliged to prove their loyalty day by day for the sake of defending this castle in the context of the european unions increasing security antirefugee and closed policies in recent years the frequent emphasis of the term fortress europe in current literature can be given as an example of the increase in both physical and symbolic borders in such conditions the idea of cultural equity is also crucial for a successful integration process for the syrian refugees in türkiye in the turkish migration studies literature there are different uses for integration processes such as social acceptance and adaptation or social cohesion another important concept is the idea of transculturation the common point of these approaches is to emphasize the new hybrid cultural formations that emerge as a result of the mutual interaction between different and equal cultures as opposed to the concept acculturation which is based on the idea that the immigrant group adopts the culture of the receiving country the aim here is to emphasize mutual cultural exchange and cultural harmony rather than a unilateral and topdown cultural transformation new habits in the culinary culture or fusion cuisines in the immigrant foodscapes can be a good example of these mutual interactions and ways of hybrid cultural formations regarding the transculturation processes reflected in the example of syrian foodscapes in türkiye first of all it should be underlined that neither türkiye nor syria has a homogeneous culture we can see syrian refugees and receiving societies in the southern region of türkiye share the same cultural patterns resulting from close networks as neighbours families business partnerships and so on however when we come to istanbul it is possible to observe that the cultural gap increases considerably cities such as konya and malatya can also be included in this realm in istanbul which has a cosmopolitan and ghettoized urban structure even before syrian refugee influx it has been difficult for syrian people to build a place for themselves in the city from nothing contrary to the southern regions cultural differentiation and conflict elements make their overwhelming pressure evident rather than cultural alikeness cuisine or culinary practices are surely an important symbol of the culture but there are different opinions on whether syrian cafésrestaurants reflect this cultural feature accordingly opinions also change in terms of food being an integrationcultural interaction tool according to some these foodscapes do not go beyond a touristiccommercial income source and the interaction in these places is very limited according to this point of view restaurants are temporary common areas where permanent relationships cannot be established and one can only come and eat for a short time according to these people real interaction should occur with a more intimate and constant relationship that recurs in daily life neighbourhood relations are the best example of this situation one of my interviewees comments on this saying eating several times at any restaurant is not an integration a relationship two cultures cannot know each other like that i will come to you you will come to me you will bring me the food you cooked and i will bring it to you that dish has a story a sincerity you talk once or twice you will know as you speak yet for some syrian refugees the foodscape is one of the most important centres for starting and ensuring a mutual cultural interaction for these people the caférestaurants in the heart of istanbul are a very important opportunity for syrian and turkish societies to find out more about their cultures and to overcome any prejudices a chickenrestaurant owner settled in fatih for 9 years says food can be a starting point for breaking prejudices and for mutual cultural interaction thats why we want to make some changes in our menu and make our meals suitable for the taste of turks as well similarly the foodscape in fatih is also a way to promote syrian culture not only to türkiye but to the whole world a wellknown hummusfalafel shop owner on the akşemsettin street explains my goal is to introduce syrian cuisine and syrian culture to the whole world our history is shared meaning turkish and syrian histories we need to know each other more and introduce our civilization to the world thats why i opened this restaurant in istanbul in these two different views we also see the effect of the distinction between public and private spaces or simply the distinction between home and workplace for syrian immigrants the distinction between homecooking and eating out is very important as a reflection of gender roles for example women working in restaurants are not tolerated men who are chefs or cook very well in food businesses rarely enter the kitchen at home if you are going to eat out ideally this should be at a place where you can eat as a whole family and the meal eaten out should be a main course or dessert that is not cooked at home therefore caférestaurants can be considered superficial for an intercultural interaction compared to a cultural exchange in a home environment but those who emphasize the importance of interaction in these restaurants are not few most of my interviewees state that they prefer to go to turkish restaurants whenever they have the opportunity so as to know more about the turkish culture and meet with new people in addition the business owners also state that the number of turkish customers has gradually increased over the years they have been here i have often heard that turks usually come with curiosity but with a prejudice but leave very satisfied after tasting the food when i talked to some of the turkish customers they also supported this view some restaurants have turkish regulars it is true that there is a certain sociocultural distance and introversion due to the language barrier prejudices and increasing hate speech in society however despite all this kitchen as a symbol of the common history and cultural heritage shared by the two cultures has a conciliatory effect in the process of mutual harmonization conclusion reflections on social cohesion between syrian refugees and turkish communities in istanbul the significant increase in the number of syrian establishments in fatih since the refugee influx to türkiye in 2011 should not mean it has become a completely separate syrian district only with syrian people on the contrary we are speaking of an ethnicallydiverse area where the local communities and different migrant populations coexist in this respect we can evaluate fatih as one of the leading centres that reflect the multiethnic and multicultural urban districts in istanbul nonetheless print and social media often portrays the district as invaded by the refugees mainly referring to syrian people judging by appearance and refugees are often instrumentalized by policy makers for their own benefits for instance the last 2023 presidential elections of türkiye were the most recent examples whereby the refugee problem was one of the key policy issues and the social tensions are on the rise as we go along these politically economically and socially turbulent times when immigrants and the receiving society create shared solidarity networks voluntarily this greatly enhances transculturation and sociocultural integration the culinary culture as an indispensable part of daily life and culture also plays a facilitating role in the formation of such networks of solidarity and natural encounters as discussed before it is important to provide an environment of interaction at the level of equality between immigrants and the receiving society trying to minimize hierarchies and discrimination while ensuring peaceful coexistence and social cohesion at this point simply opening booths at cultural fairs to introduce syrian dishes to the local people for instance will in the end foster the hostguest dichotomy and hierarchies in between although wellintentioned at the beginning instead initiatives based on commensality or cooking together syrian or turkish dishes can open the door to a nonhierarchical interaction by keeping the participants at an equal level in such an environment the participants will enter into a more egalitarian interaction by chatting while sitting at the same table and eating the food they cooked together perhaps a little hesitant at first but asking about each other and learning more about each other judging from my field research i can say that the syrian foodscapes in fatih raise hopes for this sort of natural and egalitarian interaction among diverse groups or people despite antiimmigrant attitudes in the midst of increasing social and political tensions in the country it is always possible to find common grounds for humanitarian dialogue whether it is through music art theatre literature food or whatever it is that binds us with a cosmopolitan consciousness to live together with dignity and peace

this research explores the transnational and dynamic connection between food culture and migration by examining the syrian foodscapes in istanbuls fatih district one of the most popular settlement areas for syrian refugees in türkiyefollowing the forced migration flows due to civil war in 2011 based on semistructured deep interviews 82 people and participant observation the paper aims at understanding the social transformations after migration rather than focusing on the refugee households i concentrate on the public caférestaurants food markets delis herbalists etc as places of contestation and negotiation for syrian people to construct new socialeconomic ties and to claim a right to the city social networks for

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introduction social capital has become a popular topic in public health research in recent years though there has been a lack of consensus concerning its definition 1 2 3 4 as reviewed recently by murayama et al 5 there are two distinct concepts of social capital in the literature according to one conception social capital represents the resources available to members of tightly knit communities this interpretation could be described as the social cohesion definition which tends to emphasizes social capital as a group attribute for example putnam considered social capital as features of organization such as trust norms and networks hat can improve the efficacy of society by facilitating coordinated actions 6 on the other hand in the networks theory social capital is defined in terms of resources that are embedded within an individuals social networks for instance bourdieu regarded social capital as the aggregate of the actual or potential resources which are linked to possession of durable networks 6 within the health field social capital has commonly been thought of from the social cohesion perspective and this predilection persists to this day 5 social capital can also be defined at different levels specifically at individual and collective levels 7 however the individuallevel social capital indexes are components of aggregatedlevel social capital 8 individuallevel social capital offers the most simple and clearly defined units of measurement focusing on individuals avoids the common interpretation problems of analyses that stem from the use of aggregated data in which the problem of the modifiable area unit may be encountered 9 moreover decisions to invest in social capital are generally made by individuals not communities 10 for these reasons we focused on individuallevel social capital in the current study the construct of social capital used within health fields in china may differ from that in the west owing to cultural differences 7 famously the chinese people use guanxi or instrumental personal ties to acquire the resources they need 11 investments in social capital by way of developing social networks may provide individuals with access to resources and support 6 our systematic review of the relevant literature revealed that social capital is defined ubiquitously in accordance with the networks conception of social capital in the context of health care related studies thus for this study we have adopted the networks conception of social capital as described by meng and colleagues at peking university as our operational definition 6 that is social capital in the current context refers to networks of social relationships that may provide individuals and groups with access to resources and support within the context of this definition we recognize that personal resources also include features of social structures although people generally have an intuitive understanding of quality of life as a concept it is still difficult to define it the world health organization has defined qol as individuals perceptions of their positions in life in the context of the culture and value systems in which they live and in relation to their goals expectations standards and concerns this definition focuses upon respondents perceived qol 12 qol is particularly relevant in research involving patients with acquired immune deficiency syndrome qol measures have been used to evaluate the effectiveness of treatments and factors predicting the wellbeing of aids patients 13 despite the rapid accumulation of general population social capital studies little attention has been paid to the utility of social capital by aids patients 1415 relative to the general population aids patients are more likely to be socially isolated more often diagnosed with chronic health conditions and more likely to lack access to health care resources 14 furthermore many aids patients experience chaotic personal environments that can lead to negative health outcomes 16 therefore the association between social capital and health may be different among aids patients in comparison to the general population existing researches on social capital in relation to human immunodeficiency virus have predominantly focused on the prevention of hiv transmission 17 namely positive and negative effects of social capital on hiv prevention for example encouraging reductions in antenatal hiv prevalence from 30 to under 10 were observed between 1990 and 2005 epstein noted that effective social mobilization particularly through peertopeer networking has been fundamental to this dramatic reduction in prevalence 18 in the negative effect gregson et al showed that young women participating in community groups had more risky lifestyles than those who were not participants 19 to our knowledge there have been no empirical studies on the impact of social capital on the qol of aids patients in china or elsewhere in china there were estimated 780000 people living with hivaids and 133524 aids patients cumulatively who received antiretroviral treatment by the end of 2011 20 hence the topic of qol and social capital for aids patients is gaining importance in this paper we aimed to investigate the impact of social capital at the individual level on the qol of aids patients methods ethics statement ethical approval for the study was obtained from the biomedical ethics committee anhui medical university study setting anhui province which is located in the southeast region of china has a relatively low hivaids prevalence among chinese provinces in the 1990s the primary cause of the aids epidemic in anhui province was illegal bloodcollection while in recent years sexual intercourse has become the main means of hiv transmission 21 based on the geographic distribution of aids patients in anhui province we selected one city in each of eight geographic areas maanshan city in eastern anhui chuzhou city in northeastern anhui benbu city in northern anhui fuyang city in northwestern anhui luan city in western anhui anqing city in southwestern anhui wuhu city in southern anhui and langxi city in southeastern from september 2010 to march 2011 crosssectional surveys were conducted in these eight cities study population and data collection this study examined a convenient selected sample with the inclusion and exclusion criteria outlined below since 2003 the four free and one care policy has been enacted in response to the hiv epidemic in china 22 all aids patients in china have been given the option to receive free art in fact the percentage of patients who refuse to receive art is very small treatment coverage for aids patients in anhui province was 93 in 2010 21 namely about one hundred aids patients refused to receive art mainly because of identity exposure therefore we excluded the aids patients who did not receive art in respect of their confidentiality and because it was readily feasible to do so to participate in our study aids patients needed to meet the following criteria 18 years old and art recipient for more than 1 month the requirement of at least 1 month of art was applied in order to minimize the influence of secondary drug effects on the patients perceived qol according to the national free aids antiviral medication manual in china 23 in the first month of art patients are in an adjustment period in which they may experience new unfamiliar drug side effects trained investigators from the anhui medical university conducted facetoface interviews with the patients with the support of staff at the local center for disease control and prevention all of the eligible respondents were identified from the aids patient database of the local cdc they were informed verbally via telephone of the purpose and procedure of the study the confidentiality parameters and the compensation for travelling expenses ahead of time study participants expressed a verbal understanding of these issues and signed consent forms most of the data collection was undertaken either in the local cdc or in the respondents homes other information such as cd4 count and the duration each individual has been living with hiv was obtained from the patients medical files in the local cdc with an overall response rate of 9052 we conducted full interviews with a total of 283 participants 23 in maanshan city 24 in benbu city 31 in fuyang city 32 in langxi city 47 in luan city 39 in anqing city 47 in chuzhou city and 40 in wuhu city social capital measures social capital assessment was a small part of our survey and thus we did not administer an extensive social capital questionnaire based on our operational definition of social capital explained in the introductory text of this paper and in consideration of existing comprehensive instruments and the related literature 24 we selected some commonly used items and adapted them to the chinese context four dimensions of social capital were considered social networks and ties social support social participation and reciprocity and trust social networks and ties included the number of close relatives the number of close friends the relationship within ones neighborhood and frequency of contact with the relatives friends and neighbors social support mainly addressed moral and material support social participation involved the frequency of group and community participation reciprocity and trust was measured in terms of vertical trust horizontal trust and mutual support this information is reported in table s1 individuallevel social capital was measured by producing a component score of each dimension using factor analysis which was grouped into a binary variable the mean component score was used as the cutoff point high individuallevel social capital and low individuallevel social capital 6 given that social capital is a multifaceted concept to prevent loss of important information we performed analyses of each dimension separately socioeconomic status and other risk factors the general risk factors record contained sociodemographic information including education level main occupation gender family monthly income current smoking and alcohol intake etc as well as aids related information including mode of transmission duration of living with hiv and cd4 cell count assessment of qol qol was evaluated using the 35item simplified chinese simplified version of the medical outcomes study hiv health survey questionnaire 25 the moshiv developed by wu and colleagues is one of the most widely used instruments for evaluating patients clinical outcomes and their quality of life which has been translated into various languages good psychometric properties of the questionnaire have been documented in different languages the simplified chinese version of the moshiv questionnaire has previously been demonstrated to have good reliability and validity 2225 the moshiv measures 10 domains including 8 multiitem domains and 2 singleitem domains we applied another singleitem inquiry on health transition raw item scores were summed for each domain and transformed into a 0100 scale with higher scores indicating better functioning and wellbeing two summary scores namely the physical health summary score and mental health summary score were generated from the factor analysis of the 10 scales we considered patients to have a poor quality of life if their phs andor mhs were at or below the 25th percentile of the distribution 26 statistical analysis a descriptive analysis was performed on the sample and the results were expressed as means 6 standard deviations frequencies and percentages using principal component analysis factoring for factor extraction cronbachs a values were calculated to evaluate the validity and reliability of social capital scale finally a logistic regression was conducted to explore associations between social capital and qol logistic regression a logistic regression model was employed to calculate adjusted odds ratios and 95 confidence intervals and thereby reveal whether there was an association between each dimension of social capital and qol after controlling for demographic variables including gender ethnicity educational level and marital status all analyses were performed using the spss statistical package and p value 005 was taken as statistically significant results descriptive statistics our study sample of 283 respondents had a mean age of 407661023 years and a mean cd4 count of 41463619432 cellsmm 3 a full descriptive summary of the respondents is provided in factor analysis and social capital characteristics four factors were extracted with eigenvalues above 10 after running a varimax orthogonal rotation the four factors explained 645 of the total variance table 2 shows the factor loadings of all the social capital items the results of the factor analysis were in good accordance with the original dimensions with the exception that the item would you like to provide support for the residents in your community who need help was mainly explained by social support rather than by reciprocity and trust the overall cronbachs a coefficient for social capital was 075 the cronbachs a coefficients of the four factors ranged from 044 to 079 the social networks and ties factor had the weakest internal consistency of the four factors individual respondent scores ranged from 2200 to 246 for social networks and ties from 2338 to 192 for social participation from 2070 to 381 for reciprocity and trust and from 2322 to 244 for social support the percentages of respondents with low individuallevel social capital in the four dimensions were 495 784 406 and 442 respectively multivariate regression phs score multivariateadjusted ors indicated that low individuallevel reciprocity and trust was significantly associated with a higher likelihood of having a poor phs score with respect to ses not drinking having a low income being 3039 years old or 40 years old and living with hiv for 12 months were significantly associated with increased risk of poor phs mhs score as shown in table 4 low levels of social capital in the realms of reciprocity and trust social networks and ties and social support were significantly associated with a higher risk of a poor mhs score with respect to ses respondents who were illiterate and who had been living with hiv for at least 12 months had a higher probability of having a poor mhs score than those with more education or recent infection discussion our study provides an initial exploration of correlations between the aspects of social capital and qol among aids patients at the individual level in china with further development our findings can be used to develop evidencebased policy to improve the qol of aids patients social capital and its measurement the strengths of our analysis were that careful attention was given to the design and validation of the social capital questionnaire we obtained better internal reliability values for the social capital questionnaire used in our survey than the values obtained by previous studies conducted in mainland china 627 somewhat surprisingly for three of the four domains we found that participants had high individuallevel social capital thus our findings suggest that aids patients may not be as marginalized as previously thought 14 however more evidence on social capital among aids patients is needed before making strong conclusions in this regard it should be noted that it is possible that since the participants were recruited with the help of cdc staff they were already involved at least to some degree in their health care and through that involvement may have accessed supportive social services thus involvement with the cdc and potentially referred social services may have led them to perceive government and community organizations as more trustworthy and to feel that they were in contact with social resources thus the potential biasing influence of this factor is a limitation of this study social capital and qol consistent with prior studies 2829 our analyses showed that high individuallevel reciprocity and trust was associated with a lower probability of having poor phs and mhs scores roberts et al found that mutual trust between medical personnel and patients with hivaids is a key factor in the improvement of drug adherence which enables art to have optimal effectiveness 28 more recently krause et al reported that trust in ones providers for best possible care and trust in ones providers to protect privacy were significant predictors of functional qol 29 as noted above the fact that the patients in our sample were receiving free art provided by chinese government may enhance their trust in social organizations and health service providers this art participation may also increase the patients exposure to health related information and allow them the opportunity to have any health concerns addressed as needed 30 thus it will be interesting to tease apart the role that participation in these services may have on perceived social capital and qol among patients living with aids we observed that ones level of social networks and ties was a significant predicator of ones mental health status consistent with our expectations and previous research 31 32 33 aids patients may gain emotional material and economic support from their social networks which can increase hope treatment adherence and rapid diffusion of health information which in turn would be expected to improve patients qol 34 this finding suggests that interventions targeting improvement of qol for aids patients may be enhanced by using or expanding existing social networks social capital has been used in other countries such as rwanda where those who want treatment must come to the clinic with a relative or member of their association 35 social support may provide a buffer against the adverse effects of stress caused by medical side effects which may in turn increase individual wellbeing our finding that social support was associated with mental health but not physical health is in line with previous work by bastardo et al 36 but differs from recent findings by yadav 35 who reported that social support associated significantly with both mental health and physical health further research is needed to probe the inconsistent association between social support and physical health the putative association between social participation and qol is controversial 37 in contrast to prior studies conducted in the west and in africa 3839 we did not observe a significant association between social participation and qol at the individual level there are several possible reasons for the lack of such an association in our sample firstly a relatively low percentage of our study participants reported group memberships group membership was originally developed in the western literature as a factor intended to capture integration into civil society 40 which might affect health through such factors as dissemination of information formal organizations are rare in china though people may form informal groups that fulfill similar functions and lead to collective benefits our measures of membership may have underestimated participation in these informal groups likewise aids patients in china may have access to fewer nongovernment organizations than patients in western countries another possible explanation is that aids patients may worry that regular involvement in group activities may expose their personal lives thus it may be prudent to modify the list of groups to more deeply examine whether there is an association between social participation and health in the future furthermore our findings affirm that it is more appropriate to define social capital from the perspective of networks than from the social cohesion concepts limitations our study has some limitations first the analysis of the links between the different social capital variables was crosssectional and hence cannot be used to conclude causal relationships second the results may not be generalized to all chinese aids patients our data were collected in anhui province which has a relatively low hivaids prevalence for china and thus may not reflect the situation in other provinces due to regional differences in the epidemic characteristics of aids prevention and control measures funding and policy environment finally because we measured social capital at the individual level only the impact of contextlevel social capital on qol and the interactive influence of individuallevel and contextlevel social capital on qol are not clear these limitations notwithstanding our study provides a base upon which future surveys examining the impact of social capital on the qol of aids patients in the chinese context can be built conclusions as an exploratory study it was not possible to obtain a truly representative sample of chinese aids patients but this limitation does not diminish the implications of our findings our study indicates that our selfdeveloped social capital scale for chinese aids patients has good reliability and validity that a higher level of social capital is associated with a better qol overall among aids patients in anhui province china and that social capital exhibits a stronger association with mental health than physical health china may not have fully exploited the contribution of social capital especially social participation in enhancing qol social capital development policy warrants further consideration supporting information

background with growing recognition of the social determinants of health social capital is an increasingly important construct in international health however the application of social capital discourse in response to hiv infection remains preliminary the aim of this study was to assess the impact of social capital on quality of life qol among adult patients with acquired immune deficiency syndrome aids methods a convenient sample of 283 patients receiving antiretroviral treatment art was investigated in anhui province china qol data were collected using the medical outcomes study hiv survey moshiv questionnaire social capital was measured using a selfdeveloped questionnaire logistic regression models were used to explore associations between social capital and qolthe study sample had a mean physical health summary phs score of 50136990 and a mean mental health summary mhs score of 416461168 cronbachs a coefficients of the five multiitem scales of social capital ranged from 044 to 079 when other variables were controlled for lower individual levels of reciprocity and trust were associated with a greater likelihood of having a poor phs score odds ratio or 202 or phs score or 690 additionally the factors of social support and social networks and ties were associated positively with mhs score or 230 or 417 respectively conclusions this is the first report to explore the effects of social capital on qol of aids patients in china the results indicate that social capital is a promising avenue for developing strategies to improve the qol of aids patients in china suggesting that the contribution of social capital should be fully exploited especially with enhancement of qol through social participation social capital development policy may be worthy of consideration

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introduction there is growing evidence that neighbourhood green space is beneficial for mental health the neighbourhood social environment has been suggested to be one of the mechanisms the presence of green such as trees or vegetation increases the attractiveness of common spaces in the neighbourhood thereby potentially increasing their use and facilitating informal social contacts between community members social contacts are health promoting for instance through the social support they can offer by facilitating social contacts neighbourhood green can contribute to the development of neighbourhood social cohesion ie the connectedness and solidarity among community members which has proven to benefit peoples health furthermore having green areas in the neighbourhood increases the attractiveness of the living environment thereby enhancing peoples attachment to the physical neighbourhood environment place attachment helps to create group identity which translates into a general sense of wellbeing and has been associated with reduced loneliness and better mental health the neighbourhood social environment as a mechanism for the impact of neighbourhood green space on mental health has received some research attention in the past years some studies found that social cohesion mediated the relation between green space and mental health while others did not lack of social support and feelings of loneliness were reported to mediate the relationship between green space and mental health but not social contacts inconsistencies between studies might be explained by different operationalisations of the social environment it is also possible that the relationship between neighbourhood green social environment and mental health differs across cultures for instance in more individual oriented cultures green space might be more important for the facilitation of social interactions than in more collectivist cultures where communal life is already more common in the current study we investigate the relationship between neighbourhood green space neighbourhood social environment and mental health in four european cities to examine if the social environment might be one of the mechanisms between neighbourhood green and mental health the following research questions are addressed is neighbourhood green space related to the neighbourhood social environment in four european cities are the neighbourhood social environment and neighbourhood green space related to mental health in these cities this study uses a range of social environment measures to examine if the associations depend on the operationalisation of social environment our green measures comprise both the amount and quality of neighbourhood green to accommodate the increasing evidence stressing the importance of quality of green space and its impact on health furthermore objective audit and subjective green measures are used as they may capture different aspects of greenness ie more emotional aspects with subjective measures and more tangible aspects with objective measures these aspects may relate to the social environment characteristics and mental health differently methods study background this eufunded phenotype study examined the health effects of the natural environment and its underlying mechanisms a crosssectional survey was carried out from may to october 2013 in four cities across europe stokeontrent doetinchem barcelona and kaunas study population and data collection in each city 30 neighbourhoods varying in neighbourhood green space and socioeconomic status were selected survey data were collected using facetoface interviews with the exception of lithuania where data were collected with a postal questionnaire around 1000 adults aged 1875 years were interviewed per city across 124 neighbourhoods for further details on the data collection see online resource 1 we selected respondents with complete data for the indicators of interest providing a sample of 3771 respondents in 124 neighbourhoods additionally in each neighbourhood an audit was carried out to assess the amount and quality of green space for each neighbourhood a purposeful sample of streets was selected ensuring that rare but important features of the neighborhood were included to do so we divided each neighbourhood into more or less homogeneous subareas by means of land use maps in combination with local knowledge of the areas per subarea several streets were selected and combined into a route that was inspected by two trained auditors in a systematic way using a form containing closed questions measures mental health mental health was measured using the mental health inventory mhi5 assesses nervousness and feelings of depression in the past month with answers ranging from all the time to never on a sixpoint scale sum scores of the five answers were transformed into a scale from 0 to 100 with higher scores reflecting better mental health the scale has proven to be of good validity and reliability neighbourhood green space audit amount and quality of neighbourhood green space amount of neighbourhood green space was based on six items containing information about the fraction of visible gardens garden size the arrangement of the gardens number of trees size of public green spaces and size of public blue spaces quality of neighbourhood green space was derived from one question answered by the auditors what is your general impression of the quality of the green space in this neighbourhood answers ranged from 1 to 5 indicators were standardised using zscores calculated for each city separately this way neighbourhood green was compared between the neighbourhoods within one city and not across all cities allowing the examination of the relative effect of green space on mental health subjective amount and quality of neighbourhood green space subjective amount of neighbourhood green space was measured by asking the respondents how would you describe your neighbourhood in terms of green space with answers on a fivepoint likert scale from not green at all to very green subjective quality of neighbourhood green space was measured by asking overall in your neighbourhood how satisfied are you with the quality of the greenblue environment answers ranged on a fivepoint likert scale with a higher score meaning more satisfaction with the quality we conducted ecometric analyses to calculate the average perception of neighbourhood green space this way we can include subjective assessments of neighbourhood green space while avoiding samesource bias ecometric average scores were calculated and standardised into countryspecific zscores we use the term neighbourhood green space for our natural environment measures because the audit showed that the neighbourhood natural environment consisted foremost of green elements and because mainly green space is relevant for the social interaction mechanism social environment we measured three aspects of the social environment social cohesion constructed by summing the answers to five statements from the social cohesion and trust scale people are willing to help their neighbours this is a closeknit neighbourhood people in this neighbourhood can be trusted people in this neighbourhood generally dont get along with each other and people in this neighbourhood do not share the same values using a 5point likert scale answers ranged on from totally disagree to totally agree negatively stated items were recoded so that a higher score reflected higher levels of social cohesion neighbourhood attachment measured by summing the answers to three statements i feel attached to this neighbourhood i feel at home in this neighbourhood and i live in a nice neighbourhood were people have a sense of belonging using a 5point likert scale answers ranged on from totally disagree to totally agree a higher score reflected stronger neighbourhood attachment social contacts respondents were asked how often they had contact with their neighbours answers were daily at least once a week 13 times per month less than once a month and seldom or never social contacts was dichotomised into at least once a week versus less often for the analyses with social contacts as outcome measure similar to the subjective green measures ecometric analyses were conducted to calculate the neighbourhood average scores of social cohesion and neighbourhood attachment social contacts were included at the individual level the correlations between the neighbourhood characteristics show that the audit and perceived green measures were moderately related suggesting that these indicators measured different aspects of neighbourhood green space confounders individual control variables in all analyses were sex age highest achieved educational level nationality employment status household composition and homeownership neighbourhood socioeconomic status was included as a neighbourhood level confounder see table 2 for the descriptive statistics analyses multilevel linear and logistic regression analyses were performed with individuals at level one neighbourhoods at level two and city at level three city was included as level to adjust for systematic differences in the intercept between the four cities ie city differences caused by for instance policy differences the green variables were allowed to have a different effect on social environment and health for every city by creating a separate green indicator variable for every city all four city green variables are added to the model first multilevel models assessed the association between neighbourhood green space and individual level social contacts in the four cities ecological models at the neighbourhood level assessed the associations between neighbourhood green social cohesion and neighbourhood attachment respectively next we examined the associations between social cohesion neighbourhood attachment social contacts and mental health in the four cities while adjusting for green space finally we examined the associations between green space at the neighbourhood level and mental health in the four cities the analyses with the subjective neighbourhood level green measures were also adjusted for the individual perception of neighbourhood green space to distinguish the contextual health effect of green space from the individual level effect analyses were conducted using sas 93 results neighbourhood green space and the social environment more cohesive neighbourhoods were greener and had better quality green space in doetinchem and in stokeontrent in barcelona and kaunas neighbourhoodlevel green space was not related to neighbourhood social cohesion stronger neighbourhoods attachment was found in greener neighbourhoods and neighbourhoods with better quality green space in doetinchem better perceived quality of neighbourhood green was associated with stronger neighbourhood attachment in barcelona and stokeontrent as well neighbourhood green space was not associated with social contacts in any of the cities social environment and mental health residents living in neighbourhoods with more social cohesion or with stronger neighbourhood attachment reported better mental health only in stokeontrent not in the other cities having more frequent social contacts was associated with better mental health consistently in all four cities neighbourhood green space and mental health in barcelona a higher amount of neighbourhood green was associated with better mental health 4 in the other three cities neighbourhood green space was not associated with mental health the social environment as possible mechanism in barcelona we found no associations between neighbourhood green space and the social environment and between the social environment and mental health in the other cities we found no associations between neighbourhood green space and mental health therefore we found no indications that the social environment could be an underlying mechanism between neighbourhood green space and mental health discussion greener neighbourhoods and neighbourhoods with better quality green space were more cohesive and had higher levels of neighbourhood attachment in doetinchem and stokeontrent more neighbourhood cohesion and stronger neighbourhood attachment were associated with better mental health in stokeontrent only only in barcelona however the neighbourhood green space was associated with better mental health but there we found no indications that the social environment could be the underlying mechanism study limitations the crosssectional design of this study prevents conclusions about the causality of the relationships we therefore did not implement statistical tests for mediation as mediation implies causal processes another limitation is the low response rate resulting in an underrepresentation of low educated people in all four cities it is suggested that people with a low socioeconomic status may benefit more from neighbourhood green space than those with a high ses the underrepresentation of low educated people may therefore have resulted in an underestimation of the relationship between green space and mental health third in kaunas there was no variation between neighbourhoods in neighbourhood attachment and as pointed out by the low reliability scores of green space and social cohesion in table 2 only little neighbourhood variation in case of the other neighbourhood measures because of the low reliability scores we excluded results from kaunas based on the perception measures in the discussion of the implications finally the neighbourhoods in barcelona were considerably smaller in size compared to the other cities this could have increased the chance that the spanish neighbourhoods were more homogeneous in terms of the amount and quality of neighbourhood green space which could have resulted in more precise audit assessment of the neighbourhood green space in barcelona we cannot rule out completely that a more precise audit assessment of the green space in barcelona resulted in finding a relation between audit amount of green space and mental health there neighbourhood green space and the social environment our study showed that green space at the neighbourhood level was related to the neighbourhood social environment our findings that related social cohesion consistently to neighbourhood green space in doetinchem and stokeontrent strengthens the evidence on the influence of green space on the development of social cohesion furthermore in line with arnberger and eder we report neighbourhood attachment to be consistently associated with neighbourhood green space in doetinchem as well as the subjective quality of neighbourhood green in barcelona and stokeontrent we found no evidence that neighbourhood green space is related to more contacts between neighbours in line with maas et al our findings corroborate the argument by hartig et al that physical neighbourhood characteristics such as green space influence other area characteristics eg social cohesion more easily than individual characteristics eg individual social contacts green space social environment and the relation with mental health our finding that individual social contacts were associated consistently with better mental health while social cohesion and neighbourhood attachment were related to better mental health in stokeontrent uk exclusively underlines the fact that the neighbourhood environment is in general less important for individual health than individual characteristics despite of that studying neighbourhood characteristics such as neighbourhood green is relevant as it can influence the health of many people therewith contributing substantially to the health of the population we found only weak evidence for a relationship between neighbourhood green space and mental health a study that used similar green data ie audit information reported no relation between the presence of green and general health though another study reported that the amount of green was related to mental health we could only replicate this association between the amount of green space and mental health in barcelona the barcelona neighbourhoods were considerably less green than the neighbourhoods in other cities possibly living in greener neighbourhoods in barcelona is more strongly related to mental health than in other cities because of the scarcity of green space in general another explanation for finding an association between green space and mental health in barcelona only is that especially nearby green space seems important for mental health as the barcelona neighbourhoods were by far the smallest in this study when we conducted posthoc analysis using individual perception of neighbourhood green assuming that the individual perception is based on nearby green space more than the neighbourhood average perception of green we indeed found associations between green space and mental health in doetinchem as well in our study quality of neighbourhoodlevel green was not associated with mental health which is in contrast with previous studies we used a crude measure for quality of green space possibly this measure was not specific enough to detect a relationship with mental health we found no indications that the neighbourhood social environment serves as a possible mechanism between neighbourhood green space and mental health we either failed to find a relation between neighbourhood green space and mental health or did not find associations between neighbourhood green space and the social environment and between the social environment and mental health in barcelona a highly urbanized city restoration from daily stress might be a more relevant mechanism underlying the association between green space and mental health than the social environment unfortunately we were unable to examine this hypothesis with the available phenotype dataset comparison of the cities there were marked differences between the cities with regard to the relevance of the neighbourhood environment for mental health the intraclass correlations of the cities which estimates the proportion of variation in mental health between residents that is related to neighbourhood characteristics reflects these differences for example in doetinchem the icc was very low and both green space and the social neighbourhood characteristics were unrelated to mental health in contrast with stokeontrent and barcelona with iccs of 851 and 671 respectively in barcelona this icc reflected the relation between neighbourhood green space and mental health and in stokeontrent the neighbourhood social environment was related to mental health the different findings across the cities might reflect geographical and cultural differences the differences could also reflect that despite the use of identical measurements data might still not be comparable due to cultural differences in the interpretation of survey questions and audit the use of more objective measures such as gis data could improve the comparability of the findings but this might at the same time not be the environmental characteristics that have the biggest impact on mental health furthermore more objective data on the quality of neighbourhood green or the social neighbourhood characteristics will be much more difficult to achieve future comparative studies should make efforts to also incorporate objective data to allow even better comparison between european settings conclusion neighbourhood green and the neighbourhood social environment were related to one another in two cities but did not translate into better mental health there neighbourhood green was related to mental health only in barcelona but there we found no indication that the neighbourhood social environment could be the underlying mechanism our study found no indications that improving neighbourhood green space could be a relevant public health policy nor were there indications that health benefits of green space would occur through the improvement of the neighbourhood social environment future studies should use longitudinal data to further investigate the possibility of this mechanism to improve the comparison between european settings studies should try to incorporate objective measures of both green and the social environment key points • the neighbourhood social environment has been suggested to be one of the mechanisms responsible for the beneficial effect of green space on health • this study examines the relationship between neighbourhood green space social cohesion neighbourhood attachment social contacts and mental health in four european cities • we find no evidence that the neighbourhood social environment could be the underlying mechanism between neighbourhood green space and mental health • the relevance of this mechanism needs further investigation with longitudinal data and with more objective data to improve the comparison between european settings ethical approval this article does not contain any studies with animals performed by any of the authors all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards informed consent informed consent was obtained from all individual participants included in the study

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the phenomenon of alcohol is one of the topics that has been receiving considerable attention not only from a purely medical point of view but often also in terms of history and anthropology it is observed in studies focusing on different aspects of an ordinary person the advantage of studying this topic is the abundance of sources not only from this day but also from the ancient times and the middle ages this is also due to the fact that alcohol consumption has been an integral part of human life from time out of mind after all even animals come across fermented fruit juice in the wild at first alcohol was not considered a purely negative element it was sought after for its ability to quench thirst stimulate the mind and lift the spirits until the 19th century alcoholism was not considered a serious social problem it was a moral problem only in the bohemian lands the czech national revival was heavily involved in addressing the issue of alcoholism as it perceived this social phenomenon as a danger to the entire nation and the state 1 the present study aims to highlight the involvement of the physical education movement in temperance for practical reasons however the study does not have the ambition to analyse the situation across the movement in more detail and therefore narrows it down to sokol brno i the oldest and most important moravian sokol unit the main methodological axis of the research consists in the analysis of sources and literature related to the issue under review within the teetotaller division of brnos number one temperance measures are then examined as well as the bonds that the unit has developed over time the emergence of the teetotal movement in the early 19th century must be understood as a reaction to the negative social health and economic repercussions of the increased consumption of alcoholic beverages especially the significant production of spirits as one of the byproducts of the industrial revolution the problem of alcoholism known as the liquor plague at that time was becoming an increasingly troublesome social phenomenon initially the movement was only condemning excessive use of alcoholic beverages later on it focused on the fight against any consumption of alcoholic beverages whatsoever from the very beginning the movement was gaining most popularity in the industrialised countries especially in the us scandinavia england germany and switzerland at first temperance societies were formed often backed by a womens movement but later such societies were almost exclusively promoting teetotalism the whole movement sought to bring the fight against alcoholism into the realm of the public law the production import and sale of alcohol were to be regulated by 1 for more details on alcoholism in the early modern period see e legislation the aim of such measures was to impose a total ban on its production and sale ie what is known as prohibition however the nationwide prohibition in the u s between 1920 and 1933 showed that this practice failed to achieve the desired results 2 however prohibition did not catch on in other countries either such as iceland russia and finland where it was imposed for a limited period of time 3 a second line of thought adopted mainly by physicians since the 1870s endeavoured to provide professional help to the afflicted such efforts resulted in establishing houses and asylums for drunkards theobald mathew an irish catholic priest significantly influenced central europe in this respect 4 some of the temperance movements built directly on a religious perspective 5 2 in the 1910s the antisaloon league became one of the most effective pressure groups in the us history a twothirds majority was secured in the 1916 election in both houses of congress which was required to pass a prohibition amendment to the constitution the wartime spirit of sacrifice the fact that grain was needed for food production and the wartime aversion to germanus brewers turned the whole affair into a test of patriotism the interest in the alcohol issue has been present in the bohemian lands since the 1840s this was preceded over time by the voices of the nations prominent figures 8 a true boom of the teetotal movement began in the early 20th century with growing production by breweries distilleries and wineries in the bohemian lands most of the alcoholic beverages produced were intended for the domestic market in proportion to this there was a growing concern about the increasing number of cases of alcoholism 9 the bohemian diet had to address the problem of alcoholism on multiple occasions the speech given by prof tomáš garrigue masaryk at the 8th international temperance congress in vienna in 1901 is considered to be the proverbial landmark masaryk subscribed not only to the idea of teetotalism itself for moral reasons but also to an organised temperance movement he subsequently spread the idea of teetotalism among his students at the university and in his social activities 10 in the czech environment the first representatives of the movement 6 interestingly enough the good templars of german nationality also considered the question of national descent the articles of association of the german good templar society in the czechoslovak republic stipulated that any person of the german of aryan descent was eligible to become a member of the association from their point of view the fight against alcoholism represented the salvation of the whole race 7 jančík pít či nepít p 48 8 prince břetislavs ban on taverns could be considered the first response in this context kos since the times of the austrohungarian empire german teetotallers in the bohemian lands were united in their own association the mimir union moravia occupied an important place in the movement especially the land capital city of brno josef hybeš12 the editor of the rovnost journal and a social democratic member of the imperial council was the founder of the temperance movement in the bohemian lands under his leadership the teetotaller association in brno was established in 1900 under a austrian law initially rovnost was used for the associations announcements and reports on its activities blaho lidu the first temperance magazine was launched two years later 13 revue protialkoholická a magazine published since 1904 provided space for more professional articles two years later the two periodicals merged under the name zdravotnické rozhledy 14 the response to the brno teetotal movement was more palpable in northern bohemia than in southern moravia 15 the first temperance congress was also held in brno in 1906 subsequently the land teetotaller later the moravian teetotal union which merged with čsas in prague in may 1921 thus forming its moravian land headquarters 16 the notion that alcoholism was a disease emerged later before that anticlericalism and teetotalism had converged the two movements were united by luisa landováštychová women constituted a special group of addressees of the temperance movement they were approached by women authors such as františka plamínková a supporter of a womens progressive movement pavla moudrá a writer and translator and jindřiška wurmová a writer and representative of the peace movement similarly the temperance issue found its support in the sokol movement 17 the desire to improve man to overcome his natural inclinations contributed to the fact that some anticlericalism and teetotalism activists shifted towards scientific socialism and embraced the ideas of social revolution 18 besides the question was addressed also by the social democracy which kept striving to raise the workers standard of living and considered it crucial that the workers demands should grow faster than it was possible to satisfy them the social democracy saw in this the source of the efforts to change and mend the world by exploiting the opportunities provided by the consumerist way of life the workers lost interest in achieving their goals on the basis of fleeting yet replicable gratification these tendencies were confirmed by emil vandervelde a belgian socialist and adolf braun a social democratic bavarian columnist when they noted that increased income brought increased spending on alcohol 19 the fight against alcoholism was primarily a fight against its producers 20 before world war i the social democrat teetotallers could not find common ground with the bourgeois teetotallers the social democrats believed that the latter saw the social issue and the temperance issue as one and the same assuming that the eradication of alcoholism would solve the social issue the social democrats rejected such approach 21 the association of teetotaller socialists was formed relatively soon within the čsas as its 16 raš za ostřízlivění národa p 14 popov mudr jan šimsa průkopník léčby závislosti a psychoterapie v čechách in adiktologie 2017 vol 17 no 2 p 170 nma the čas f inv no 8 c 1 mareš historie abstinentního hnut p 5 jančík pít či nepít p 48 17 raš za ostřízlivění národa p 15 on the question of the womens emancipation movement in sokol see strachová emancipation of women in physical education paper on history of the womens unit of sokol brno i in historický časopis 2019 vol 67 no 2 p 265 18 pokorný krásy života bez alkoholu in hospody a pivo v české společnosti prague 1997 p 181 19 fröhlich alkoholní otázka a třída dělnická in zdravotnické knihovny dělnické 1908 no 1 p 24 20 lihový kapitál naším úhlavním nepřítelem in abstinentní věstník 1911 vol 2 no 1 p 3 21 pokorný krásy života p 180 own division 22 serving as a point of contact for the čsas with other social democratic and communist organisations 23 the whole issue resonated strongly in the society even before the war 24 after the outbreak of world war i most teetotalism activities declined this was partly due to the lack of awarenessraising workers which was caused by the mobilisation partly this was due to regulated production and sale of alcohol state interventions were exacerbated by the shortage of raw materials ironically as a result of the war the teetotal movement was partially accomplished after all 25 this state of affairs was present in the bohemian lands even in the first postwar year already during the war the mutual relationships between teetotallers and friends of teetotalism were growing deeper 26 after the devastating war their real task seemed to be the creation of a new state a new nation a kind of a higher nation as referred to in a letter published by prof břetislav foustka on behalf of all the teetotallers these circles were convinced that a general sobering up of the whole nation would be the only thing to crown the czech national revival 27 in the autumn of 1918 foustka therefore drew up a proposal for a social and health programme emphasising the eradication of alcoholism 28 the public however viewed teetotallers as eccentric individuals trying to set themselves apart from others at all cost other organisations and associations engaging in the sphere of ethics social issues and hygiene physical education and other matters were also heavily involved in the movement naturally such organisations had their representatives in the čsas they formed a loose association in moravia under the name of the teetotaller council the čsas was the umbrella organisation for all those matters and its activities were driven by intellectuals with university teachers doctors lawyers economists and educators of all types of schools taking up the leading posts the teetotal movement achieved partial success in the czech environment in the area of health care efforts to establish a treatment centre for alcoholics were fulfilled p bedřich konařík was actively involved in this activity founding the society of cross for the establishment and maintenance of a hospital for alcoholics in 1910 which was to be part of the international teetotal association of cross the society of cross with the support of čsas built a treatment facility in velké kunčice the first medical facility of its kind in the czech territory which operated between 1911 and 1915 although the facility disappeared during the war it served in varying degrees as a model for similar facilities later especially for an alcohol rehab treatment facility for curable male drinkers in the tuchlov castle near teplicešenava opening in 1924 29 alcoholics would be placed in psychiatric institutions only if alcoholism was associated with any disease generally the term correction was used rather than treatment 30 treatment facilities were places where the background material for press campaigns was often created not only for the facilities themselves but also eg for sokol since 1920 a series of bills were introduced in the parliament to counter the negative effects of the alcohol industry society was divided into two camps bringing together a wide spectrum of views the temperance camp was acting in a rather offensive manner 31 the other camp invoking the liberal principles of free entrepreneurship reacted defensively and had considerable lobbying potential 32 ostmittelund südosteuropa 19191945 referred to as hollitschers law or lex hollitscher in the literature it was the very first piece of legislation in czechoslovakia that dealt with the temperance issue 34 for example karel anděl a member of parliament for the czechoslovak trade and commerce party spoke against the bill while he did not deny the laws noble efforts he did point out the negative impact it would have on certain trades 35 the adoption of a proposal by czech women mps to include the education on the harmful and pernicious effects of nicotinism and alcohol consumption in the curricula of elementary middle and secondary schools was another success 36 the sokol regulations did not expressly prohibit the consumption of alcohol although alcohol would often be prohibited at meetings 37 the brno unit showed interest in the temperance movement even before world war i however this was an endeavour by the education division in cooperation with the regional progressive womens organisation the department held a teetotal exhibition in brnolužánky between 10 and 24 november 1912 the exhibition was followed by an academy on 23 november the end of the exhibition was complicated by a misunderstanding between the organisers in a letter dated 25 february 1913 the progressive womens organisation complained of deliberate devaluation and disrespectful treatment by sokol as sokol appropriated the proceeds of the event to itself only sokol objected in a letter dated 8 june 1913 in which it urged the progressive womens organisation to withdraw its earlier accusations 38 however the actions did not provoke any significant response within the unit itself the education division also organised lectures on the harmful effects of alcohol and nicotine as well as on sex education and eugenics nevertheless the temperance movement took hold in moravia and brno would host multiple temperance conventions 39 in the early 1920s teetotaller divisions were established in sokol in královo pole and in sokol in bzenec at the same time both divisions were affiliated to the mzú čsas over time their activities ceased altogether as their officials changed and mainly due to the lack of support 40 in brno only the teetotaller division of the mzú čsas would perform any temperance activities since the midtwenties the division focused on education sessions held in the winter for students in secondary and vocational schools the divisions events were organised in a highschool canteen with an average attendance of 150 students the programme included music singing poetry reading lectures and debates 41 the temperance issue only returned to brnos number one in the early 1930s the teetotaller division of sokol brno i was established in a situation when the brno police recorded 1156 persons arrested for drunkenness annually 391 of whom were women 42 naturally not only under the impression of the statistics but mainly because of the desire of a few individuals that in the unit where the gymnastic component of the activity is well taken care of the other no less important part of the sokol idea education and refinement of the spirit be also put into practice the division initially aspired to hold smokeand alcoholfree friendly parties for the members but did not find sufficient support for this as a response a part of the members established a teetotal group on 13 december 1930 43 the group tried to achieve its goals by cultural and education activities namely by organising lectures hikes noble pastimes etc the groups other activities included the dissemination of teetotalism brochures and press the group intended to interfere with the division that was organising puppet shows emphasising that no plays containing pub scenes or moods caused by the consumption of spirits were admissible 44 mudr leopold sonnek was elected the groups first chairman karel hrabec was elected vicechairman leopold synek was elected executive director františka samková was elected treasurer jan šimek was elected recorder and reporter however the idea of teetotalism was not embraced by the units members the group therefore appealed to the sokol members to let the group work regardless of their own beliefs the desire to find out what the members thought is also reflected in a considered questionnaire survey 45 following its establishment the group held a sokol debate on sunday 25 january 1931 at 730 pm in the foyer space of its stadium this first public performance set a precedent for all the subsequent events the audience were introduced into the foyer with flower decorations on the tables and the podium where the presidents bust rose from the rich greenery at the front after the introductory speech given by mudr sonnek an artistic program ensued featuring the artist zdeňka stejskalovágräfová the singer boža patočková and conservatory students josef musil and sámo kovář the guests were treated to tea and desserts during a break 46 the organisers were pleasantly surprised by the net proceeds of the event which exceeded czechoslovak crown in view of the considerable demand a second sokol debate was held in the large hall of the stadium soon after on 28 march commemorating jan amos comenius the 400 visitors who came that time were intrigued both by a speech given by prof ladislav jandásek and by the rest of the programme the net proceeds of the event exceeded kč 880 then which was considered a considerable success a third sokol debate took place on 12 september to commemorate jindřich fügner and prof miroslav tyrš in his speech mudr vladimír kubeš referred to a slogan by tyrš what you have gained through exercise are your morals and moderation do preserve it for yourself which became the main motto for the sokol teetotal movement in the future the sokol tradition attributed the first temperance ideas in the bohemian lands to miroslav tyrš the tradition relied on statements taken out of context as a result many perceived what used to be harsh criticism of sokol in completely different connotations 47 similar emphasis was placed on the question of nationality where the authority of prof tyrš acted as an arbiter of beer culture which he viewed as a product of germanisation efforts no slavic nation is said to have as many pubs and taverns as the czechs which we have picked up from our neighbours 48 but let us return to number one in brno the aforementioned debates were followed by a joint listening session to a ceremonial radio broadcast on 28 october in the stadiums hall specifically the transmission of the speech by the speakers of the national assembly and the subsequent response by the president moreover three friendly working meetings of the members of the teetotaller group and its supporters took place the first meeting was held on 5 october where prof jan uher made a speech explaining the causes and history of the sobriety movement and stated that the teetotaller movement was an effort to master selfcontrol further meetings were held on 21 november with a presentation by a kladivová and on 12 december with a presentation by dr otakar vičer throughout 1931 the group disseminated 1000 copies of tomáš garrigue masaryks information booklets the unexpected response within and outside the unit led the group to morph into the teetotaller division on 12 december subsequently it was attached to the education board 49 in 1932 the division organised two sokol debates and two lecture evenings on 29 january a debate was held in the large hall of the stadium under the title colourful evening its purpose was to point out that abstinence was not to be regarded as austerity and asceticism but that cheerfulness and joy were to be pure and natural untainted by the enjoyment of alcohol a second sokol debate was held in the same place on 6 march to celebrate the presidents birthday then on 23 may karel kálal who was perceived as a diligent promoter of life without smoke alcohol and card gambling was commemorated in the small hall of the stadium an education evening was organised on 12 november moreover the division in cooperation with mzú čsas published a promotional letter which was distributed during a commemorative cafés put on the sokol training robes penitentially take pains for your own benefit and for the benefit of the nation and finally make amends for the sins committed against your health freshness and bravery tyrš vážné slovo o sokolu pražském a o věci sokolské vůbec in národní listy vol 17 no 300 1 november 1877 p 2 sak and tyrš sokol myslitel výtvarný kritik prague 2012 p 118 48 bca f r77 inv no 320 hlasy tisku o činnosti abstinentního odboru sokola brno i zprávy sokola brno i vol 8 no 7 waitová abstinence v sokole in věstník sokolský list svazu československého sokolstva vol 35 no 15 13 april 1933 p 226 49 bca f r 77 inv no 320 z abstinentního kroužku zprávy sokola brno i vol vii no 8 20 october 1931 ibid the sokol headquarters had long recognised the importance of teetotalism but only in theory ie in terms of morality and education but otherwise it completely ignored and neglected the issue under the impression of the success achieved by the teetotaller division of the brno unit and marginally also under the impression of the resonating scandal in connection with the sale of tobacco products at a sokol gathering 51 in the spring of 1932 the presidium of the education board of čos decided to elect josef helcl as a special reporter for the temperance issue it was also decided that a friendly relationship would be established with čsas at the čos autumn congress a proposal was adopted to formalise teetotal activities by setting up a special committee at the presidium of the education board this was subsequently confirmed on by the čos presidium on 30 november 1932 the committee prepared guidelines which were to govern the teetotal activities across sokol among other things the committee highlighted two main principles first of all that sokol education in this respect should take the form of instructions and advice rather than bans or coercion the second principle consisted in a methodological clarification of the concept of teetotalism for the word teetotalism was not supposed to mean abstinence from alcohol and nicotine only but from anything that undermined the human no 1 2018 p 4363 51 sokol would traditionally issue an edition of sokol gathering cigarettes the sale of which was to promote the gathering and increase the proceeds of the event however this caused considerable resistance among some of the sokol members čos management defended itself by saying that the sokol cigarettes were to be produced at the suggestion of the finance division to generate profit for the sake of the gathering that this was neither about drinking nor about sobering up nor was it an attack on teetotalism no one is forcing anyone to buy and smoke the sokol cigarettes let the brothers sisters and gentlemen themselves raise funds for the gathering and give us about kč 100000 to 250000 františek v pokorný from brno the editor of nový lid turned to the finance division for the gathering promising a collection and guaranteeing to raise kč 100000 at least if čos refrained from the idea of the tobacco products for the gathering this was rejected by the čos presidium in the end čos lost kč 78000 on the sale of tobacco products at the gathering vojna o sletové cigarety in věstník sokolský list svazu československého sokolstva vol 34 no 5 4 february 1932 pp 76 organism including unrestrained eating and unrestrained enjoyment of bodily pleasures in general there was a belief that smokers and alcohol drinkers should not be looked down upon as this would compromise the whole education efforts beforehand in the eyes of the public 52 at the first march čos presidium meeting in 1933 a resolution was adopted according to which the presidiums statement in this regard was to be published in věstník sokolský 53 at the same time the presidium included in all physical education schools a compulsory lecture on teetotal education and called on the sokol administrative districts to do the same 54 in the meantime the teetotaller division in number one continued to organise education debates in the stadiums large hall in 1933 the first debate took place on 22 january the cultural and historical character of the whole event was underlined by the performance of karel höger a member of the land theatre in brno a second debate was organised on the occasion of tyršs 101st birthday under the title tyrš in a friendly circle of gymnasts this was followed by an education evening titled through education to a new life hosted on 25 april in addition to the abovementioned events the division was involved in the evening to commemorate charlotte masaryk which was organised by the unit together with the associated brno womens societies on 13 may all of these events brought in a net profit of kč 3421 in 1933 in addition to organising events the division also drew up rules of procedure summarising the ideological guidelines 55 in this way the division went on to organise cultural and education events with a rich programme featuring artists engaged in brnos culture also in the next year a debate held on 11 february 1934 featured karel spurný a member of the land theatre in brno and prof emil šotola božena žáková and vladimír vozák a debate on 28 october organised by the unit was cohosted by kriváň a slovak academic association the aforementioned events brought in kč 1404 debates were not the only endeavour the division also delivered speeches to the members in april and then again in november for two womens divisions in addition to that mudr leopold sonnek gave a lecture at a youth party on 17 february the division continued to assist in some of the education boards events such as a party or the anniversary of the battle of lipany 56 however the teetotaller division did not show much effort to bring the temperance ideas into the public arena the division stayed within the boundaries closely tied to its own membership base how much attention the division received from its members is illustrated by a questionnaire campaign organised by the division in the middle of 1935 its purpose was to find out where and why the members disagreed with the divisions efforts or what was their idea of what the division should do next the division placed 4000 printed questionnaires as an insert in the sokol brno i newsletter and also distributed them on suitable occasions however only eightysix members responded to this mass campaign of which sixtynine had already been affiliated to the division 57 the division viewed the event as a success the division relied in its activities on its efforts to educate towards teetotalism through entertainment and education events in 1935 the last three sokol debates were organised the first one on 27 january the second one on 28 october on the occasion of the national holiday and the third one on 30 november 58 at that time a scandal was reverberating throughout the society caused by a mass methyl alcohol poisoning in nová budeč běchovice and úvaly claiming eleven lives 59 it was not until 1936 that the division began to be more active towards the public at that time the division focused on a regional gathering where the division decided to sell milk and bread and butter 60 however the worsening international situation led the division to react the debate of 28 october 1936 focused on czechoslovak unity rather than the temperance movement the event featured not only moravias and slovakias numerous prominent figures often accompanied by members in national folk costumes but also by the band of 56 výroční zpráva tělocvičné jednoty sokol brno i 1934 p 117 57 sokol brno i had a total of 2659 fullyfledged members and 128 not fullyfledged members in 1935 it should be noted however that there were far fewer members who would actually do exercise on average around 29 of males výroční zpráva tělocvičné jednoty sokol brno i 1935 p 20 58 výroční zpráva tělocvičné jednoty sokol brno i 1935 p 107 59 původci hromadných otrav zjištěni in lidové noviny vol 43 no 617 10 december 1935 p 4 hromadné otravy jedovatými likéry in lidové noviny vol 43 no 618 10 december 1935 p 1 hon na původce hromadných otrav in lidové noviny vol 43 no 619 11 december 1935 p 5 nebezpečné porušování lihovin in lidové noviny vol 43 no 620 11 december 1935 p 2 nová otrava na českém venkově in moravská orlice vol 73 no 287 10 december 1935 p 3 nová hromadná otrava v obci u prahy in venkov vol 30 no 287 10 december 1935 p 6 jedovatý líh zavinil otravu 9 lidí in venkov vol 30 no 288 11 december 1935 p 6 60 bca f r77 inv no 35 iv schůze 30 v 1936 ibid v schůze 14 ix 1936 infantry regiment no 10 subsequently the division together with the unit of the czechoslovak legionnaires prepared a celebration of the 86th birthday of president tg masaryk which took place on 8 march at the stadium on that occasion the land theatre in brno was represented at the event by the opera soloist vladimír jedenáctík accompanied by prof vilém blažek on the organ the programme also included a performance by conservatory pupils led by prof rudolf walter the division also invited astronomer dr karel hujer who gave two lectures one of them titled when will the world end given on 27 march and one titled following total solar eclipse through siberia via china to japan given on 15 october the division prepared máchas evening on 22 april the division was able to hand over net profits of kč 790435 to the unit generated from all of its events in 1936 a trip to subcarpathian rus was a true novelty where the divisions representatives promised to help with awarenessraising by the local central teetotaller committee for subcarpathian rus in berehov 61 the divisions activities continued in this fashion in the late 1930s however the division decided to pursue its goals by new means it organised the first teetotaller sokol new years debate in the large hall of the stadium on 1 january 1937 this alcoholfree format of the new years eve was what brought sokol brno i the greatest popularity 62 as a substitute for the celebrations of president t g masaryk and 28 october that had fallen through the division organised debate evenings on 6 and 28 april and on 13 october in the late 1930s the division got into a dispute with the operator of a restaurant at the sokol stadium the division accused the operator of charging disproportionately higher prices for soft drinks for that reason it was decided that the matter would be addressed in the next lease agreement 63 moreover the division again took care of spreading teetotalism through reports in the zpravodaj newsletter and speeches olga sobotková gave a speech supplied by the division at a civil defence meeting on 18 april and dr bohumír tichánek gave a speech at a regional education school on 11 december 64 61 výroční zpráva tělocvičné jednoty sokol brno i 1936 p 92 62 this is also illustrated by the report which stated the wish of many participants that similar events be held on a monthly basis the division ruled this option out as technically unfeasible bca f r77 inv no the new years debate launched the teetotaller divisions activities in 1938 the debate was followed by the annual meeting of 29 january where mudr vladimír kubeš gave a speech the division organised a friendly meeting in the committee room dedicated to the memory of t g masaryk on 7 march another friendly meeting to commemorate labour day was organised by the division on 30 april masaryks memorial evening planned for 14 september 1938 could not take place in view of the extraordinary international situation all the attention of the sokol units was focused on the 10th sokol gathering where the division again sold milk and other soft drinks a teetotal debate as an accompanying programme of the gathering was also considered 65 moreover the division promised the regional teetotaller headquarters in subcarpathian rus a lecture with slides as the division was unable to keep the promise the units committee donated at least kč 500 to the organisation for the publishing of a temperance oneact play from a peasants life by ivan ustijanovic the social situation radically shifted the priorities of each sokol unit so it comes as no surprise that the divisions activities declined somewhat compared to the previous years the whole time however the division continued its cooperation with mzú čsas in brno and the čsas headquarters in prague 66 that cooperation was supported by the aforementioned associations which provided the sokol units with professional base and material for leaflet campaigns conclusion in the czech environment the reformist zeal driven by a desire for moral propriety and adaptability did not prove successful also because it did not enjoy the wide social support as it did eg during world war i in the us moreover the us example showed that the noblest of intentions translated into legislation would not do without proper tools for their enforcement from the beginning prohibition faced public thirst sluggish support from local authorities and profits stemming from smuggling and underhand trade a regulated market repeatedly proved to be a better tool for mitigating risks and damage in czechoslovakia prohibition was primarily promoted by čsas as the main representative of the 1937 p 93 o novoroční besedě in zpravodaj tělocvičné jednoty sokol brno i vol xiii no 1 29 january 1937 p 18 za masarykem in zpravodaj tělocvičné jednoty sokol brno i vol xiii no 5 26 may 1937 p 85 bayer odkaz masarykův in zpravodaj tělocvičné jednoty sokol brno i vol xiii no 8 23 october 1937 p 157 65 bca f r77 inv no 35 výborová schůze dne 11 ledna 1938 66 výroční zpráva tělocvičné jednoty sokol brno i 1938 p 100 abstinentní odbor in zpravodaj tělocvičné jednoty sokol brno i vol xiv no 1 p 16 abstinentní odbor in zpravodaj tělocvičné jednoty sokol brno i vol xiv no 4 p 76 temperance movement among the movements activities publishing stood out as its primary activity moreover other means were used for selfpromotion of the movements ideas and interests temperance exhibitions which allowed for a concentrated effect on a wider range of addressees and multiple senses at the same time various conferences debates rallies demonstrations but also petition drives and lawsuits brno was the birthplace of the temperance movement in the bohemian lands it took twelve years for the ideas of josef hybeš from 1900 to reach the local sokol movement the first cooperation on the eve of the war conflict did not spark any lasting interest of the sokol unit sokol brno i initially marginalised the whole issue it revisited the topic only in the early 1930s when on the initiative of a handful of enthusiasts a teetotaller group was first formed then expanding into a division naturally the latter used the same means to achieve its own goals as čsas over time the form of its selfpromotion took shape of organising entertainment and expert debates education evenings speeches and a leaflet campaign this was supplemented by special celebrations and anniversaries which were chiefly the subject of leaflet campaigns in the late 1930s the division decided to leave its comfort zone and repeatedly ventured into todays transcarpathian region the division had major concerns about hosting alcoholfree new years eve celebrations but they received the greatest public response two trends gradually emerged first a growing emphasis on the unfavourable international political situation and second the realisation that the education efforts had absolutely no effects on the middle let alone the older generation greater attention was thus given to the youth as the hope of the nation it is important to point out that the unquestionable success of brnos number one and the response it had among the sokol members led the presidium of the čos education board revisit the whole issue the temperance movement embraced this as part of its own goals thanks to which the teetotaller division of sokol brno i became a model department for the other sokol units in the mid1930s about the authors

the tradition of temperance movement in the bohemian lands dates back to the early 20th century it gained momentum after world war i which was perceived by the movement as a consequence of the decline and the movement sought to prevent any similar conflicts in the future its aim was to solve the issue of alcoholism which posed a serious social and health problem the movement was based and relied on the knowledge and current trends coming from western europe and the us it found support among professionals and laymen alike often through the prism of religion the article discusses the temperance movement in the bohemian lands in the first half of the 20th century the article traces the movements origins and history especially its acceptance by education and sports associations clubs and societies special emphasis is put on the sokol organisation and its diverse temperance activities which were intended to lead its own members to voluntary sobriety and complete abstinence teetotalism such activities were meant to offer an example for the entire nation the main emphasis is on the moravian region which spearheaded the temperance movement and would influence the rest of the bohemian lands for a long time it also considers local conditions and the communitywide support as well as what the entire movement achieved from the times of the austrohungarian empire until the end of the first czechoslovak republic it also looks closely at the interconnectedness and synergies among the various temperance organisations

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in her long durée history of vital needs dana simmons recently showed how the struggle for labor reform and decent pay in fin de siècle france was tied to a discourse about vicious and superfluous needs that were supposed to corrupt the nation while socialists fought for structural reform of the workplace conservatives argued for the rationalization of the spending habits of women who were either immoral ignorant or both 1 the discourse examined by simmons was not unique to france as we will argue in our contribution to this special issue the same discourse can be found in the early progressive era in the united states where one group of reformers aimed to solve the social question by institutional reform of working and living conditions of the urban poor while others concentrated on educational programs to rationalize their needs we will take socialist and labor reformer florence kelley and mits first woman chemist ellen richards as exemplars of women reformers whose reform strategies related to these different sides of the social question while kelley canvassed for the reform of working conditions richards concentrated on the reform of the vital needs of the household into a homogenized american mold that celebrated individual over institutional change kelley and richardss reform strategies briefly met in 1893 the year of the chicago world fair at hull house one of the prominent sites of the american settlement movement located at the crossroads of south halsted and west polk street in todays chicago west loop at the time one of the poorest chicago slums hull house attracted many women social reformers interested in new forms of education and social support for the largely immigrant class of working poor on its rapidly expanding premises hull house first introduced a kindergarten a library a variety of cultural clubs and then also a public kitchen which had been developed by richards in boston as a site of experiment on dietary habits at the time kelley was living and working in hull house conducting social surveys in its surrounding slums to collect evidence on the evils of the sweatshop system that was allpresent in chicagos garment industry in her history of poverty research in the united states alice oconnor makes the useful distinction between structural and cultural reform programs which overlaps with simmonss distinction between the reform of labor conditions and the reform of an individuals needs structural reform programs aim at institutional change and cultural reform programs at the change of individual behavior oconnor discusses kelleys social surveys and their impact as part of a structural reform program but she misses the importance of dietary research as a strategy of cultural reform as harvey levenstein reminds us in his history of the new england kitchen no cultural habits are more persistent than food habits while florence figure 1 hull house at the crossroads of south halsted and west polk street around 1900 the library building is on the left the public restaurant and cafeteria with takeaway meals cooked in a new england kitchen are on the right source hull house photographic collection special collections and university archives university of illinois at chicago call mark jamc000001320150 kelley used the social survey to provide lawmakers with evidence in support of legal reform of labor conditions ellen richardss food research focused on the improvement of the socioeconomic position of the poor by changing their food habits oconnors distinction between structural and cultural reform thus captures the contrast between social reformers who used the social survey to enforce structural change in working conditions and liberal reformers and scientists who brought nutrition research from the laboratory to the public to change its behavior while leaving working conditions to the whims of the market in what follows we contrast the reform strategies of kelley and richards to see how they entailed different diagnoses about the root causes of social harm and its remedies this is not just a matter of ideas but of research practices at specific sites of social reform we will concentrate our discussion on their preferred methods of research and on the propagation of the results of their investigations into the public sphere hull house kelleys walks through the chicago slums and the new england kitchen at the 1893 chicago world fair will play an important role in our story florence kelley hull house and the antisweatshop system legislation let us start with florence kelley and the social surveys she conducted first for the illinois congress and then as factory inspector for the illinois and federal bureau of labor statistics florence kelley wischnewetsky moved from new york to chicago seeking refuge with her three children from an abusive husband when she first crossed the doorsteps of hull house on a snowy morning between christmas 1891 and new years 1892 she felt welcomed as though we had been invited by the women who lived in this social settlement in one of the poorest slums of chicago hull house was an important center of the american settlement movement situated in the nineteenth ward at the west end of chicago 2 the founders of hull house jane adams and ellen gates starr arranged with their friends jesse bross lloyd and the famous muckraker journalist henry demarest lloyd to take care of kelleys children at their home in winnetka where they stayed on and off for the six years that kelley lived and worked at hull house 3 with hull house as her unconventional home base kelley quickly became one of the main spokespersons of the workingclass movement in chicago she conducted social surveys first as employee of the illinois bureau of labor statistics for the illinois congress and then as factory inspector for the federal bureau of labor statistics on the socalled sweatshop system that dominated the surrounding immigrant neighborhoods for these surveys kelley and her collaborators made doortodoor visits to inspect labor and living conditions of the chicago working poor these surveys are commonly considered as one of the starting points of the social survey movement of the american progressive era they led to important changes in labor regulations for women and child labor most notably through the famous brandeis brief for the american supreme court in 1907 in muller v oregon in which social science data on womens health collected by florence kelley and josephine goldmark kelleys first biographer were for the first time accepted as court evidence supreme court justice felix frankfurter considered that florence kelley had probably the largest single share in shaping the social history of the united states during the first thirty years of this century florence kelley was born on september 12 1859 in philadelphia pennsylvania the daughter of caroline bartram bonsall and us congressman and strict abolitionist william darrah kelley william kelley was one of the founders of the republican party and a close friend of abraham lincoln as a congressman he became known as pigiron kelley because of his unwavering support for the tariff to protect the pennsylvania steel industry at the age of sixteen florence kelley began studying at cornell where she became a phi beta kappa member she did not graduate until 1882 partly due to illness but also because a lack of reliable statistical data made it difficult for her to complete her bachelors thesis on the changing legal status of the child as a woman kelley was denied advanced studies for a law degree at the university of pennsylvania she therefore went to zurich where she attended courses in political economy and the social sciences at the time zurich was a hotbed of socialists and one of the few places where women could obtain a masters degree she became a socialist who believed in the central importance of marxs theory of surplus value and its concomitant analysis of the class conflict between labor and capital she met friedrich engels with whom she kept in correspondence and translated his condition of the working class in england in 1844 a book that in many ways colored her later path in life 4 this translation on which she worked from 18841887 was the only one in english until 1948 very much against the wish of her parents she married the russian medical student and socialist lazare wischnewetzky in 1883 which led to a rift that would only heal shortly before her fathers death the couple perceived the hay market riots in may 1886 in chicago as the moment capitalist class struggle had reached america and decided to return to be part of this revolutionary moment they settled in new york where kelley became involved in the socialist party her husband failed to secure a stable position as a physician which forced them to turn to florences family despite the rift for financial support wischnewetzky became increasingly abusive especially after kelley began using english for daily conversation with their three children it would take another eight years after her escape to hull house in late 1891 before they divorced and the specter of losing her children to her husband vanished the american settlement movement was inspired by the philosophy of william ruskin and the arts and crafts movement in britain and by londons toynbee hall which aimed to disrupt class barriers and improve the lot of the poor by bringing education and culture to the slumsnot through charity but by living among and with the poor most american settlement houses were managed by women of the middle class hull house established by jane addams and ellen gates starr at the crossroads of south halsted and west polk street was no exception addams and starr founded hull house in 1889 after a tour through europe during which they had visited oxford and toynbee hall in london beginning with a child nursery the house quickly expanded its functions and became a center that offered education and other services to the local mostly immigrant community 5the settlement movement in the united states was closely related to the social gospel but hull house was special in that jane addams invested a substantial part of her personal fortune in its development addams conceived of hull house as a social experiment that should adapt itself in line with its ruskinian moral philosophy to new initiatives and changing circumstances within a few years the place provided a base and space for a multitude of clubs educational initiatives and music and theatre performances hull house thus came to function as a family home for the neighborhood run by women and largely for women hull house was a settlement that as kelleys biographer kathryn sklar notes conveyed the feeling of a home but which in contrast with settlement houses depending on christian charity could afford itself an activist profile for social change this profile was enhanced by the arrival of florence kelley in 1891 which galvanized hull house as addams remembered into more intelligent interest in the industrial conditions all around us kelleys involvement with the socialist party in new york meant that she was already wellacquainted with the labor movement in chicago when she arrived at hull house in the aftermath of the hay market riots labor activists such as mary kenney elizabeth and thomas morgan and abram bisno had concentrated their activism on the evils of the sweatshop system that permeated the chicago garment industry mobilizing the press and gathering statistical evidence to expose its evils garment factories outsourced their work to sweatshops that is to workplaces in private dwellings and family homes where men women and children were contracted by their ownersthe sweatersat racetothebottom contract prices that followed a strict division of labor between immigrant communities in 1888 the chicago tribune published a series of investigative articles called slave girls of chicago and in 1891 elizabeth and thomas morgan published a pamphlet for the chicago trade and labor assembly entitled the new slavery investigation into the sweating system as applied to the manufacture of wearing apparel the combination of political and social pressure and the evidence presented in these and other publications enlarged the base of resistance to the sweatshop system among the illinois middle and upper classes and prompted the state of illinois to start an investigation into the chicago sweatshop system kelley had thus arrived in chicago at the right moment in need of work to pay the rent for hull house and at the suggestion of jane addams kelley took up a job with the illinois bureau of labor statistics to which this investigation was promulgated she visited between 900 and 1000 tenements of which she retained 666 for her report 6 residents of hull house remembered her swollen feet from her walks through the neighborhood this survey was subsequently enlarged for the 1894 report of the federal bureau of labor statistics on the slums of americas east coast cities which was commissioned by the house of congress and supervised by the director of the bls carroll d wright 7 under kelleys guidance four men in the service of the bureau of labor statistics devoted their entire time for the week of april 6 1893 to an examination of each house tenement and room in the district and filling out tenement and family schedules wright designed the questionnaires for these surveys which he based on the american census forms 8 they included more than sixty questions about the state and the status of the tenement the use and dimensions of the rooms the composition and working conditions of the families living in these tenements the fact that the local population was acquainted with the community service work of hull house and approved of its activities helped kelley gain access to the tenements in the neighborhood but it also increased her trust in the answers and in those cases where sweaters refused her entry the fact that the survey was commissioned by the illinois congress guaranteed her access her first report was published in 1892 and led to the states antisweatshop regulation of 1893 6 seventh biennial report of the bureau of labor statistics of illinois 1892illinois 369 report and findings of the joint committee to investigate the sweat shop system together with a transcript of the testimony taken by the committee 7 on wright see macdonald 8 in a series of informative blogs to celebrate 125 years of hull house papers and maps sharon lohr explains the relation between these forms and the questions of the american census available online at blog2020520hullhousemapsat125 accessed march 27 2023 both elizabeth morgan and florence kelley drafted a version of the bill but kelleys more radical version which recommended an ambitious expansion of state authority and the establishment of an office of factory inspection became the blueprint of the final bill to get this law through kelley had to maneuver between the conflicting interests of the different labor unions and political parties which she did in close collaboration with labor union front man abram bisno a jewish immigrant from ukraine whose family had fled to the united states after the kyiv pogrom of 1881 9 the resulting law proposed to curb the sweating system by prohibiting childrens work below the age of sixteen and restricting working hours for women to eight hours it was unanimously approved by the illinois congress and governor john peter altgeld subsequently appointed kelley to the new post of chief factory inspector for the state of illinois10 however the success of the sweatshop campaign proved shortlived challenged by the illinois manufacturers association in ritchie v people the illinois supreme court ruled in 1895 that restricting working hours to eight hours only for women violated the fourteenth amendments guarantee of freedom of contract 11 see for more details sklar bulmer bales and sklar see in particular the seventh biennial report of the bureau of labor statistics illinois 1892 and the report and findings of the joint committee to investigate the sweat shop system together with a transcript of the testimony taken by the committee 1893 the social survey as a book of grievances historians of social science and statistics have commonly focused on kelleys spectacular visualization of her social survey with the colored wage and immigrant maps that accompanied the hull house papers and maps and on the scientific soundness of her methods of surveying published in 1895 the book collected essays from the hull house community offering a vivid impression of the social conditions of the neighborhood and of the activities undertaken for their improvement the book was published as the fifth volume of wisconsin economist richard t elys library of economics and politics but only after ely capitulated to kelleys threat to withdraw her cooperation in response to his suggestion to suppress the maps kelley insisted that the charts are mine to the extent that i not only furnished the data for them but hold the sole permission from the us department of labor to publish them i have never contemplated and do not now contemplate any form of publication except as two linenbacked maps or charts folding in pockets in the cover of the book similar to mr booths charts in her introduction to the hull house book agnes sinclair holbrook wrote that the maps of charles booths london poverty project had served as a warm encouragement for kelleys visualizations 12 but instead of being the start of an investigation into the causes of poverty as in booths case kelleys maps served as public exhibits to show what her survey had confirmed the exploitative nature of the sweatshop system the keys to the maps show these differences in purpose instead of booths moral classification of poverty kelleys color codes referred to different wage levels without reference to poverty in one set of maps and to different immigrant populations in the other combined the maps displayed the geographical correlation between wagelevels and immigrant groups which kelley had explained in her report for the illinois bureau of labor statistics hull house maps and papers was published in 1895 after the sweatshop campaign that led to the illinois factory act of 1893 this campaign gained steam with the state of illinois gubernatorial election in fall 1892 which was won by john peter altgeld on a democratic ticket in fact in the runup to the chicago world fair none of the candidates proved willing to defend the sweatshop system public meetings were organized that made the wealthy part of chicago aware of the conditions under which their garments were produced sometimes for audiences as large as 2500 people one of the arguments was that these labor conditions made the garments unfit for consumption because they were a health threat joanna waugh noted how on a meeting of february 19 1893 at chicagos central music hall with demarest lloyd florence kelley and mary kenney as its speakers a grim display of infected cloaks and shirts taken from various sweatshops reminded the listeners of the everpresent dangers of unregulated sweating labor thus when kelley started working on her social survey her report did not just serve to chart the facts but rather to show the evidence and advocate for social change it functioned as a cahier des doléances as simmons acutely observes of similar statistical work in the french caseas a book of statistics that served as accusatory evidence against capitalist exploiters garnering momentum for social change while working on her report for the illinois bureau of labor statistics in 1893 kelley invited congress committee members and journalists to join her on her visits of the tenement dwellings thus garnering support for its findings these tours started with hull house as beginning and endpoint and were covered by the press the february 12 1893 issue of the chicago tribune reported on one such tour in terms of the surveys questionnaire in the rear of a fine brownstone the committee found a typical sweat shop amid the whir and din of a gas engine and twenty sewing machines twenty girls and four men were found at work in a room 20 x 36 feet several of the girls were apparently not 13 years old but when asked their ages they replied that they were much older the sanitary arrangements were poor and the odor of the place was foul these tours quickly became an obligatory rite de passage for politicians and government officials when the state of illinois installed a committee of its own to investigate the sweatshop system kelley was invited as expert witness asked by the committees chairman for advice on how to investigate the evil of the sweatshops kelley invited the committee members for a walk through the ward around hull house thus reenacting her visits for the illinois bureau of labor statistics abram bisno also present suggested they begin taking testimony at once because the jewish shops were about to close for the shabbat the tour with the committee members was prepared in advance but the facts already known to the committee members from kelleys report became real once they crossed the sweatshops doorsteps the transcript of the joint committee reads the committee then started out accompanied by the representatives of the press and the first place visited was the sweat shop of k a garbulsky in the rear of a frame tenement house at no 257 west polk street the place consisted of three rooms one of which was used for a workshop the other for a kitchen which opened into the workshop and the third room as a sort of storeroom for coal which also opened into the workshop the workshop and kitchen were small rooms about 12x7 the ventilation was bad and the smell from decayed matter and dirty clothing which were strewn around the rooms was almost unbearable in the kitchen was a door which opened into a watercloset which was in a most unsanitary condition and was used by the family and employés in common there were seven in the family including four small children one of whom was in a dying condition with the measles and three others of whom were just recovering the proprietor garbulsky was examined by senator noonan as follows q what is your business a manufacturing knee pants q how many employés do you have here a that is a question of how much l have to do sometimes two three and five q how old is this girl working on this machine a fourteen years old q what is her name a lizzie champ q how many hours a day do you work your employés a about ten kelley had collected her data with doortodoor visits to the tenements surrounding hull house and diligently transformed them into the tables and cursory descriptions in her report the descriptions in the press and tours with lawmakers through the sweatshop district turned these abstract tables and numbers back into public political experiences it is one thing to see a table in a report as in figure 3 that we took from kelleys report it is another to sense and smell their meaning figure 3 fragment of table 1 of kelleys report on the sweatshop system for the illinois bureau of labor statistics of 1892 the table shows the kind of garment made the number of men women and children working the size of the dwelling and its sanitary conditions source seventh biennial report of the bureau of labor statistics of illinois 1892 1893 springfield ill state printer p 419 science in context thus by reenacting the steps for her survey florence kelley mobilized political support for her draft legislation just as the spectacular maps of the hull house maps and papers served as illustrations for a larger educated public of the dire living conditions of the immigrant urban poor so did the visits of the joint committee and its coverage by the press convince lawmakers of the need to regulate labor working conditions they transformed statistical evidence into the need for regulatory action ellen swallow richards experiment stations and the iron law of wages let us now turn to the work of ellen swallow richards and her reliance on laboratory experiments as the preferred method for social change ellen swallow richards opened the doors of the new england kitchen on january 24 1890 the kitchen located at 142 pleasant street a respectable part of boston in a quarter with small shops and businesses was designed for the sale of healthy nutritious takeaway food to its working population these meals had been developed by richards in her laboratory at mit and were to be tested and perfected by confronting them with the tastes and appetites of the public that could buy these meals at low cost richards who has been described as the single most influential scientist you probably never heard of was the first woman to be allowed advanced studies at mit during the 1880s she conducted laboratory research to improve sanitary conditions and nutrition of the working urban poor at the turn of the century she was a key founder of the home economics movement which became an integral part of womens academic and vocational training at land grant colleges in the interwar period her combined field and laboratory work with mit chemist thomas brown set the first standards for water quality in massachusetts and led to the socalled richards maps which indicated the level of water pollution in different parts of massachusetts working with food journalist mary hinman abel she gained the financial and scientific support to open the new england kitchen from willard ogburn atwater professor of chemistry at wellesley college and director of the national network of agricultural experiment stations and from edward atkinson a prolific boston businessman and free trade publicist who served on the mit board of trustees this new england kitchen was not intended as a community center but as an experiment station that would give a cosmopolitan flavor to richardss laboratory meals and teach its clients the newest scientific knowledge about how to cook healthy nutritious and affordable meals 15richards was born 1842 in dunstable massachusetts the only child of a shopkeepers family of modest means she died in 1911 while deeply involved in the institutionalization of the home economics movement richards received her bachelors education at vassar college a womens college established in 1861 just at the start of the civil war as noted above much of her early research was in sanitary and food science but her interest in what was to become home economics began at the philadelphia world fair of 1876 the exhibits of european countries like sweden and russia convinced richards of the underdeveloped state and lack of knowledge in americanot only about food but about all matters related to the management of the household richards thus became interested in catharine beechers system of teaching the american housewife how to clean the house 16 in contrast with beechers religiously inspired program of family visits however richards put faith in modern scientific insights gained by experiments to improve womens habits instead of visiting the family home she created public spaces in which to show and teach these insights leaving it to the public to implement these findings in the private sphere richardss program of home economics gained speed with the annual conferences she organized from 18991908 with annie and melvil dewey at their resort in lake placid 17 in the 1920s educational programs in home economics covered the whole spectrum of household and consumption activities but in the 1880s and 1890s richardss main focus was on the improvement of the dietary habits of the american working population richards concerns with the dietary habits of americans fell squarely into contemporary debates about the standards of living of the urban poor controversies about the unionization of the american work force and the minimum wage for her dietary research richards joined forces with the wesleyan professor of chemistry wilbur olin atwater the boston laissez faire businessman and inventor edward atkinson and food publicist mary hinman abel atwater was a wellknown chemist in nutrition research who imported the caloric measurement system into the us he studied at wesleyan university in connecticut to which he returned as a professor after his chemistry degree from yale in 1869 and his travels through europe atwater participated in carl von voits laboratory work on nutrition in munich and became an ardent promotor of the german system of agricultural experiment stations he became the director of connecticuts agricultural experiment station and after the hatch act passed congress in 1887 of the federal system of agricultural experiment stations atkinson was a successful boston businessman inventor and publicist on political economy he was a democrat and a vocal defender of free trade in the manchester tradition of the cobden club he frequently intervened in public debates about the workers struggle for higher wages and unionization both of which he considered a very bad idea because of his political economic convictions and because he considered freedom of contract essential for the american concept of liberty 18 he embraced the classical political economists theory of the wages fund which implied that the immutable laws of supply and demand in the short run did not allow for wage increases but disputed that this boiled down to the lasalles iron law of wages because statistical evidence showed the substantial improvements of the standard of living of the american working class in the period following the civil war instead of cultivating the classantagonism between labor and capital working class families would do better to scrutinize their spending behavior and especially as he did not fail to repeat should consider the tremendous gains they could make by saving on their most important category of expenses food in his presentations to unionists atkinson backed up his arguments with diagrams that pictured the division of revenues between labor and capital however inevitable the difficult contemporary working conditions might bewhich he fully admittedthey would improve in the long run because of the many innovations that lowered costofproduction railways were his recurring example and time and again he challenged his public by arguing that vanderbilts wealth was dwarfed by the huge wage increases in real terms of american workers instead of organizing in unions to increase their wages to the detriment of the incentives for businessmen like vanderbilt to innovate american workers should embrace the spirit of liberty of the american constitution as inscribed in the fourteenth amendments guarantee of an individuals freedom of contract in a concerted effort to bring their arguments to a larger public atwater and atkinson published a series of articles in the century that linked atwaters research on the calorie to the savings that could be made by spending on a more nutritious and cheaper diet in this series atkinson also explained the working of the energy efficient oven he had invented the aladdin 17 the past decades have seen an increased interest in the importance of the home economics movement for american culture and for the history of economic thought 18 for atkinsons role in the formation of american political economy see coats atkinsons biographer harold williamson pays surprisingly little attention to the importance of atkinson for american food research and its relation to the social question see williamson oven a slowcooking oven that was particularly fit for the cooking of stews and broths atwaters research and atkinsons liberal economic position provide the context for the dietary experiments of richards and abel to which we now turn the new england kitchen experiments during the 1880s richards investigated optimal dietary composition in terms of carbohydrates fat and proteins for which she relied on atwaters research atwater had developed norms for calorieintake for men and women and for different kinds of work his research was based in turn on voits research on the calorie which he adjusted upwards because he considered american workers more productive than germans and therefore consuming more energy initially richards composed her meals without consideration of their taste but merely with regard to their nutritious value her next step was to improve the dietary habits of the american working population by testing these meals on their palates in 1890 richards was on the jury of the lomb prize from the american health association which awarded mary hinman abel the first and second prize for her essay practical sanitary and economic cooking during her travels with her husband john abel a professor of pharmacology at johns hopkins mary abel had been impressed by the german and french public kitchens richards and abel joined forces to develop a similar initiative but adjusted to the american situation and to the exigencies of richardss research agenda this meant that their kitchen should not function as a community center but as a takeaway they argued that americans preferred to consume their meals with their families and more generally takeaway food was better adjusted to modern working conditions richards and abel argued that what we call the working classes suffered from a lack of planning in the preparation of food which made that lastminute cooking mostly consisted of low qualityhigh price meals for richards the suppression of the community function underlined that they were concerned with an experiment to determine the successful conditions of preparing by scientific methods from the cheaper food materials nutritious and palatable dishes which should find a ready demand at paying prices with financial support from atkinson and his network and a grant from the elizabeth thompson fund richards and abel opened the new england kitchen in boston on january 24 1890 the kitchen was equipped with three aladdin ovens for slow cooking and a gas pit for fast cooking richards had intended to name the kitchen the rumford kitchen the name that was used for their model kitchen at the columbia world fair of 1893 because of the american scientific credentials of count rumford it was an open kitchen with large windows that flooded the space with sunlight and ventilation there were a few tables where customers could be seated while their meals were being prepared this also gave them the opportunity to inspect the ingredients and utensils used in his very interesting analysis of the new england kitchen nicolas williams argues that the dietary program of richards and her collaborators turned the human body into a site of social reform by trying to change the food habits of the american population it is precisely an example of what oconnor considered a program of cultural change of the behavior of the poor but richards and abel also conceived of the new england kitchen itself as a site of social reform instead of entering the household to change its conditions the new england kitchen created an alternative space which they sometimes called a household experiment station it sought to bring the latest scientific results to its clients by using them in experiments designed to determine the optimal composition of meals not only in terms of nutritious value but also in terms of taste and costs this space belonged to no school no sect and antagonized neither class nor individuals as it was designed as a site of improvement for all americans it taught lessons about the root of many evils and sought to direct public efforts and private household life to better methods of living the new england kitchen counter served as a rallying point that gave them access to many classes of people in ways not available to the agent of the census or of the labor bureau by opening conversations about food and kitchen utensils far beyond our own experience testing the meals on the publics palate was a twoway process on one hand the meals had to be adjusted so that they fit the taste of the customers on the other hand the taste of the customers had to be adjusted to the optimal nutritious composition richards had calculated in her laboratory at mit for example richards and abel initially refused to add dumplings to their soup whose sodden name was enough to condemn it and which scientific authority forbade them to include but they soon realized that they were bracing themselves against a very popular dish and that they therefore had to invent an acceptable replacement in spring tomato soup was called for but the acidity of the dish posed a substantial problem because it demanded substantial research to make this soup sufficiently nutritious in which they succeeded by adding meat broth and sugar these adjustments were negotiated at the kitchen counter of the new england kitchen and finetuned in richardss laboratory at mit to which she returned to adjust and check the composition of meals against her optimal nutrition standards on average this adjustment process took them a month per dish the final result should be a cosmopolitan dish that is a dish that would suit the taste of as many different consumers as possible without compromising on nutritious value the rumford kitchen at the chicago world fair initially the new england kitchen proved very successful abel and richards soon opened two additional branches in districts of boston with larger immigrant and africanamerican populations in 1891 they began serving school luncheons at a boston high school and womens college and in 1894 they were granted a contract to cook luncheons for all nine high schools in boston atkinsons lectures on the new england kitchen inspired columbias chemistry professor thomas egleston to promote the new england kitchen in the settlement movement and settlement houses in new york philadelphia and at hull house in chicago all bought a new england kitchen but their largest exposure no doubt came from their presence at the chicago world fair as part of the scientific submission of the state of massachusetts this gave them the opportunity to follow through on their call to educate the public in general the columbia world fair visited by a stunning twenty million visitors from a population of sixty million turned the new england kitchen from an experimental site into an experimental theater richards had already played with the name of count rumford to stress the historical links of the new england kitchen with american science and rumford seemed an excellent choice for this purpose 19 count rumford born in 1753 as benjamin thompson some fifteen miles from benjamin franklins place of birth was a colorful angloamerican scientist and inventor whom historians of science remember for his experiments on heat he invented a chimney opening with a restricted and more efficient updraft creating a smokefree and more energy efficient kitchen during his extensive travels he became an advisor to the prince of bavaria where he started a food kitchen for the poor the prince was so impressed with his work that he awarded thompson with the title of count he was sent to britain to take up the post of ambassador of bavaria but this proved impossible because of his english descent he stayed however in britain and set up the royal institution of england in 1799 with the help of joseph banks and with humphrey davy as its first lecturer he married lavoisiers widow in 1804 in an unhappy marriage and died in paris in 1814 the association with this colorful american scientist and inventor whose work had served the public good clearly served to emphasize that food and nutrition were not just a womens business but a matter of national interest this was also the reason that richards had lobbied successfully to have the kitchen included as scientific exhibit of the bureau of hygiene and sanitation of massachusetts and not as part of the womens exhibits which also showed a model kitchen when he opened the rumford kitchen at the columbia fair economist and mit president francis amasa walker emphasized its scientific status the rumford kitchen he argued applied the principles of chemistry to the science of cooking it was financially supported with pecuniary assistance from certain publicspirited citizens of boston but it was not a moneymaking exhibit the rumford kitchen was to be regarded as as absolutely a scientific and educational one but it was also an effort to standardize american tastes based on the best findings of american science the exhibition building which looked like an american homestead was divided into two separate rooms one room was dedicated to the work of benjamin thompson count rumford its walls were decorated with his many wisecracks on food and it included a library of his publications which was open to the public in the main room were seating tables and a new england kitchen the kitchen served ten representative dishes to its visitors to give them a taste of what a healthy american way of life should look like over the months some 10000 meals were sold 20the main room contained billboards and posters with the latest scientific findings on food and nutrition which were also included in a series of pamphlets the rumford kitchen leaflets which could be taken home they contained historical information on count rumford and his scientific work on heat and nutrition on the history of the new england kitchen on its scientific basis its results and its future 21 there were also handouts that compared the nutritious values and costs of the dishes against the food standards of voit and atwater for a mans days ration of calories in her history of the new england kitchen published as rumford kitchen leaflet 17 mary hinman abel explained its meaning for the american workman as americans increasingly moved away from their traditional new england slow cooking dishes by replacing them with quick and expensive lownutrition food american workmen came to nourish themselves at the expense of other vital needs the wage earner is illy sic nourished on money that is allsufficient if rightly expended to buy him proper food this is a serious question because here there is the chance of more saving than in any other item of living and what can so easily be saved here can be applied to better shelter which is a more evident if not more vital need figure 5 photograph of the rumford kitchen building at the chicago fair source ellen richards 1899 plain words about food boston rockwell and churchill press pp 1011 source edumanifestsviewdrs2936825 18i was supervised by atwater for an account of the fairs significance to the modernization of american taste see graff and edwards 21 in 1899 richards published these leaflets most in their original form and with illustrations from the world fair abel evoked statistical evidence carefully compiled by the federal bureau of labor statistics on the lower costs of food in america compared with europe and observed that this difference had not led immigrant americans to lower their food expenses she cited a german workman for whom american freedom and prosperity had the very limited meaning of meat on the table three times a day but the meals abel and richards had developed with their experiments at the new england kitchen showed that a lowell factory operative who spent 200 out of his 360 total income on food could have secured better nutrition for 100 and have 100 to put into better shelter and a dress for his wife who had had none since her marriage seven years before thus the information and meals presented and served at the rumford kitchen not only aimed to inform the audience of the recent findings of science but also tried to convince them as richards wrote in euthenics to accept and apply the knowledge that investigators are gaining in the laboratory to change their spending habits if a man eats not he shall not work richards focus on the export of laboratory research to the domestic sphere did not exclude the use of social surveys indeed in the early 1890s kelley and richards reform programs briefly met when richards supervised a survey on the dietary habits of wageearners and their families in philadelphia and chicago the opening phrase of richardss report published by the state board of health of new jersey inverted the biblical relation between work and food by putting food first and work second if a man eats not he shall not work emphasized that the health of the american work force was primarily seated in its dietary habits when these habits could be improved the health of the nation would improve as well just as had been the case with figure 6 interior of the rumford kitchen which was equipped as a new england kitchen the large poster on the cupboard in front shows the average composition of a 70 kg human body the label on the sink was designed to strengthen the link between scientifically informed cooking and the laboratory in ellen richards 1899 plain words about food boston rockwell and churchill press pp 1819 source her research into the water quality of massachusetts richards combined laboratory and field work to measure her laboratory norms against the actual state of affairs for chicago the survey was conducted in spring 1892 with hull house as its base and with the help of hull house resident caroline hunt richardss later biographer in philadelphia her coauthor amelia shapleigh conducted the survey robert dirks notes that workingclass families were warned not to participate in such surveys because rumors circulated that investigators wanted to see how cheaply people could eat so that employers could cut wages accordingly but the familiarity of both surveyors with the neighborhood helped to secure their residents collaboration in her report richards noted that she experienced no difficulty in securing the cooperation of families with this study as the work of hull house was well known to them and appreciated kelleys survey following the method of the census had aimed at completeness in contrast richards randomly selected a limited number of households which can be seen as a precursor of random sampling which she then checked for their typicality of different immigrant groupsincluding in the case of philadelphia its africanamerican population 22 according to richards this procedure did not make the data collected less trustworthy other problems did such as the tendency of women to overstate their food expenses when interviewed or when selfreporting to note food expenses inaccurately overall richards considered the survey nevertheless of substantial worth because it provided at least some empirical evidence on the diets actually consumed by the different indigenous and immigrant communities in urban centers of the united states somewhat to her surprise richards found that the survey showed that families had better food habits than she had expected but this did not mean further improvement was impossible richards saw that an increase of income led to an increase in foodconsumption whereas her laboratory results and the meals she had composed in the new england kitchen had shown that a higher nutritious value could be reached with fewer expenses for example with cheaper cuts of meat or cheaper more nutritious vegetables as a result there were immigrant families who just like the german immigrant quoted by abel now had meat on the table three times a day instead of diversifying their expenses to other necessities of life the difficulties of changing dietary habits became manifest at the new england kitchen hull house had bought for its public restaurant and cafeteria in spring 1893 in her personal recollections jane addams remembered how hull house had tried to use the kitchen to change food habits in the neighborhood which so sadly needed better feeding families suffered from exactly the kind of problems signaled by richards and abel in their history of the new england kitchen children were asked to buy something just before the closing time of shops because their mothers had not found the time for shopping or to prepare a decent meal but instead of shortening the working day as kelley proposed richards proposed adjusting dietary habits to market conditions addams followed richards in her judgement that the improvement of food habits could be best accomplished in public kitchens where the advantage of scientific training and careful supervision could be secured thus ellen richards former student julia lathrop who had recently moved to hull house was trained in the use of the new england kitchen edward atkinson himself inspected the aladdin oven used at hull house it soon became evident that it was easier to reverse a biblical phrase than to change food habits hull houses cafeteria managed to sell some of its carefullyprepared soups and stews in the neighboring factories but realized that it was unable to change the wide diversity in nationality and inherited tastes in contrast addams noted the public kitchens function as a community center which had been suppressed by richards and abel was a success as the hull house cafeteria was one of the few places in the neighborhood were social gatherings and meetings could be held addams recounted how the neighborhoods estimate of the food cooked in the new england kitchen was best summed up by the woman who frankly confessed that the food was certainly nutritious but that she didnt like to eat what was nutritious that she liked to eat what shed ruther sic richards biographer caroline hunt considered that this pronouncement which can also be found in richards rumford kitchen leaflets sounded the death knell of the new england kitchen richards became increasingly impatient with women of different immigrant groups who were unwilling to follow the precepts of science either out of prejudice or because they lacked the time and knowledge to take care of the family home according to levenstein the failure of the new england kitchen to change the food habits of the poor made her shift gears to a program that was directed at the education of middleclass women a program which she developed with the home economics movement and its institutionalization at land grant colleges in the progressive period one can see this shift in the many brochures richards wrote at the turn of the century about the costs of food and the cost of living which no longer addressed the lower incomes but were directed at the wise spending of the middleclass strategies of social reform like many other social scientists and reformers of the late gilded age and progressive era florence kelley and ellen richards were concerned about the improvement of the living conditions of the urban working poor but they followed different strategies to enact a change starting from oconnors distinction between structural and cultural reform programs we have seen how kelley immersed herself in a social survey on the working conditions of the poorest population in chicago while richards concentrated on the optimization of its dietary habits canvassing tenement dwellings doortodoor kelley charted the living conditions of the poor and turned her statistical and local knowledge into a weapon for social reform kelleys socialist convictions made her situate the problem in the opposition between labor and capital but she did not seek for a solution in revolutionary reform but in legal change her object of study was the urban poor but her audience consisted of local elites and lawmakers who had to be convinced of the need for action her social surveys provided the evidence that would induce legal change kelleys strategy was not limited to socialists but can also be found in the men and religion forward movement the survey movement initiated and supported by paul u kellogg editor of the survey and director of the famous pittsburgh survey and in the work of wisconsin institutionalists critics have denounced the early survey movement for its lack of technical statistical refinement and lack of theoretical grounding but as mary furner pointed out such criticism takes the first chicago school of sociology of parks and burgess as its frame of reference and fails to see that these early surveys fit in much better with the social scientific model of wisconsin institutionalists like richard t ely and john r commons 23 for them social knowledge consisted in knowledge useful for legal reform marianne johnson recently exemplified how one of the strongholds of the wisconsin model the wisconsin legislative reference bureau a forerunner of the congressional research service helped draft legislation in a partnership between the bureaus chief charles mccarthy commons and the progressive governor robert lafollette producing such laws as wisconsins civil service law and the public utilities act florence kelley fits into this model her social survey showed the scope of the social evils of a specific mode of production which was in need of legal regulation but her case also makes clear that such knowledge was most effective when it was grounded knowledge rooted in a local community with which the researcher was well acquainted her social survey reenacted by lawmakers and the press provided the evidence that moved her target audience to action this enabled kelley to convince lawmakers that the regulatory state not free markets was needed for social improvement but kelleys success depended substantially on the support and trust of the local population around hull house as allies in her crusade for social change chemist and propagator of the home economics movement ellen richards situated the problem and hence its solution not in exploitative working conditions but in the inefficient and wasteful usage of available resources by the working poor as richards wrote in euthenics the science of controllable environment no state can thrive while its citizens waste their resources of health bodily energy time and brain power any more than a nation may prosper which wastes its natural resources laboratory work would enable the development of optimal standards and educational programs should bring these standards to the public my means of models and exhibits as she wrote programmatically the force of example the power of suggestion should be used fully before coercion is applied exhibits and models come before law with this aim she constructed public spaces that she ran as laboratories for food and sanitary experiments richards thus flipped the household inside out instead of the researcher entering the home women should be taken out to learn by experiment and instruction in hybrid laboratory spaces such as the rumford kitchen while florence kelley aimed to change the living and working conditions by entering the household with questionnaires richards aimed to change the behavior of the manager of the householdthe housewife seeing the example she argued should incite the public to modify their behavior into a homogenized american mold the new england kitchen and later the rumford kitchen at the columbia world fair were examples of such public theatres of experiment such model homes and model kitchens some of them mobile became stockintrade at world fairs and extremely popular from the 1920s onwards with the work of christine frederick and lillian gilbreth the mary lowell stone home economics exhibit for example toured from boston via baltimore philadelphia trenton new york and chicago to the louisiana purchase exhibition in st louis in 1904 and aimed to show the meaning of home economics in relation to shelter food and clothing as antoinette lafarge explains there was an innate theatricality to these model homes an intersection of private space and public spectacle which performed anglosaxon versions of domesticity in the spotlight 24richards considered that the great challenge of her program was to make efficient selfsustaining citizens who do not feel the pull of the law or the bond of outside care solving the conflict between the ideals of individualism and those of the community need subordinating the individual preference was the way forward this could only be attained when social reformers relied on the findings of science as a lever for social progress knowledge that was gained by researchers in their laboratories should be taught to the public and accepted and applied by the individual richards reform strategy thus entailed a completely different attitude toward the public the public was not perceived as an ally in a crusade for social change but as a collection of experimental subjects who needed to follow the science and change their suboptimal nutrition and sanitation habits when it became apparent that experimental subjects prefer their own way of life richards voiced her exasperation about women who were unwilling to follow a scientific understanding of the households organization and asked them to no longer stand in the way as they are surely doing today in an address to the american public health association in richmond published as chapter x of her euthenics the science of controllable environment richards wrote that nearly every investigation of sanitary evils leads back to the family home and a great deal of the health authorities work is saving at the spigot while there is a hundred times the waste at the bunghole she continued that it was finally beginning to be thrown in the faces of sanitary authorities that the laboratory wisdom does not reach the street that there is not enough or rapid enough improvement in general conditions she concluded that sanitary authorities should see to it that their inspection efforts of the family homes were not wasted on an inert partially hostile clientele but with her emphasis on the hierarchical transfer of knowledge from the laboratory to the public richards forgot one of the important lessons learned from the new england kitchen behavioral change is never just a matter of control but also of voluntary collaboration when abel and richards added an indian pudding to their standard dishes an irish boy exclaimed oh you cant make a yankee of me that way changing the food preferences of a diverse immigrant population to fit a homogenized american mold was never just a technical but always a deeply cultural affair q what is the size of this room a 12 by 7 one of the other employés a boy apparently about 12 years old who was working on a machine was questioned as to his age and stated he was 15 he said he made 300 a week and worked from seven oclock in the morning until six at night by senator noonan q do you ever do any work after supper in the busy times a no i dont work more than ten hours 14

this paper contrasts the research strategies of two women reformers florence kelley and ellen swallow richards which entailed different strategies of social reform in the early 1890s social activist florence kelley used the social survey as a weapon for legal reform of the working conditions of women and children in chicagos sweatshop system kelleys case shows that her surveys were most effective as grounded knowledge rooted in a local community with which she was well acquainted her social survey reenacted by lawmakers and the press provided the evidence that moved her target audience to legal action chemist and propagator of the home economics movement ellen richards situated the social problem and hence its solution not in exploitative working conditions but in the inefficient and wasteful usage of available resources by the poor laboratory work she argued would enable the development of optimal standards and educational programs should bring these standards to the household by means of models and exhibits with this aim she constructed public spaces that she ran as food laboratories and sanitary experiments kelley and richards thus crossed the doorsteps of the household in very different ways while florence kelley entered the household to change the living and working conditions of the poor by changing the law richards flipped the household inside out by bringing women into hybrid public laboratory spaces to change their behavior by experiment and instruction

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introduction men who have sex with men have been severely affected by hiv in the united states with notable increases in the number of new infections among young msm 1 ymsm often socialize with other men in the community contexts of gay neighborhoods some gay neighborhoods form gay enclaves that take visible forms of community contexts with concentrations of gay institutions such as gay bars and clubs and represented by gay subcultures 23 these gay neighborhoods accentuate social behaviors of gay men serving as both hiv health promoters and as risk subcultures 2 that is they encourage both risktaking and protective health behaviors 4 the influence of neighborhoodlevel social environments on these mens health interacts in a complex way with individuallevel characteristics such as socioeconomic status sexual orientation and racialethnic identification 5 in some regions many residents in gay enclaves are not gay and thus the gay enclaves are distinct from other neighborhoods without concentrations of gay institutions but with substantial concentrations of msm 3 ymsm of color and low ses often travel outside of their home neighborhoods to socialize with other msm 6 irrespective of whether gay neighborhoods exist in a given city or not spatial clustering of hiv is associated with neighborhood characteristics 7 hiv risk behaviors may be clustered by neighborhood and thus hiv transmission tends to be geographically bounded in high hivprevalence areas 8 neighborhood factors that influence hivrelated risk and disease prevalence among msm include sexual orientationbased discrimination 9 the level of physical or social isolation living in less walkable neighborhoods and the proportion of vacant buildings 10 in this regard the migration to urban gay communities 5 is an important factor to consider with regard to hivrelated behaviors gay presence within a neighborhood may influence protective sexual behaviors among msm 11 social support networks among gay men provide sources of social capital 12 through their reinforcement of norms about protective behaviors or the constraint of norms of conformity to risk behaviors 3 and shape msms health and risk behaviors 13 14 15 16 17 these social networks are interrelated with neighborhood and geographic factors that influence hiv risk and transmission as the networks are likely to be formed and maintained in the same neighborhood 8 more specifically the association between gay neighborhoods and hiv risk behaviors is mediated by the composition of the social networks among gay men 2 for instance network membership in residential neighborhoods is different from those of urban areas as has been documented in the case of african american msm who have younger gayidentified friends as social network members at bars and clubs and who are different from the members of their network based on the location of their residence 18 this implies that the social capital resources that flow into gay mens personal networks are shaped by neighborhoods and geographic factors highlighting the importance of neighborhood conditions on health inequalities at the community level in this study we conceptualize social capital at the neighborhood level and assume that resources that serve ymsm aged 16 to 29 flow through relationships among venues with different network contexts these venues include ymsmrelated social and health service venues and network contexts include intervenue linkages based on collaboration competition and sponsorship relations 19 by theoretically framing neighborhoodbased social capital with network theory in organizational studies our study aims at investigating whether venues that are centrally located in network contexts are also geographically concentrated thus indicating that they have power over hivrelated resources methodologically we examine the associations between network centralities of various relational types and any geographical clustering among them taking into account several neighborhoodlevel factors such as hiv seroprevalence poverty level and income inequality in our analysis we employ both a social network analytic approach to compute network centralities and a spatial statistical approach that models the intensity of the venue location patterns in chicago and houston neighborhoodbased social capital resources social science research on socioeconomic determinants of health integrates pierre bourdieus resourcerelated conceptualization of social capital 20 into a theoretical framework of neighborhood social processes 2122 the bourdieubased neighborhood social capital theory conceptualizes social capital as constituting the resources that are inherent within a social network in a neighborhood 2122 consequently residents differential access to the neighborhoodlevel social capital resources determines individual or population health 23 the neighborhoodbased social capital theory however is limited to a view of social capital resources that flow through the personal networks it does not encompass a systemlevel view of social capital resources that flow through those networked with other communities institutions and the political structures 21 from which a neighborhood can draw its resources neighborhoods exhibit the levels of available resources through the existence of gay institutions which constitute a community structure social capital also can be conceptualized at the neighborhood level as resources that flow through a networked system among physical spaces that are formed in response to the communitys need to serve the marginalized population 8 to examine the contextual network conditions that impose resource inequalities across communities we incorporate the structure of the interorganizational networks into the theoretical framework of neighborhoodlevel social capital resources centrality in organizationalvenue networks a network perspective conceives of a community structure as an aggregate network of interorganizational relations 24 and the position determines the degree of power that an organization has to generate resource dependencies from others in the network 24 25 26 27 28 a central position based on indegree which is a measure of relative frequency of receiving resources from network members reflects the proximity of power and dependence in the network 28 in the context of the msm community organizationalvenue networks that serve msm are often geographically concentrated in gay enclaves such as montrose in houston boystown in chicago chelsea in new york and castro in san francisco as grounded in the network concept of centrality we posit that a few gayserving institutions are located at the center of the intervenue networks have power over hivrelated resources and generate dependencies from other marginal venues in different geographical locations community structures driven by the geographically based power and dependence among venues reflect a disparity in the resource distributions that serve young msm hiv testing prevention and treatment services tend to be clustered in a central community and this centralization constitutes a structural barrier to more universally accessible community resources in lowincome marginal communities such as in the case of the san salvador metropolitan area within which no healthrelated ngos are located 29 methods sampling procedure and data the current study uses data collected from the larger multisite longitudinal network study ymap young mens affiliation project of hiv risk and prevention venue which is ongoing in houston texas and chicago illinois for ymap we created a list of 161 venues in chicago and a list of 168 venues in houston based on their importance to the ymsm population as identified by investigators staff members community consultants experience and familiarity with the sites and from prior research conducted in similar ymsm populations we further validated the lists based on consultation with the members of community advisory boards and various community informants to ensure the listed venues did in fact serve ymsm these venues were then categorized into four types according to hivstd risk and prevention risk social health and others we conducted twoto threehour semistructured interviews with a representative identified from each venue the selection criteria for the representatives were having been affiliated with that venue for at least six or more months not planning to leave the venue in the next two years being legally able to enterjoin the venue not being intoxicated mentally or emotionally unstable or otherwise unable to participate adequately in the interview the interview included questions about venue characteristics and their relationships with other venues on the master list venue interviews were conducted using a computerassisted personal interviewing protocol programmed in qualtrics software 30 data venue network datathis study used three different types of relationships between venues the first relationship is collaboration which concerns whether venues have worked together on any activity project or event with a common goal formally or informally the second relation is competition which focuses on whether a venue regards the other venue as a competitor for revenue clientele or membership employees or other resources the third relationship is sponsorship which pertains to whether a venue financed part or all of an activity project or event carried out by the other venue respondents were provided with a roster of all venues inclusive of both physical and virtual venues and were asked to nominate any additional venue under each of the relational types spatial venue dataa pointpattern dataset was created from the spatial locations of all of the observed gay venues in chicago and houston we used euclidean coordinates measured in kilometers by projecting the coordinate system for the data from longitude and latitude onto the appropriate utm coordinates through the r packages sp and proj4 for our analysis we used 116 physical venues in chicago and 102 venues in houston excluding other venues that are virtual or without physical addresses communitylevel datacdc hiv surveillance data through 2012 at the zip code level were obtained through aidsvu 31 we used zip codelevel hiv prevalence rates from 2008 to 2014 per 100000 equivalent hiv rates in cases per 100000 blacks an index of income inequality measured by the gini coefficient with 0 reflecting complete equality and 1 reflecting complete inequality and percentage of population that was living in poverty for houston and chicago we used zip code level data because this produces relatively small geographic regions compared to census tract or county level data social network analysis visualization of networks among venueswe employed the igraph software package v071 32 in the r statistical software system v312 to visualize the structure of venue networks for each relational type in each city centrality measurewe computed indegree centrality 33 by counting the number of received ties from other venues for collaboration competition and sponsorship ties using ucinet 6 34 among various measures of centrality 33 we chose indegree centrality that is based on direct incoming ties for both theoretical and methodological reasons theoretically indegree centrality better reflects the influential and prestigious roles that venues incorporate within the network and methodologically it is more robust to low sampling rates when compared with most other centrality measures 35 spatial statistical analysis we fitted parametric models of the intensity of the assumed spatial poisson point processes that underlie the observed point patterns of gay venues these models took the form of the exponential of a linear predictor such models are referred to in the literature as log linear models our datasets of spatial locations of msmserving venues were augmented by two conceptually different types of numerical variables namely marks and covariates 36 the marks are associated with the spatial locations that constitute the point pattern and may be conceptualized as being additional coordinates of the points in contrast covariates are variables that are defined at all points of the observation window for the point patterns under study the observation windows consisted of the cities of chicago and houston covariates are potentially explanatory variables from which the intensity of the underlying process may be estimated the marks that we have used in the analyses are numeric marks that consist of the three types of indegree centrality measure as discussed in the preceding section on social network analysis we also created a categorical mark with the categories surveyed and other a point is designated as surveyed if that venue was included in the survey that was conducted to collect data otherwise the point was categorized as other the chicago point pattern data consisted of a total of 116 venues of which 53 were surveyed and 63 were other venues the houston data consisted of a total of 102 venues of which 59 were surveyed and 43 were other venues in our modelfitting procedure we considered as potential explanatory covariates four zip codelevel variables namely the overall hiv prevalence rate the equivalent rate for the black population the gini index and the percentage of the population that was living in poverty we also considered linear and quadratic terms in the cartesian coordinates for each city a modelfitting exercise was undertaken in which we sought the simplest model that was not significantly different in its explanatory power from an initial full model that included all of the covariates referred to above the modeling was conducted using the ppm function from the spatstat package version 1400 37 in the r statistical software system v312 the indegree marks are of primary interest in this study but there is little or nothing available in the currently available methodology of spatial analysis for modeling point processes in terms of numeric marks consequently we conducted a diagnostic analysis of the indegree marks in terms of the mark correlation function of the patterns for each of the three indegree measures the mark correlation function 37 measures for each distance r the statistical dependence between the marks attached to two points of the process at locations separated by that distance using the mark correlation function we can test the null hypothesis that there is no relationship between the mark valuesindegree valuesof pairs of venues and the distance that separates these pairs of venues the goal here is to investigate whether the indegree values influence interaction between venues in estimating the mark correlation we allowed for the fact that the underlying pattern of gay venues is inhomogeneous by using weights computed as the reciprocal of the estimated intensity function of the process the mark correlation functions were estimated using the markcorr function from the spatstat package version 1400 37 in the r statistical software system v312 hypothesis testing was conducted using the envelope function from the spatstat package and the digglecressieloosmoreford test implemented in the spatstat function dclftest results spatial analysis figure 1 shows kernel density maps that are overlaid on top of hiv prevalence rates in houston and chicago the results demonstrate that venues are distributed in a spatially inhomogeneous manner in both cities in houston physical venues are concentrated in central houston which is a region with high hiv prevalence rates in chicago in contrast venues are concentrated in two major areas on the north side an area that is described as a gay enclave and the mideast sides of the central business district with high and middle levels of hiv prevalence rates there are also small pockets of concentration on the south side the concentration is most dense around hyde park an area that is most generally frequented by young adults from the gay community but by other young adults as well collaboration networks exhibit different structural characteristics by city houstons collaboration network comprises two major clusters one of which was formed by a few highindegree service venues and the other by several social venues in contrast the structure of chicagos collaboration network was determined mainly by a cluster of a few highindegree service venues with entertainment and social venues occupying marginal positions in the network these marginal entertainment venues in chicagos collaboration network however turned out to be highindegree venues in the competition network in both cities sponsored networks show similar structural patterns with entertainment venues rarely being funded while a few service venues are well funded table 1 shows the descriptive statistics of the variables observed in our sample social network analysis spatial statistical analysis fitting poisson intensity model for venue patterns chicago fitting a poisson intensity model that included four major zip code level covariates produced results in which three of the predictors namely hiv rate black hiv rate and the gini index were significant at the α 0001 level the fourth predictor poverty was significant at the α 001 level the estimated coefficients of the first three predictors are all positive indicating a tendency for the intensity of the process to increase as the values of these covariates increase it should be noted that the value of the positive coefficients of hiv rate and black rate were very small indicating that the influence of these covariates on the intensity of the process may not be practically significant the coefficient of the poverty covariate is negative indicating a tendency for the intensity of the process to decrease as the percentage of the population that lives in poverty increases a possible explanation for this phenomenon is that gay venues might tend to become established in regions that can afford them ie wealthier regions the addition of linear and quadratic terms in the cartesian coordinates did not produce a significant improvement over the model with only the four zip codelevel covariates houston choosing a poisson intensity model for the houston data required a more complex and elaborate fitting and simplification procedure the details of which we omit the model that was finally chosen contains the predictors hiv rate and linear and quadratic terms in each of the cartesian coordinates all coefficients in the chosen model were significant at the α 0001 level the estimated coefficient of the hiv rate covariate is 00007 which is positive as one might expect but very small and as such may not be of practical significance the intensity surface is roughly conical with its maximum at x 3093 and y 2658 and it falls away from its maximum very rapidly this roughly conical surface is a distortion of the smooth surface that arises from the effect of the cartesian coordinates 3 displays plots of the estimated mark correlation functions 36 for the pattern of gay venues marked by each of the indegree variables for chicago and houston diagnostic analysis of indegree mark correlation functionsfigure the black lines are the estimated mark correlation functions for the observed venue pattern the dashed red lines are the means of the estimated mark correlation functions of 99 patterns generated under the null hypothesis that there is no relationship between the mark valuesindegree valuesof pairs of venues and the distance that separates the corresponding pairs of venues the envelopes indicated by the boundaries of the grey area show the limits of the way that one would expect the mark correlation function to behave if the null model were appropriate to the data deviations or excursions above the upper envelope are an indication that venues separated by such distances tend to have large indegree values the range of rvalues over which the excursions occur is an indication of the separation distances at which pairs of venues tend to both have large marks if a result is significant the black line deviates from the mean in a more extreme manner than any of individual mark correlation functions that come from the randomly generated patterns if the results are not significant there is no evidence that the observations differ in any way from what one would expect under the null hypothesis chicago the collaboration and competition indegree variables have mark correlation functions that differ significantly from that which would be expected under the null hypothesis the corresponding monte carlo pvalues are 005 and 004 respectively we observe that the mark correlation function for collaboration makes no actual excursion outside the simulation envelopes and that for competition makes only a small excursion however the estimated functions for the real data deviate substantially from the mean of the functions estimated from simulated data sets with the deviations being most pronounced at distances from 4 to 45 kilometers the mark correlation functions for the real data are noticeably larger than the mean from the simulated data sets at such distances the interpretation of this result is that pairs of venues separated by distances of 4 to 45 kilometers tend both to have large values of the collaboration and competition indegree variables the monte carlo pvalues for other two indegree variables are both equal to 047 very far from being statistically significant houston only the competition mark correlation function deviates significantly from the mean of those from the corresponding simulated patterns the observed mark correlation function for competition tracks the upper envelope fairly closely and consistently lies above the mean from the simulated patterns it makes a substantial excursion above the upper envelope at around 12 km where its deviation from the mean is greatest this implies that pairs of venues separated by distances of about 12 km tend both to have large values of the competition indegree variable this may be a reflection of venues being more geographically dispersed in houston as compared to those in chicago the digglecressieloosmoreford test pvalues for collaboration and sponsorship are very large 086 and 055 respectively the shapes of the envelopes for the houston data are very different from those for the chicago data which may be related to the quasicircular shape of the houston pattern and its window as contrasted with the more elongated quasirectangular shapes that appear in the case of the chicago data discussion the current study employed both social network analysis and spatial statistical analysis to examine the structural characteristics of indegree centrality in various types of relations of venue networks as a correlate of the geographical clustering of venues that serve young msm our results indicate that gayserving social and service venues found in clusters tend to have large centrality indegree values based on competition in both cities and collaboration only in chicago this result could be interpreted as indicating that spatial proximity may create competition at the very least for example service venues might tend to be located where a community is located or where there are other similar venues and such circumstances might lead to competition it also may be the case that competition between venues drives the decisionmaking process by which venues determine where to locate in chicago a longstanding gay enclave and more mature hiv service organizations could have resulted in increased collaboration over the years that comes from prolonged conflict or competition in neither city was there evidence that venues that occupy a central position in the sponsorship network are geographically clustered this observation indicates that resource recipients are not concentrated or focused geographically for chicago our analysis of the communitylevel environment in relation to social determinants of service indicates a tendency for venues to become more concentrated as the hiv rate and the black hiv rate increase and as the income inequality becomes wider in contrast we found a tendency for venues to become less concentrated as the percentage of the population that lives in poverty increases on the other hand in houston the concentration of venues appears to be determined largely on a geographical basis with a slight tendency for the concentration to increase as the hiv rate increases the difference between cities is likely explained by the marked geographic segregation by race in chicago with limited investment in black neighborhoods and with high hiv rates in both the black neighborhoods and the gay enclave this may reflect the existence of venues that cater to young msm beyond the gay enclave in chicago following the spread of the epidemic to largely black communities that is social capital in the form of health service and social venues and related individual networks may have spread along with the venues this could be the result of more social openness for such venues in these communities in chicago and the economic and civic resources to support them ultimately however poverty may be a limiting factor our results have several limitations first we analyzed a single crosssection of data and thus the directionality of influence between network centrality and geographic concentration is uncertain further often the distinction between relational context and physical context may not be clearcut 37 although our results indicate a correlation between a specific type of network centrality and geographical proximity it is not possible to infer that resourcerich venues choose to physically locate in the center of msmserving communities or around areas where other resourcerich venues are located for ease of communication among those venues it is also possible that venues at the center of msm communities may become influential and thus resource rich due to their physical location having more opportunities to interact with the other resourcerich venues future research should investigate the dynamics that link network centrality to spatial location second in our modeling of the intensity of the process that generates the locations of gay venues we have assumed a poisson process some diagnostics that we have run indicate that for both chicago and houston this assumption may be invalid that is there may be some form of interaction between the points of the process our diagnostics indicate that the interaction if present takes the form of attraction or clustering exploring the nature of this interaction is a topic for future research third the venues are located on city streets thus strictly speaking distances between them should be ideally measured along the streets consequently these patterns should ideally be analyzed as patterns on a linear network 36 not as patterns in the euclidean plane such an analysis however would require obtaining the locations on street maps as well as determining the scale of the distances along the streets because the analysis of patterns on linear networks is much more subtle and complex than the analysis of patterns in the plane and the development of the theory and methodology is in its infancy we consider our method of using planar point pattern analysis to be an acceptable approximation nevertheless it could be reexamined by means of the analysis of patterns on linear networks in future research fourth while our venue samples are representative within each city our findings may have some limitations in respect to generalization to other cities in the us or other cities internationally the patterns found within each city however may apply to other northern and southern urban areas at the national level ie results from chicago may be applicable to other large segregated midwest cities and those from houston to other large southern cities in addition because of particular political structures in different regions of the us the resulting funding climate may influence formation of venue networks in gay communities 19 although such generalizability is beyond the scope of this twocity study it is worth exploring in future research lastly as the goal of this paper is to examine geographical concentration in relation to network characteristics our analysis excluded venues that are not public such as private parties we also excluded events assuming given that singular events likely have limited impact on venues over time our analysis also excluded virtual venues and nonphysical based organizations for the same reasons ie lack of a physical address and the potentially nested nature of virtual venues within physical venues that may confound results virtual venues are becoming increasingly important in how ymsm meet one another and may in fact play an important role in understanding how the ymsm community is structured future research should explore potentially mediating effect of such venues on the association between network centrality and geographical proximity despite these limitations our study demonstrates the utility of conceptualizing neighborhoodlevel social capital at the venue level and examining structuralcontextual factors that characterize a networked system among geographically based msmserving venues further this study demonstrates the potential importance of competition relationships among risksocial or service venues it is unclear however whether competition among venues has a positive or negative impact on service delivery or socialization nevertheless we expect that this competition to increase as the hiv epidemic continues to decline with the concomitant decreases in funding for services and with the msms becoming more integrated into society and more evenly dispersed geographically future hiv prevention interventions must thus account for this competition and take advantage of the efficiency that such competition may bring to the table while at the same time ensure that clients are able to socialize and receive services that are based upon their individual needs and the respective agencies mark correlation functions for the pattern of houston gay venues and chicago gay venues marked by each of the indegree centralities

this study examines network centrality of intervenue networks formed by collaboration competition and sponsorship relationships among venues that serve young men who have sex with men msm aged 16 to 29 years in relation to their geographical concentrations in chicago illinois and houston texas our data on the physical venues comprised 116 venues in chicago and 102 venues in houston we examined the relationship between the network centrality of different relations and the geographical intensity among these venues and considered neighborhoodlevel socioeconomic determinants of health the results indicate that young msmserving social and service venues found in close physical proximity to one another tended to have large centrality indegree values based on competition in both cities and based on collaboration only in chicago no evidence however was found that occupying a central position in the sponsorship networks was related to geographic concentration combined these results suggest that hiv prevention interventions should consider the organizing force for competition such a strategy could result in better services yet there may still be potential for overlap and redundancy in services at the expense of underserved regions where proven interventions could have the greatest impact

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introduction merely looking at another person people spontaneously form impressions about fundamental personality characteristics such as trustworthiness competence and attractiveness 1 2 3 4 such snap judgments have been shown to influence realworld decisions in many contexts including political voting sentencing leadership or online dating 5 6 7 8 9 less known however snap judgments seem also to play a role in the context of sexually transmitted infections 1011 where people draw inferences about potential partners and make decisions about whether to use effective protection research shows that people report that they often just know whether a person is risky or safeeven when they do not know much about the respective persons past sexual behavior or personality 1213 for example many people who contracted hiv during unprotected sexual intercourse report they had assumed their partners were safeand that they regret being wrong 1415 focus groups on hiv prevention point to a related phenomenon participants often express trust in their ability to detect potentially risky sex partners based on their appearance even though research suggests that they cannot 1617 impressions of partner safety or risk based on intuitive snap judgments may thus influence reliance on effective protection strategies particularly during hot sexual encounters that impair deliberation and make impulsive decisions more likely 18 19 20 21 intuitions about riskiness may not only influence sexual risk behavior but may also come into play in the medical context for instance when paramedics or nurses approach patients or victims and need to decide on the spot whether or not to wear protective gloves furthermore a recent study indicated that a mismatch between patients personal profile and the stereotypical risk factors for hiv resulted in delayed diagnosis of hiv by doctors 23 not only did the participants report surprise at their diagnosis indicating that people without the stereotypical risk factors for hiv fail to make the connection between their behaviors and risk of hiv but medical experts made the same error the participants reported having seldom been offered hiv tests despite visiting physicians over a period of years with hiv symptoms ie weight loss persistent infections swollen lymph nodes suggesting that the stereotypes of who is at risk of contracting hiv are also present in the medical community the intuitive nature of risk perception has been strongly supported by a series of studies relying on neuroscientific measures eventrelated potential studies revealed that erp responses to risky as compared to safe individuals diverged early in the processing stream this speed precludes systematic reasoning about health risk and thus supports the notion of intuitive processing 24 moreover erp differences between intuitively risky and safe partners emerged at the level of the late positive potential an erp component known to respond to affective significance 25 portraits of riskylooking individuals prompted larger lpps which may serve as an intuitive alarm signal for attentive processing 26 27 28 this interpretation was corroborated by a subsequent fmri study that found increased activation toward individuals later judged as risky within the saliency network a set of brain regions involved in attention and relevance detection 29 perhaps the strongest support for the intuitive nature of hiv risk perception comes from studies which revealed similar erp and fmri correlates of risk processing for implicit and explicit conditions 2829 together these findings indicate that people are highly sensitive to cues of riskiness and rapidly and spontaneously form impressions about hiv risk to tap into the nature of the associative memory representation underlying hiv risk stereotype several studies related hiv risk perceptions to a broader set of person characteristics across different stimulus sets a strong inverse association of hiv risk perception with ratings of trustworthiness and responsibility emerged 2730 this is consistent with work suggesting that trustworthiness and responsibility lie at the core of a high hiv risk stereotype in young adults 31 interestingly and compatible with the erp findings research on person perception indicates that inferences about trustworthiness are formed spontaneously and based on the information available in short glances 3233 for example judgements of traits like trustworthiness or health state have been linked to facial features shape and color 334 these findings show that humans form impressionswhether about risk or trustworthinesswith ease but they do not imply that the inferences are reliable or accurate additionally both commonalities and differences have been found for cuebased judgements across cultural backgrounds highlighting the importance of possible crosscultural differences 3536 in sum an extant literature in evolutionary psychology and face perception has identified that such cues matter in a wide array of judgements such as trustworthiness attractiveness and health 35 37 38 39 furthermore there is a robust literature in social psychology regarding personality impressions based on thin slices of information 40 part of which also focuses on underlying cues 41 42 43 the current study examined this issue using portraits that were similar to how people present themselves on social media and dating websites creating ecologically valid conditions for the study of hiv risk impressions thus our research focuses on early stages of hiv infection which are not reliably associated with visible signs of illness or health deterioration the research design consisted of two independent sources of rating data first the entire stimulus set was evaluated according to a list of specific cues deemed relevant to person perception towards this end a list of perceivable cues was derived from the literature and via focus groups resulting in a set of over sixty cues and general impressions each portrait was then rated on all cues to measure the extent that a cue was present second an independent group of raters evaluated the depicted persons according to hiv risk as well as further person characteristics of trustworthiness health and attractiveness these additional characteristics were assessed to determine the relationship of hiv risk perception to fundamental person characteristics brought out by previous research on trust 3444 health 3439 and attractiveness 364546 we first report the intraclasscorrelation to support the notion that perceived riskiness is reliably measured and shared among participants secondly we adopted a brunswikian lens model perspective to study the relationship between perceivable cues and hiv riskiness ratings 47 in brief brunswiks lens model serves as framework for the relationship between the environment and perception which is mediated probabilistically by cues that are used to form impressions 3441424748 critically we do not consider the relationship between cues and the objective external variable ie actual hiv status called cuevalidity coefficients but rather focus on the psychological impression of perceived hiv risk or intuitive riskiness ie the cueutilization coefficients next we test whether a model based on multiple cues can be trained to predict hiv risk impressions in new data lastly to reveal the relationship between cuebased models of hiv risk and models of trustworthiness and their distinctiveness to models of attractiveness we test whether cuemodels trained to predict one variable can predict another method cue judgment methods selection of cues each photograph was evaluated according to general personality characteristics and a large set of perceivable cues general personality impressions are listed in table 2 and were selected based on previous research on person perception 41 42 43 4849 in order to implement a brunswiks lens model perspective it is crucial to represent the possible features and characteristics underlying snap judgments in the list of cues towards this end in a first step a large set of possible cues and impressions was identified by an extensive literature search of the relevant literatures on personality impressions and person perception 485051 which included journals from social and personality psychology face perception and vision health psychology as well as human medicine textbooks from these diverse sources we compiled a large list of several hundred possible cues and conduced a focus group consisting of the two leadpostdocs two doctoral students and several research assistants to identify additional potential cues for hiv risk impressions that were not listed in the literature classify the cues across the spectrum from concrete semiabstracted abstracted form broader categories along which the cues can be clustered reduce redundant or synonymous cues and remove cues that were not possible to rate with the present stimulus set the final list consisted of 60 perceivable cues which were sorted into ten higher order categories of face and body appearance and setting as well as 13 general impressions stimuli the stimulus set consisted of 240 photographs of persons in daily life scenes and was the same as in previous research 27285253 to have high ecological validity stimuli were selected based on the following six criteria a colored photo of a single person located in the foreground with their face clearly visible in terms of age and race only photographs of young european descent were included to resemble natural conditions and to facilitate impression formation only portraits of individuals in which context features beyond the face itself were visible such as attire clothing or aspects of the situation in which the picture was taken half of the pictures depicted male and female targets respectively the photographs were retrieved with permission from a popular online photosharing community cue rating procedure booklets for collecting ratings were distributed across the groups with 810 cues or general impression rating scales for each participant the study was conducted by an experimenter who presented 60 target photographs on a projector screen and participants provided their ratings for a given cue in booklets each participant rated all 60 photographs on one cue and then viewed them again with the instruction to rate the next cue with this procedure which lasted about 45 minutes per group we obtained cueratings from eight judges per cue 54 the study was presented as a general inquiry of person perceptions specifically participants did not know that cueratings would be related to criterion judgments of hiv risk or other personality characteristics criterion judgment methods hiv risk stimuli and procedure criterion ratings were obtained for the same stimulus set as in the cue rating study these ratings were obtained by aggregating data from previous studies in schematic overview of the current study and example stimuli ratings for observable cues and criterion ratings are collected from independent groups of raters for a large set of target photographs averaged cue and criterion ratings are then combined and correlations are assessed between each individual cue vector and the hiv risk criterion judgments this strategy identifies cues that may be utilized to infer hiv risk and thus comprise a brunswikian semilens order to obtain a ratio of 40 criterion judgments per image from oppositesex raters 2728 each participant was tested individually and the rating procedure was operated by a computer running presentation software each picture was shown for 2 s followed by the presentation of the rating scales the order of rating scales was randomized for each image and the order of the picture stimuli was determined randomly for each participant perceived hiv risk was assessed by the question how likely do you think is it that this person is hivpositive on a 7point likelihood rating scale ranging from very unlikely 1 to very likely 7 in addition to perceived hiv risk participants also provided ratings of perceived trustworthiness health and attractiveness for each image 2745 in order to determine the relationship of visual cues and risk perception it is necessary to demonstrate that the stimulus materials actually varied in their ascribed hiv risk thus risk ratings were calculated across participants for each individual picture indicating substantial variation in risk mean risk ratings increased linearly from very low risk to very high risk similar findings emerged for trustworthiness attractiveness and health data analysis we first examined the reliabilities of aggregate ratings and compute associations between individual cues and the criterion ratings of hiv risk next we combined cues into a multiple regression model specifically we used regularized lasso regression with 10fold crossvalidation as implemented in scikitlearn 5556 thus within each fold a training model of cuecriterion relationships was constructed based on a subset of the data to validate the model the coefficients from the training model were then applied to the heldout set of photographs that were not used for training in other words multiplying the cuevalues for novel photographs with the trained model coefficients the model generates cuebased predictions of hiv risk these are then compared against the actual hiv risk ratings and predictive accuracy is measured using r 2 and the standard error of the estimate and averaging them results reliability measures we first assessed the reliabilities of the cueratings among the eight raters who evaluated to what extent each cue was expressed on the images across the set of cues the average icc was 84 as for the cues we assessed the reliability for the criterion ratings hiv risk had an icc of 92 and similar values were obtained for ratings of trust health and attractiveness relationships between individual cues and perceptions of hiv risk the cueutilization correlations in table 1 indicate the relationships between each cue and perceptions of hiv risk as can be seen multiple cues mostly showing lowtomoderate effect sizes are related to perceived riskinesssafeness for instance if a person wears lots of body adornment has an unconventional appearance or appears tiredlooking then independent judges will regard this person as having higher hiv risk furthermore the visibility of cigarettes provocative clothing and a facial expression signaling negative emotional states are also linked to heightened hiv risk conversely lower hiv riskor a safer impressionis associated with having positive emotional expressions an average face and with persons who are observed within nature scenery predicting hiv risk impressions from visual cues we used a linear regression model to capture the relationship between cueratings and hiv impressions and to test whether and to what degree a trained model could predict hiv risk ratings in unseen data based on the learned cuecriterion relationships specifically we used regularized lasso regression with 10fold crossvalidation as implemented in scikitlearn 55 56 57 we found that the model performed substantially above chance explaining on average more than half of the variance with an r 2 056 and a standard error of the estimate 057 fig 2 shows the correlation between predicted and actual hiv risk ratings which amounts to r 075 175 p 00001 thus a model trained to predict hiv risk solely from visual cues can accurately predict hiv impressions for new pictures notably even when confining the set of predictive cues to concrete ones and disregarding more abstract inferences the predictive model still performed remarkably well 119 p 00001 r 2 035 standard error of the estimate 069 also applying conventional linear instead of lasso regularized regression did not meaningfully change these findings together these findings suggest that intuitive inferences about hiv riskrather than being unknowable and random are systematically related to visual cues how does hiv risk perception relate to general person impressions impressions about hiv risk are likely embedded in a network of various other social dimensions that might also be inferred from short glances 2749 to gain insight into these relationships we also obtained ratings for all images on 13 more general impressions table 2 lists correlations between each general impression and perceived hiv risk as shown perceived low responsibility is most strongly associated with perceived hiv risk this is consistent with previous research on hiv risk 2731 and with recent work on social impressions 58 where this dimension also ranks first for impressions of trustworthiness further riskylooking people are seen as rather uneducated and selfish and as less cautious less likeable and less popular the relationship between impressions of hiv risk to perceptions of trust health and attractiveness the same methods used to examine and forecast ratings of hiv risk can also be applied to other criterion ratings such as trust health and attractiveness specifically the correlation between predicted trust and actual trust ratings was r 075 for health r 084 and r 089 for attractiveness this suggests that for each of these characteristics the overall impression of a given person can be predicted with relatively high accuracy from a set of cues importantly the trained model based on trust was able to significantly predict hiv risk ratings with lower trust ratings being associated with higher hiv risk in contrast the health and attractiveness models did not predict ratings of hiv risk very well r 023 for health and r 006 for attractiveness discussion sexually transmitted infections are a great burden at the individual and societal level with more than 1 million of stis being acquired per day 5960 major health organizations consistently report and warn against a knowledgebehavior gap in hiv prevention specifically while knowledge about effective hiv prevention is high levels of protective behavior are low 60 the reliance on ineffective rather than effective strategies to prevent infection may help to explain the knowledgebehavior gap 17 specifically basing hiv perception on the appearance or trustworthiness of the partner may give people the feeling of risk control while not providing effective control in order to further understand appearancebased hiv risk perception we reveal in the present research how visible cues in photographs of personssimilar to the ones used in online datingrelate to impressions of hiv risk how impressions of hiv risk can be predicted from the cues alone with relatively high accuracy and how impressions of hiv risk relate to broader impressions of trust health and attractiveness perhaps the most notable finding of this study is that how risky a novel person will be evaluated on average can be predicted by their appearance by linking the cueratings to the criterion judgments through crossvalidated predictive modeling the trained model significantly predicted hiv risk ratings for new target photographs importantly all that is fed in to this model are the cuemeasures for each image which are then weighed by the learned coefficients to yield predictions of hiv risk in particular we found that cuebased models can explain about half of the variance in perceived hiv risk and that this finding is robust to specific modeling choices these numbers are surprisingly high considering that cues and criterion reflect consensus ratings not considering individual variation in appearancebased risk perception measurement errors in the assessment of cues and criterion and that additional relevant cues may not have been incorporated in the model inspection of the model coefficients revealed the most important cues for riskiness or safety the top five riskenhancing cues were unconventional appearance a worn face lots of body adornment a coquettish gaze and reddened eyes in contrast cues associated with more safety were a friendly expression a musculous stature an average face a tall body and overweight of note as some of these cues are themselves abstractions we also inspected topranking cues in the models that were reduced to concreteonly cues in that model additional top cues for hiv risk were alcohol visible and spotty skin whereas lowered risk was predicted by picture taken in nature food visible and pimply skin overall when it comes to judgments of hiv risks at zero acquaintance information contained in a fairly small set of visible cues is systematically related to the consensus among perceivers about what constitutes hiv riskiness the present findings close a gap of knowledge in the understanding of the processes leading to intuitive decisions to engage in risky sexual behaviors we proposed previously that riskiness is judged according to a stereotype of hiv 2728 this reasoning builds upon the findings that distrust and lack of responsibility are key features of a high hiv risk stereotype 61 that hiv risk ratings are negatively associated with ratings of trust and responsibility 2728 and evidence that trust is perceived intuitively 1 according to this reasoning hiv risk and trustworthiness are assumed to rely on common cues the observed cueutilization coefficients strongly support this notion specifically a model trained on cues for trustworthiness was able to significantly predict lowered perceptions of hiv risk and the model trained on hiv was able to predict perceived trustworthiness further insight into the nature of the suggested hiv risk stereotype can be gleaned by inspecting the relationship between hiv risk and ratings of 13 other general impressions the strongest association emerged between hiv risk and a perceived lack of responsibility followed by the perception that the depicted person was uneducated selfish and generally less likeable this replicates previous findings obtained using verbal procedures to elicit stereotypic associations 2761 overall adopting a brunswikian lens model perspective supports the notion that intuitive hiv risk perception may reflect the activation of the high hiv risk stereotype utilizing cues associated with trust and responsibility while the present study specifically focused on the cueutilization process it has to be noted that the cues utilized in intuitive risk perception are presumably not valid to our knowledge only one study directly examined the ability to detect early stage hiv positive individuals by presenting pictures and short vignettes from hivpositive and hivnegative people 17 participants were at chance level in detecting hiv risk which suggests that relying on snap judgments of hiv risk is ineffective this finding is consistent with the analysis on the conditions leading to good or bad intuitions 62 specifically the low base rate and the lack of corrective feedback were identified as main conditions leading to bad intuitions which apply to the present case ie judging hiv risk on person appearance thus even if some cues were statistically associated with actual hiv risk status reliance on such cues would still provide an ineffective strategy to prevent sexually transmitted diseases from this perspective studying how visible cues systematically affect hiv risk ratings may provide the basis for new kinds of public health interventions in which participants can make direct experience with the fallacies of relying on appearance based risk perception to prevent infection with sexually transmitted diseases furthermore targeting intuitive hiv risk perception may also have implications regarding discrimination of certain individuals given the robust literature on stigmatization of hiv positive people 236364 to relate the current findings to previous research in health psychology and psychophysiology the present study examined the intuitive perception of hiv risk however from a public health perspective it is relevant to determine in future research whether the current findings are specific to hiv or extend to other sexually transmitted diseases while base rate of hiv is comparably low chlamydia gonorrhea syphilis and trichomoniasis are stis with much higher prevalence rates ie an estimated 500 million people becoming infected each year 60 and similar to hiv a person can be infected with chlamydia or trichomoniasis without presenting visible symptoms there is first evidence that the risk stereotype associated with chlamydia is highly similar to the stereotype associated with hiv 65 thus it seems possible that the current findings are not specific to hiv and may generalize to other stis however there is evidence that perceptions of hiv risk can be separated from leukemia risk which is equally a lifethreatening disease with no initial visible signs but not contagious 526667 compared to leukemia which is viewed as affecting innocent people by fate hiv is at least on average associated with more negative attitudes greater attribution of irresponsibility and stigma 23636466 interestingly contrasting hiv and leukemia risk perception revealed a pronounced dissociation in eventrelated brain potential responses associated with high and low risk for both diseases 52 this finding implies at least some specificity of intuitive hiv risk perception rather than a generic response to all kinds of diseases however a more comprehensive assessment of intuitive risk perception associated with a range of stis and other diseases is needed to assess the memory representations accessed by intuition for key characteristics of illness representation ie contagiousness and seriousness 67 the current research is rooted in the health psychological and public health literature on hiv risk behavior in young adults 101168 however a highly relevant but henceforth largely unconnected line of research exists on the topic of face perception in social and evolutionary psychology regarding impressions of health 39 attractiveness 69 and social impressions more broadly 170 we found that hiv risk shows a small to medium association with how illlooking the depicted persons are perceived which is substantially lower than eg the correlation to responsibility we interpret this as evidence that people seem to judge hiv risk more based on personality characteristics and less on cues for health however several cues that emerged in the cueutilization analysis such as reddened eyes or spotty skin are compatible with cueutilizations reported for health 357172 more abstracted cues such as an exhausted or sad facial expression were also related to judgments of hiv risk and such cues have also been reported in the literature on health and disease perception based on facial appearance 72 the relationship of attractiveness and hiv risk perception is less clear although there is evidence that physical attractiveness drives sexual interest which can influence partner selection and may play a role in the context of hiv risk 457374 in principle both a positive or a negative relationship between attractiveness and hiv risk seem possible a positive relationship might arise based on the idea that attractive people have more sexual opportunities and thus are likely more at risk on the other hand the whatisbeautifulisgood stereotype 75 suggests that more attractive people should have lower risk and the same prediction arises from the notion that attractiveness advertises health 76 in the current dataset the correlation between hiv risk and attractiveness is low and the cuemodels trained to predict attractiveness were not able to predict ratings of riskiness and vice versa overall while the relationship of attractiveness may vary with the attractiveness of the models and experimental methodology 7778 we observed no robust relationship of attractiveness and perceived hiv risk in our stimulus set future research should examine how these impressions relate to broader notions of disease avoidance 7980 and to general models of person impressions 170 over the past years researchers have made great advancements in modeling facial appearance 8182 and understanding interactions between cues and higherorder judgments for realworld outcomes 4 5 6 224672 renewing the interest in the structure of social impressions and their predictability from photographs 83 84 85 86 recent research suggests a 2or 3factor model of social trait impressions 70 comprising approachabilitytrustworthiness dominancemasculinity and youthfulnessattractiveness although our work differs with respect to the stimuli used as well as regarding the concrete traits studied previous findings using similar factoranalytic techniques found a comparable organization in which a factor comprising trustworthiness responsibility and risk was dissociable from a factor for attractiveness health and willingness to interact 27 to comprehensively position hiv risk within this social trait space requires studying a broader variety of images and the assessment of more traits 83 interestingly in the domain of trust recent research demonstrated that different images of the same person are associated with different ratings of trust 87 presenting multiple images of the same person in future research may not only provide further insight into the association of risk perception with the key characteristics of the hiv risk stereotype but would also reveal the extent to which risk perception varies with situational context the present study has limitations with regard to the stimulus materials as well as the examined cues and person characteristics while our stimulus materials were selected to represent naturalistic person presentations on social media a larger number of stimuli would be desirable related to the issue of stimulus sampling future work should extend our findings to different cultural contexts and vary both the observers and targets extending our work beyond the western setting in which our study was conducted could provide insights into commonalities and differences of social inferences across cultures 88 additionally in recent work we found differences in hiv risk ratings based on both the gender of the person that is to be judged as well as the raters gender 30 within the current work the entire cuecriterioncorrelation vector for males and females showed a large correlation future work might examine possible gender commonalities and differences systematically using larger sample sizes furthermore while we undertook considerable effort to include relevant cues to person perception based on literature research and focus group discussions it is always possible that the inclusion of additional cues would result in larger cueutilization coefficients however the strong association between riskiness and multiple cues may be considered as evidence that our cue selection covered most obvious aspects we also note that the ratings of hiv risk as well as other characteristics are inherently relative and should be interpreted with respect to the current set of stimuli and questions furthermore it would be helpful to see how hiv risk impressions relate to additional person characteristics including for instance competence warmth or intelligence 189 additionally assessing measures of confidence in the perceived person characteristic may provide valuable information on the association between trust responsibility and hiv risk ratings such work may also point to subtle differences when moving from general to more specific person characteristics summary and conclusion this study reveals visual cues that are systematically linked to snap judgments about a persons hiv risk hiv risk impressions appear to be embedded in a stereotypical set of beliefs about negative personality attributes knowing only a handful of cues is sufficient to predict perceptions of hiv risk these findings provide insight into the phenomenon of intuitive risk perception and can be used to design health campaigns and interventions aimed at reducing the burden of hiv and sexually transmitted infections all data files and code to reproduce the analyses are available on github supporting information s1

field studies indicate that people may form impressions about potential partners hiv risk yet lack insight into what underlies such intuitions the present study examined which cues may give rise to the perception of riskiness towards this end portrait pictures of persons that are representative of the kinds of images found on social media were evaluated by independent raters on two sets of data first sixty visible cues deemed relevant to person perception and second perceived hiv risk and trustworthiness health and attractiveness here we report correlations between cues and perceived hiv risk exposing cuecriterion associations that may be used to infer intuitively hiv risk second we trained a multiple cuebased model to forecast perceived hiv risk through crossvalidated predictive modelling trained models accurately predicted how risky a person was perceived r 075 in a novel sample of portraits findings are discussed with respect to hiv risk stereotypes and implications regarding how to foster effective protective behaviors

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introduction there are many threats and challenges to face in the present and the near future at the same time inequalities especially economic and social are multiplying and are filling every gap in the fabric of community life making a full quality of life increasingly difficult our everyday reality is perceived as more complex unpredictable and filled with barriers created by notsoevident factors that can stifle thought reflection and the desire and energy to act the pandemic has contributed to this and the war now affecting europe can only further exacerbate the negative global conditions balbaa et al 1 have highlighted the geopolitical and cultural tensions and the lowering of global growth expectations due to uncertainty about the impact of the conflict especially on the global supply chain conflicts have led to energy commodity and trade supply shocks and to rising energy food and commodity prices thereby causing global inflation in many countries increased economic and political instability and social and civil unrest 2 all of this comes at time of growing poverty high rates of emigration and immigration persistent levels of social heterogeneity exploitation of natural resources and environmental degradation amplifying the presence of negative conditions and the reduction of physical and psychological wellbeing for many people and encouraging the presence and escalation of situations of vulnerability which are rapidly increasing today 3 growing vulnerabilities lets start with the concept of vulnerability which generally indicates the susceptibility to being damaged by natural phenomena or human activities 4 to experiencing conditions that may lead to difficulties discomfort and negative consequences from a social economic and psychological point of view 5 research over the last decade has highlighted that there is no such thing as vulnerability there are vulnerabilities 6 in addition to the more traditional and better known forms of vulnerability such as those connected to the presence of disabilities disease conditions of economic poverty and migration other forms of vulnerabilities are now strongly emerging and by intertwining with the traditional ones are exacerbating their consequences the emerging vulnerabilities are environmental or climate change vulnerabilities ecological vulnerabilities financial vulnerabilities healthrelated vulnerabilities digital vulnerabilities and professional vulnerabilities environmental vulnerability expresses the degree to which a system or individual is unable to cope with the negative consequences of climate changes it represents the degree of exposure to such changes together with that individuals sensitivity and ability to adapt 7 nguyen 8 identifies the three main aspects of climate vulnerability the degree of exposure to significant climate variations the sensitivity to these variations and the associated damage which is perceived more by certain groups and the adaptive skills linked to the presence of social physical and financial resources guillardgonçalves and zêzere 9 highlight the need to use complex indicators to measure this type of vulnerability these indicators cam simultaneously take into account social aspects and environmental characteristics health vulnerability refers to exposure to the risk of developing disease or suffering physical harm these aspects can be made more consistent by a number of different personal collective and contextual aspects 10 a recent example we are all familiar with is the exposure to the covid19 pandemic this phenomenon is associated with significant physical and psychological health risks 11 in addition to this today and in the near future health vulnerability will be exacerbated by environmental pollution the who has reported that in 2016 about 600000 children died from acute lower respiratory tract infections due to air pollution 12 moreover the risk of chronic diseases such as cardiovascular diseases increased for different age groups financial vulnerability is defined as the exposure to different forms of financial shocks that may lead to an unexpected loss of income andor a sudden and uncontrollable increase in expenditure 13 chipunza and fanta 14 note that the financial structure of our society is a complex system penetrable for the few and impenetrable for the many understanding it requires a set of specialised information that only certain groups of people have thus financial vulnerability is linked to the less than optimal management choices of ones own assets compared to those who are not exposed to the same difficulties whether it be the management of savings investments or the adoption of a more advantageous lifestyle moreover these situations can be even aggravated by scams and manipulations perpetrated by those who tend to exploit the lack of skills of certain people have in this area and their naivety 15 digital or cyber vulnerability is defined as the exposure to the risk of being attacked in the system processes or internal checks of a computerized processor these digital vulnerabilities can lead to actual cybercrimes allowing hackers to illegally access systems and cause serious damage to data privacy 16 therefore cybersecurity vulnerabilities are extremely important to monitor for the overall security posture as gaps in one network can lead to a largescale system breach with this in mind wijayanto and prabowo 17 highlight how the covid19 period and the subsequent increase in the amount of time people spend on the internet has exposed them more to cybercrime phenomena through the cybersecurity behavior vulnerability scale the authors measured the level of cybersecurity in universities and in particular in data management the collected results showed that the lack of knowledge connected to cybersecurity is linked to high rates of digital vulnerability and to the possibility of being exposed to a higher number of cybercrimes ong et al 18 use this scenario to describe parents sharing behaviour while acting in the hope of receiving feedback and support these parents expose themselves and their children to a form of digital predation lastly professional vulnerability is linked to the proposal of undignified jobs which expose people to various forms of exploitation and prevent them from drawing personal and social value from their different work experiences that in addition occupy a large part of the day and life 19 gutiérrezbarbarrusa 20 highlights the four main dimensions that characterise professional vulnerability insecurity regarding the continuity of the employment relationship which makes it difficult for workers to exert control over their future professional and social life a poor salary that does not allow them to adequately face costs and expenses the weakening of workers social protections with the consequent progressive weakening of the legislation in support of quality working conditions increased discretionary power of employers combined with insufficient coverage of public social protection systems this is particularly true for unemployment benefits and pensions thus increasing the levels of workers insecurity in the face of market forces from the above it is clear that there are numerous vulnerabilities of which we must learn to speak in the plural these tend to affect an increasingly growing portion of the population and are intertwined and are capable of creating systems that trap people in ever deeper forms of impoverishment inclusive sustainable socially and environmentally just context we must oppose this spread of vulnerabilities and the substantial devaluation of the idea of the human person the progress and flourishing of communities are achieved through cooperation coexistence and the construction of inclusive fair and supportive contexts it is important to start from the idea of inclusion which has nothing to do with the idea of placement 2 inclusion is not about being interested in the single individual with vulnerabilities but focusing on the context and the capabilities our living environments have to allow everyone to actively participate and have a satisfying level of life 24 inclusion explicitly considers with equal emphasis the right everyone has to receive the attention flexibility and adaptations they need according to the writings and words of shafik asante former leader of the new african inclusion is on the one hand closely linked to uniqueness inclusion is recognizing that we are one even though we are not the same on the other hand inclusion is connected to the recognition of the heterogeneity of all contexts and working to ensure that said contexts can allow every person with their uniqueness to actively participate in social and civil life 25 we would like to focus our attention on a core idea of the concept of inclusion vulnerabilities are considered contextdependent and require as argued in the universal design approach the breaking down of contextual barriers 26 if on the one hand there are individual aspects such as the presence of impairment diseases etc that can characterise peoples lives on the other hand it is important to highlight the significance of events contextual economic legal administrative and ideological conditions and other circumstances linked to the macrosystem often activated by those with more power and opportunity to influence which characterise multiply and accentuate the difficulties people have 5 carelessness ignorance and cynicism give rise to different conditions and create pain insecurity discomfort and loss 27 vulnerability cannot be the explanation for struggling phenomena 28 an individual has a vulnerability or worse is vulnerable because they have poor risk management skills are less able to defend themselves and face negative events and to protect their interests the idea of inclusion does not consider all this as an individual responsibility and a defeat of an individual it encourages us to consider the role of the contexts and the conditions that can create vulnerabilities barriers and obstacles it invites us to highlight them and examine them carefully in analyses and intervention projects sustainability is a complex construct that is articulated in environmental economic social and educational sustainability 29 environmental sustainability considers firstly the integrity of the terrestrial ecosystem and the quality of the environment intended as an asset that improves the quality of life and consequently leads to development economic sustainability involves creating income and working for peoples sustenance with a longterm view for sustainable and intergenerational equality this is achieved through the rational and efficient use of resources and reducing the use of nonrenewable resources 30 social sustainability aims at an equitable social distribution of benefits and costs in a world where men and women can manage the environment this should be done on a global scale to diversify and integrate both sociocultural and economic human resources to value heterogeneity and diversity local identities and biodiversity thus fulfilling the values of universal design 31 educational sustainability aims to build awareness and knowledge of sustainability issues as well as to develop students and schools that can think critically innovate and provide solutions towards more sustainable patterns of living developing a transformative participatory cosmopolitan and ecocentric agenda this agenda should be based on taking a step back from neoliberal policies overhauling existing institutions integrating environmental values and expanding participatory governance 32 for these reasons sustainability is at the centre of national and international efforts so that policies and actions at different levels can be inspired by it to support this idea let us mention just two documents the 2030 agenda and the recent amendments to the italian constitution the 2030 agenda for sustainable development signed in september 2015 by the governments of the 193 countries of the united nations has developed an action plan expanding the intervener context that is to say the fields and actions that concern organisations systems policies and social practices that can be modified to pursue the goal of a sustainable world from an environmental economic and social point of view 33 looking at italys constitution since 8 february 2022 sustainability has been included specifically in articles 9 and 41 the new article 9 of the constitution states that the italian republic protects the environment biodiversity and ecosystems also in the interest of future generations the new article 41 states that if private economic initiative is free it cannot take place in contrast with social benefit or in a way that damages health environment safety freedom and human dignity these deep considerations are in line with groppis work 34 because sustainability is about the aspiration that a certain present value environment the wealth of a country cultural heritage etc will continue to exist in the future the use of an asset or a resource does not destroy it but allows it to be passed on to future generations this is also in line with cellas work 35 which emphasises the topic of social dilemmas situations in which interdependent individuals face choices in which maximising shortterm interest produces results that leave everyone worse off in essence sustainability is a complex issue that involves the ability to deal with the dilemma of balancing the very short term with the long term in order to create the conditions to reduce the afore mentioned vulnerabilities these contents are linked to the topics of social justice and environmental justice among the different definitions we mention the following the fair treatment and meaningful involvement of all people regardless of race colour national origin or income with respect to the development implementation and enforcement of environmental laws regulations and policies they will be achieved when everyone enjoys the same degree of protection from environmental and health hazards and equal access to the decisionmaking process to have a healthy environment where to live learn and work 36 recent literature highlighted that the promulgation of environmental and social justice issues may be mutually reinforcing 6 environmentsocial justice promotes climate policies that also address social inequities such as affordable housing green jobs renewable energy projects in traditionally disadvantaged communities and access to public transportation 37 it is increasingly clear that if we care about improving the living conditions of people and reducing the possibility of experiencing vulnerabilities we must take action we have to stop the socalled natural and social lotteries 38 ie the inequalities linked to ones genetic andor social background that work to the disadvantage of many people we also need to act with increasing urgency also to avoid the negative consequences of what we can call geographical and temporal lotteries ie the inequalities associated with the place and time of birth according to japanese professor fukuyama 39 in order to make life possible in the future and to ensure quality lives it is necessary to support the evolution of society not only in terms of economic and individual wellbeing but also of environmental and social wellbeing encouraging the development of a good life with and for others and supporting sustainability and justice toward a 50 society we must recognise that we have the duty to promote the worldviews that take into account the abyss that lies before us we are threats to the creation and at the same time we are guardians of the creation 40 this worldview must involve a new idea of quality life for everybody focused not only on personal wellbeing and the i but also on the we the earth 41 environmental and social characteristics the quality of air water and soil and the characteristics of inclusion and social justice 42 today the idea of hedonistic wellbeing requires to add value to happiness created by sustainable responsibility and processes of careful and responsible consumption at the same time the eudemonic construction of meaning should be increasingly focused on the contributions to sustainability and inclusion the european commission itself underlines the importance of focusing our attention on social justice and sustainable development and the need for a profound transformation it does so in the document industry 50 towards a sustainable humancentric and resilient european industry 43 and in the idea of a 50 society in general 44 society 50 aims to improve everyones living conditions and to solve problems at the micro meso and macrosocial levels this will be possible thanks to technological support and a socioeconomic system that is no longer centred on unstoppable profit but that instead respects the value of human and natural capital therefore to be effectively recognised as a super smart society as we hope it must also demonstrate that the wellbeing of people and our planet is its primary interest in support of this it must also prove to have successfully addressed the fears and perplexities associated with the development and spread of automation in the world of services and products 39 this is a society that according to bryndin 45 will have to be characterised by the creation of equal opportunities for all and also providing the environment for realization of potential of each person and through the use of emerging technologies will have to remove physical administrative and social barriers to allow people to achieve selfrealisation in this way every individual including elderly people and women can live a safe secure comfortable and healthy life and each and every individual can realise their desired lifestyle from this perspective from this moment on we all have to commit ourselves to tackling the health social and environmental threats and problems identified 46 47 this must be done while avoiding the use of visions paradigms and tools of the past some of which are even considered accomplices or even causes of the malaise we wish to remedy 48 conclusion societies 50 are not born alone they need the investment and work of everyone they need strong and incisive legislative economic and cultural processes above all they need strong cultural processes a culture based on a critical awareness of various factors primarily those that are fuelling inequalities and vulnerability widespread poverty and concentrated wealth from this point of view it is necessary to move on to carefully consider inclusivity sustainability social and environmental justice human rights without ifs and buts and the dilemmas they entail to finally move to indignation and collective commitment 49 11 there is a need for research and professional responsibility for all disciplines and knowledge to focus on the constructs described together with a deep awareness of the inequalities the various complex dynamics that define them and the relationships between local and global moreover it is necessary to create connections with other disciplines activism and intertwined collaboration between different scholars and professionals to tackle such complex problems 50 in cases where we try to act in this way it seems to be possible to move in this direction with children 51 and adults alike focusing on the latter the pilot and innovative experiences started with the national federation of the italian press with the advanced training course telling the truth how to inform while promoting an inclusive society for journalists 52 this shows that it is possible to build challenging but incisive and transformative communitybuilding experiences these make it possible to instil in those who work a culture for new societies for a regenerative process an energetic one within a path of collective social flourishing

our everyday reality is perceived as more complex unpredictable and filled with barriers created by notsoevident factors that can stifle thought reflection and the desire and energy to act all of this intertwines with the reduction of physical and psychological wellbeing for many people encouraging the presence and escalation of situations of vulnerability which are rapidly increasing nowadays in addition to the more traditional and known ones such as vulnerabilities connected to the presence of disabilities or diseases today other forms of vulnerabilities are strongly emerging such as environmental vulnerabilities or vulnerabilities connected to climate change ecologic vulnerabilities financial vulnerabilities healthrelated vulnerabilities digital vulnerabilities and professional vulnerabilities considering this standpoint in this chapter we will focus to inclusivity sustainability social and environmental justice human rights furthermore we introduce the construct of society 50 that aims to improve the living conditions of everyone and to relatively resolve problems at the micro meso and macrosocial levels

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introduction china is currently experiencing a surge in its aging population which continues to increase rapidly at the end of 2021 142 of the population were aged 65 years and older up from 7 in 2000 12 it is expected that the population of old adults will exceed 400 million in 2033 and reach a peak of 487 million in 2053 accounting for a quarter of the global older peoples population the old adults demand for health medical treatment rehabilitation nursing and other services is constantly increasing 3 given the widespread coexistence of functional decline and multiple chronic health conditions in older people the traditional pattern of aged care in china relying on social care delivered by family members volunteers or nursing homes has been unable to meet their needs there is an urgent need to integrate medical and nonmedical care resources to improve service capacity and quality for older adults some wellknown initiativesprograms applying this concept have already been established in developed countries for years such as pace 4 and cbss 5 in the united states the aged care reforms in australia and embrace 6 in the netherlands in 2020 the world health organization launched the icope implementation pilot program which aimed at delivering integrated and personcentered care for older people in recognition of the need for a transformation of health and social care systems and services although starting at a relatively late stage china has also begun pilot work in this area in 2013 the state council of china promulgated several opinions on accelerating the development of the elderly care service industry which officially pointed out for the first time that a service mode delivering integrated health and social care for older peoplereferred to as yiyang jiehe in chinesewas scheduled to be actively promoted 7 since 2016 china has set up 90 nationallevel pilot cities for this service mode chinas integrated health and social care system for older people is rapidly developing in three primary ways expanding existing institutions this consists of two subtypes the first of which involves adding health care to aged care units the second subtype involves adding aged care to health care units joint operation this is based on the framework of cooperation agreements signed by health and social care units in this way health care providers regularly deliver healthrelated services such as common disease screening and diagnosis chronic disease management etc holistic homeand communitybased care this delivers family doctortype services such as establishing sickbeds in home settings and primary care staff providing home visits to older people in need in addition to changes in policies and practices chinese research has been enhanced by the international concept of integrated care since the first piece of chinese academic literature with the theme of yiyang jiehe was published in 2005 8 related research has developed rapidly in china some bibliometric analyses employing citespace showed that since 2004 there has been a steep growth in the amount of research on integrated health and social care for older people in china 9 however most studies have focused on expounding the theoretical basis of the integrated service delivery models 10 analyzing and evaluating supply and demand 11 or proposing optimization mechanisms for theoretical operation 12 chinese academic research on the integration of health care and social care for older people was intended to extend beyond macrolevel theoretical analysis and begin to search for empirical evidence and practical solutions at the meso and micro levels furthermore there has been a striking lack of analysis and evaluation of the system performance of this emerging service delivery mode through the lens of older people as service recipients especially based on evidence from china the perspective of service recipients should be valued more highly in integrated care for older people focusing on the following two aspects first the older adults individual experiences form a core value of personcenteredness in care 13 the client experience data could play a key role not only in evaluating the overall performance of the integrated care system but also in improving service quality and accountability and redesigning care delivery 14 15 16 second the nature of public services and the increasing consensus on coproduction in integrated health and social care programs calls for involving clients in the design and monitoring of services 1718 research on customervalue orientation and the qualityofcare orientation have different definitions of the client experience but they all focus on service recipients subjective feelings and judgments during and after the journey through the care service system 19 although health care does have many particularities it is after all a service 2021 several recent studies have integrated these two approaches to form a conceptual framework of the older adults experience which contends that an individual becomes a patient at the onset of disease and a service user or customer in the first contactinteraction with health care services 21 quantitative research continues to predominate in the field of the client experience of integrated aged care especially in china these studies have mainly adopted crosssectional study design and satisfaction instruments to evaluate older individuals experience of health care services lacking dynamic consideration of service processes and recipients psychological changes across the continuum of care therefore the current study employed a qualitative methodology to gain an indepth understanding of the experiences of institutional older people during the whole process of receiving integrated care services the analysis explores the influencing factors and mechanism of the client experience of older adults in the context of china in order to put forward suggestions for the improvement of a highquality aged care service system materials and methods this research was designed to explore the influencing factors and mechanism of the service experience of integrated health and social care for older people based on the qualitative method of grounded theory this method searches for the core concepts reflecting social phenomena in the systematic collection of data and then constructs theories from the bottom up through exploring the connections among these concepts 22 compared with other qualitative methods emphasizing description grounded theory pays more attention to the construction of theories 23 sample selection the study sample was taken from institutions delivering integrated health and social care to older people in changsha city hunan province china hunan is one of the most aging provinces in china in 2000 hunan formally became an aging society and since then the aging rate has accelerated in 2020 148 of the total population in hunan province were older people aged 65 and over an increase of 504 and 737 respectively compared with 2010 and 2000 as the provincial capital city of hunan changsha was selected as one of the initial national pilot cities of integrated care for older people in 2016 and has made remarkable achievements in the expanding existing institutions mode of health and social care integration in the list submitted to the central government in 2022 for the election of nationallevel demonstration institutions of integrated health and social care for older people the changsha region accounted for five out of nineteen institutions in hunan in accordance with the principle of theoretical sampling advocated by the grounded theory method 2425 from june 2019 to february 2020 we conducted a twostep survey in changsha first based on a review of the literature and visits to health and civil affairs departments in hunan province and changsha city we determined a sampling frame and selected six institutions in which to carry out the survey as there are three main types of integrated care institutions for older people in china nursing home assisted living community and residential care facility 26 the institutions were selected based on their types at first in the meantime the chosen institutions indicated a willingness to participate along with diversity and a reputation for delivering integrated health and social care during this process we combined stratified sampling and snowball sampling considering regional distribution institutional categories and data availability for instance when a nursing home was chosen and the investigation was completed it was required to recommend another integrated aged care facility of the same type the recommended institution was supposed to be geographically separated from the previously completed sample the research team continually examined the theoretical saturation of data in the subsequent interviews after two rounds of sampling the theoretical saturation was found to be reached when six institutions were investigated second we employed random sampling and snowball sampling to recruit suitable older individuals among these institutions residents the inclusion criteria were as follows ≥60 years old no significant hearing or vision impairment basic cognitive ability and communication ability to participate in indepth interviews having used at least one type of integrated health and social service in the sampled institutions for more than one month a total of twenty older adults from the six sampled institutions across two institutional settings formed the final sample the number of samples was determined according to the principle of theoretical saturation where sampling continues until the new sample no longer provides new information data collection in this study facetoface indepth interviews were used to collect data the interviewers were five senior postgraduate students under the supervision of a professor in social medicine and health care management the research team had received training in grounded theory and communication skills according to the requirements of grounded theory the interviewers did not begin with a fixed strict and unified outline the five interviewers independently conducted the interviews without any interferences or presets during the interviews they did not interrupt the speech of older residents and avoided inducing behaviors therefore the data collection process consisted of two phases the first one was a smallscale preliminary interview mainly inquiring about the most urgent needs of older people their feelings about the health and social care services delivered by the institutions and their satisfaction with the national support policies for older people the feedback from this phase was used to determine whether the scope of the existing interview questions needed to be widened or if a new group of interviewees in other institutional settings needed to be involved thus in the second phase a detailed investigation of the older individuals family situation economic conditions social status mental health and interpersonal communication was added to the interview to ensure interviewees right to know the details of the data collection after obtaining informed consent from the participants the interviewers clearly informed each interviewee of the purpose and significance of the interview and of the use and protection methods of the data in addition the study also adhered to the voluntary principle of participation each staff member was interviewed for approximately 30 min and had received permission from their supervisors their supervisors did not intervene or interrupt while the staff member was being interviewed the names of the interviewees and institutions were saved in the form of codes to avoid interviewees making any unnecessary presuppositions the interviewers only played the role of explaining the theme and deepening exploration of the topic during the process interviewees were allowed to express their opinions as much as possible until they ran out of content to discuss each interview lasted for approximately 3060 min depending on the individual situation each interview was recorded to ensure that no information was omitted the recordings were transcribed into text form within two days with one researcher transcribing the data and another checking the transcription when inconsistent results occurred during the transcription process communicative validation was performed according to the following three principles coding the inconsistent results separately and then discussing them together making judgments based on opinions of a third person when there is a conflict of views referring to the literature all the information was synthesized into a verbatim manuscript of more than 70000 words one researcher interpreted the meaning of the data through constant comparisons gradually reducing transforming and abstracting the original data into higherlevel concepts and categories and proposing a conceptual framework through indepth analysis of the nature characteristics and relations of the categories in the entire process the data were compared summarized and deduced in a circular manner to form a theory that conforms to the original materials the research team agreed upon the interpretation of the results reliability and validity credibility and dependability have been used to describe various aspects of trustworthiness in qualitative content research 27 we believe that in addition to the elaboration of clients perspectives practitioners perspectives should also be explored therefore in order to ensure the credibility of the collected data an interview was conducted with a staff member randomly selected from each sampled institution who has close contact with older individuals and directly participates in the service delivery the encoding reliability test method advocated by huberman and miles was adopted in this study and the scientific reliability of the encoding results was confirmed through analysis of the coding consistency percentages of two independent coders 28 the specific process involved randomly selecting two copies of the verbatim transcripts another coder recoding them according to the coding scheme comparing the two coding results and calculating the number of mutual agreements and disagreements between the two coders through this calculation the reliability was found to be 9053 and the internal consistency was 9462 indicating that all the coding had good reliability furthermore the research team invited two professors of social medicine and health management and two care managers at the integrated aged care institutions to evaluate the degree of consistency between the results and the actual situation their positive feedback verified the high validity of the research results data analysis and processing we used nvivo 110 to perform auxiliary coding and analysis given the interviewees linguistic expression conventions and the format of the data structure sometimes multiple lines of data were needed to express a complete concept or category 29 therefore this study did not strictly adhere to the principle of linebyline coding required by grounded theory 30 rather wordbyword coding sentencebysentence coding linebyline coding and paragraphbyparagraph coding were used comprehensively to code the interview data according to the threelevel coding method of grounded theory proposed by strauss and corbin 31 to start the data analysis first we applied concept naming to all the original material then we merged similar concepts establishing the ascription between phenomenon and categories some ambiguous or overlapping concepts had to be repeatedly compared and analyzed to complete the categorization next we discovered and established logical connections between the categories by categorizing and analyzing the scattered data and integrating them again selective coding is the final step which organizes the data and discovers the core category by describing the storyline of the phenomenon 32 results information regarding sociodemographic data of the participants a total of twenty older adults from the six sampled institutions across three institutional settings formed the final sample as shown in table 1 the average age of older adults living in institutions is 797 years old among which the proportion of females is much higher than that of males and the educational level is concentrated in those with a high school education or below in addition through interviews we learned that the aged care service institutions in changsha set tiered charging standards generally based on the physical conditions of older adults the basic service fees of public aged care service institutions are managed by the government with a guided price ranging from cny 2000 to 5000 while the fees of other institutions are slightly higher mostly more than cny 3000 the monthly income of most older people is less than cny 3000 which makes it difficult for them to fully cover the cost of institutionalization and the difference is mostly paid by family members as shown in table 2 most of the staff members are female and older most of them come from rural areas with a low educational level and they also lack vocational nursing skills training the form of employment is mostly in the form of temporary and contract workers so the wages are relatively low mostly concentrated around cny 3000 information regarding analysis based on the qualitative method of grounded theory through the process of developing the concept and refining the categories by open coding we obtained a final total of 28 categories based on which spindle coding was performed by integrating the scattered data again and identifying the logical connection between the categories a total of three main categories and seven subcategories were summarized the specific coding rules for the interview records are shown in table 4 analysis dimension influencing factor example of reference points scene construction social foundation institutional functions we are currently in a state of loss and there is no profit but the headquarters will provide some subsidies the ministry of civil affairs provide subsidies based on the number of bedstens of yuan per month which are limited we cooperated with the community health center in this activity it was supposed to be a promotion of family doctors practice in the home setting however the community health center is a little far away from the community and the doctors do not have so much time to go doortodoor for physical examinations so it is very difficult to provide oncall services we changed it to a different form the doctors offered free consultations in the community at a fixed time each week individual minds perception and emotion cognition and understanding the support worker who just came in has the worst attitude she has only been here for a few days with a particularly bad attitude and she steals things after i took traditional chinese medicine during the day i went to the washroom more often so she became impatient the night shift support worker has a better attitude and has worked for several years she boils traditional chinese medicine for me it is good to eat traditional chinese medicine which can get to the root cause of disease the body will detoxify if you urinate more i am 91 years old what kind of service do i still need i only blame myself for living too long why live so long sigh interaction and communication intimacy and trust participation look this is the wechat group called yf old baby and the medical staff are also in this group my eyes are not good now i used to watch the wechat group a lot but now i dare not be so presumptuous i can only look at it for a while and take a break and sometimes i do not look at it for a few days my mobile phone is an old one so i use the tablet for wechat the overhaul began in may last year we moved again and again from the 19th floor to the 17th floor the 17th floor to the current 20th floor and the 20th floor back to the 17th floor she later asked for everyones opinion and said you old people dont want to move just live here and dont move ill just stay here and not moving its too tiring to move around thats regular probably in every month or two they send us forms and let us fill in our opinions relatively satisfied notes the number of nodes refers to the number of occurrences in the reference node during the encoding process coding rules of interview records for the sake of respecting the wishes of interviewees the names of all interviewees are hidden and replaced by a combination of english letters and numbers the capital letters indicate interview location and the lowercase letters denote respondent category where a represents older individual b represents staff member and the number represents the serial number of respondents in our study influencing factors of the client experience of integrated health and social care for older people was defined as the core category which is composed of three main categories scene construction individual cognition and interactive communication thus the related storyline can be summarized as follows the client experience of integrated health and social care for older people is mainly affected by scene construction individual minds and interaction and communication according to the storyline the typical relationship of the factors affecting the client experience of integrated aged care for old people in china was initially constructed based on the detected relationships among categories we constructed a model of the influencing factors and mechanism of the client experience of integrated aged care as shown in figure 1 the model includes three dimensions scene construction individual minds and interaction and communicationand six factors among which there are six influencing paths influencing path 1 institutional functions → client experience the nature and scale of institutions to a certain extent determine the object scope and level of the services provided the governmentled public aged care institutions are generally favored by older chinese due to their low fees and good reputation but the amount of beds is rather limited some older people who cannot find a provider are prioritized for admission as stipulated by the government meaning that such institutions are often oversubscribed in china many older people have to turn to private institutions some of which struggle to carry out diversified service projects due to limited capital and space however such institutions tend to look for other ways to compensate for the deficiencies caused by insufficient service supply such as enhancing brand characteristics in influencing path 1 institutional functions → client experience the nature and scale of institutions to a certain extent determine the object scope and level of the services provided the governmentled public aged care institutions are generally favored by older chinese due to their low fees and good reputation but the amount of beds is rather limited some older people who cannot find a provider are prioritized for admission as stipulated by the government meaning that such institutions are often oversubscribed in china many older people have to turn to private institutions some of which struggle to carry out diversified service projects due to limited capital and space however such institutions tend to look for other ways to compensate for the deficiencies caused by insufficient service supply such as enhancing brand characteristics in the facility environment or entertainment activities it is worth noting that the living environment has become an important factor influencing the client experience of older individuals from the traditional client perspective 3334 institutions which allow older people to decorate their rooms according to their own wishes and create a warm environment similar to home have been found to result in a more positive client experience than institutions that smell of disinfectant like a hospital for example an involved older adult said they didnt let me put pictures on the wall or table saying it was unsafe my husband has passed away this is a group photo of us and i would like to watch it many times every day influencing path 2 social foundation → institutional functions → client experience the social foundation includes the allround support of the economy politics and culture it directly promotes the development of integrated health and social care for older people but it has a more indirect impact on older adults experience mainly through improving the service delivery of integrated health and social care 35 systemic flaws may hinder the promotion of policy the ministry of civil affairs as the administrative department in charge of nursing homes and other aged care institutions faces difficulties in effectively coordinating with other departments in charge of the health care system such as the health ministry and the national medical insurance bureau which have caused some policies to be implemented inadequately moreover the aged care service is only a part of the civil affairs in the case of limited resources there are differences in the degree of policy support enjoyed by integrated aged care institutions of a different nature and size not implemented it is just not implemented by the lowlevel governments there is an example for people over 80 years old their pensions are tens of yuan the money in the last quarter has to be paid in the next quarter what is the trick look its like a game the money in december has not arrived yet it will not arrive until february what do you think the trick this is what can i do the government is just like this do you think the leader is aware of this does he know nobody tells him influencing path 3 social foundation → cognition and understanding → client experience the social context is a part of the cognition system and cannot exist independently of cognitive activities compared with the macro context of the institutional system and financial investment older people pay more attention to media reports and public evaluation things they can access on integrated health and social care diversified modes of news communication are widely favored by older people which to a large extent meet their requirements for leisure entertainment and daily communication convenience the interpretation of integrated care policies by the media and the reports of related events could shape and affect their cognition particularly if some biased news reports and comments mislead them the older people bring their fragmented cognition into the service process and compare the reality with their subjective understanding they become constructors of information and influence the groups experience or satisfaction through their relationship network for example one older adult stated you can see on the mobile phone that the babysitter steals things and abuses the older people all day long many children dont know about it and they have to install monitors to find it there is no filial son in front of the bed after a long illness if your own children are unwilling to serve you how can they be sincere to you influencing path 4 perception and emotion → client experience older adults experience of integrated health and social care is related to their inner perception and emotionthe two factors have been proven to be more inseparable than is commonly assumed 36 before and after being enrolled in the service system as services are not as visible and easy to standardize as goods at present chinas integrated health and social care for older people is still in the exploration phase and there is uneven development among the various institutions institutions that pay more attention to relatively observable attributes of service which positively or negatively affect older adults perception and judgment of service quality 3337 and emotion receive significantly better client experience evaluations some participants recounted that we can accept the bad living conditions but the staff must be good to us which is the most important thing service belongs to nonphysical configuration while living conditions belong to physical configuration if there is only physical configuration and no nonphysical configuration the residence will not be interesting some old people want to go home and their children take them back once a month well i am alone i cannot move or go home now and everything is taken care of by them their services basically cover all aspects of my life but sometimes i feel really lonely influencing path 5 intimacy and trust → client experience the client experience of integrated health and social care for older people takes services or service behaviors as the carriers and is jointly manifested through the interaction between service providers and recipients it is worth noting that although interaction between staff and clients has been widely recognized as one of the key factors contributing to the client experience 38 we found slight differences in the way staff interact with older people at different stages generally older people will have a period of adaptation after they have just settled in at an integrated aged care institution during this period staff need to focus on psychological comfort and debugging for older people to help them adapt to their new lives as soon as possible at this time the interaction is more oneway consisting of staff output once the older people have gone through the period of adaptation they might receive less attention from staff due to the limited numbers and heavy workload of staff members older people will actively seek to interact with the staff and older people around them and make the interaction a twoway process of service information feedback and communication when this interaction results in an intimate interpersonal relationship the services delivered by the staff and institution will be more likely to gain credibility in addition to forms of interaction such as cobuilding wechat groups with medical personnel the personal characteristics of managers their leadership style management philosophy and understanding of policies will also exert an influence on the experience of older people the interviews showed that most managers of aged care institutions know better than their peers in other industries to remain humble and charismatic in interactions with seniors this not only affects older peoples sense of intimacy and trust but also affects the attitude and behaviors of staff 39 for example an interviewee noted the following monitor peng is a real warmhearted man he is the labor chief and a veteran party member those surrounding communities rely on him the most the communities are engaged in garbage sorting these days and he is on duty at 7 oclock every morning young people cant do it 326 influencing path 6 participation → perception and emotion → client experience most studies have shown that customer participation in service production is conducive to creating happy experiences and meeting their personalized needs 40 more often the interactions between older people and service providers are aimed at emotional communication rather than satisfying service demand even if the problem that may cause a negative experience is not eventually solved as long as the older people feel engaged in the quality improvement process based on their feedback their experience satisfaction and even loyalty could be enhanced 41 participation may provide older people with selfconfidence a sense of belonging and being respected pleasure psychological comfort etc which may also lead to a positive client experience one interviewee mentioned last time i said that the food was too bland and tasteless she told me that she did not dare to make it too salty relatively mildflavored food is good for your health and you should take care of the taste of most seniors she told me that and i understood she said that she could cook me some slightly more flavorful meals alone but i would definitely not accept it it will undoubtedly increase the workload of others after all i am not living in my own home and there are so many older people living here discussion aims at understanding the experience of older people during the whole process of receiving residential integrated care services and making policy proposals this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the chinese context overall we found that the vast majority of older people were satisfied with their experience of integrated health and social care even some smallscale institutions with limited health care facilities also received high praise from older people because such institutions tend to make improvements to the nonphysical aspect of care delivery to compensate for shortcomings in the physical aspect this study identified six factors in three dimensions affecting the client experience of integrated health and social care for older people and revealed how they function in the chinese context the results are consistent with the research of jiunsheng chris lin et al and generally cover the seven topics of service experience they summarized customeremployee emotion service employee management service environment customer participation selfservice technologies service failurerecovery and customer loyalty management 42 in addition one of the few similar qualitative studies published in chinese academic journals argues that there are four themes influencing older adults experience of integrated care policy manpower nursing care delivery and medical insurance qualification 43 in the field of service users satisfaction and experience of aged care more quantitative research has been conducted whose conclusions focus on the factors causing heterogeneity in older individuals and service providers paying less attention to the situational factors at the level of policy economy culture etc 44 this study differs from existing studies in that its findings not only cover the heterogeneity of both sides of the service but also take into account situational factors with chinese characteristics dimension of scene construction this research shows that the selfreported experience of institutional integrated health and social care for older people is grounded in the scene construction of care delivery there are numerous critical factors in institutional characteristics such as size location level service content etc which all influence residents experience 45 studies have validated that the level of care facilities and the service quality of caregivers are important factors affecting client experience 46 in addition previous studies have argued that mitigating physical and spatial constraints and offering immersion into the desired environment and situation could contribute substantially to the health and experience of older residents in institutions 47 similarly the current study showed that the internal layout and decor of institutions matters to older people providing older people with a certain degree of permission to decorate their rooms at will bringing comfort and familiarity to their living environment could result in a positive client experience for older residents in integrated care institutions we also discovered that chinas social foundationincluding factors of political and economic support atmosphere of public opinion and contradictions existing in the structure of the implementation systemindirectly impact the client experience of integrated health and social care for older people through institutional functions such as the scale of institutions layout of the living environment service content and brand image in the chinese context the functions of integrated care institutions are shaped by medical and longterm care insurance policies landuse planning etc studies in china have likewise confirmed the causal relationship between policies and service quality of institutional care 48 preferential policies according to local conditions reform of the medical and health services system and encouragement of nongovernmental sector engagement contribute to enhancing the service content which in turn affects the institutional functions 49 moreover the publics belief in institutional aged care also has an indirect influence on the client experience of integrated health and social care for older people public institutions of integrated care are often the first choice for older adults and their families who are considering institutional care in china because the public generally believe that they deliver higherquality and safer health care however although these institutions have relatively sufficient and stable sources of funds they must accept a certain proportion of older adults who are widowed and childless as stipulated by the government during the economic downturn and pandemic this has indeed guaranteed a source of stable income but the governmental funds are far from enough to cover all the costs for those older adults as a result institutions intend to balance this by accepting more selfpaid older people which may lead to a decline in the resources available to each older individual and result in negative experiences dimension of interaction and communication consistent with the existing studies we also found that the service encounters between older adults and staff are crucial to the evaluation of service experience across the care continuum 50 older adults form a judgment of whether the service providers are trustworthy and close enough to them based on the attitudes and behaviors of the staff at each moment of interaction and they construct part of the client experience on this basis they acquire information and support from staff through trusting and continuous relationships as facchinetti et al concluded 51 in addition older adults will also take the rate and nature of interaction with staff as important indicators in the evaluation of client experience under the condition of relatively limited care capacity most older people are eager to receive as much attention as possible from service providers this attention may be expected to provide timely solutions to problems reported by service users as evidence of their participation in the process of improving the quality of care on the other hand inadequate participation demand and ability of older adults may hinder the staffresident interaction in the institutional setting from the perspective of staff they prefer to interact more with residents with a higher degree of mental functioning rather than with residents with a lesser degree of mental functioning 52 dimension of individual minds cognition is constructed on a social foundation this study discovered that the client experience of older people is influenced by cognition and understanding based on a social foundation for example the social evaluation of aged care institutions influences the choice of institutions for older people some previous studies have suggested that private nursing homes tend to be more popular with older chinese people because of their better social reputation evaluation and publicity than their public counterparts 53 however our research shows that public care institutions are the first choice for older chinese people and their families in need of integrated care our interpretation of this difference is that when it comes to integrated care for older people the key to the experience and outcome of service delivery lies in the capability of medical sectors and their connections with nonmedical aged care sectors in china publicfunded medical sectors are generally considered to be technologically capable in leading to better integrated care delivery processes and outcomes nevertheless our findings are consistent with the existing literature in that the social foundation can indirectly impact the selfreported experience of aged care by influencing the cognition and understanding of service recipients this study also confirms that the perception and emotion of older people have a direct effect on client experience older peoples perception of services is influenced by their physical health education level socioeconomic status and emotions 5455 an interesting phenomenon we observed is that due to emotional factors older people usually hope that staff members specifically care assistants care more about them than they do about the other seniors once they notice that the staff take special care in catering to the needs of certain individuals they might feel that their rights and interests are being neglected the resulting sense of unfairness would not only lead to adverse effects on their health 5657 but also cause complaints about the staff this irrational factor could be moderated by objective predictors such as physical health education level and ses which are often positively correlated with the service experience of older people on this basis our study verifies that participation of older people can influence the client experience indirectly by affecting their perceptions and emotions the participatory model that emphasizes collaboration and partnership can lead to changes in the balance of power between staff and clients 58 this balance makes older people feel valued and enhances the client satisfaction this observation might help explain the consistent findings that higher client engagement tends to result in a better client experience 59 and improved service quality 60 limitations and recommendations despite its strengths in initially addressing the factors and mechanism of institutional integrated care experience among older people in china this study has limitations in the following two aspects first the diversified and personalized service needs of older people with different health conditions are supposed to affect the client experience of integrated health and social care but this study only involved older people with clear cognition and expression failing to examine the differences in the client experience between physically or mentally disabled older people and other older people second this study employed a constructivist approach and the proposed theoretical model requires further empirical evidence the next step is to test the fitness of the model among older adults in china and beyond through the development of quantitative tools and structural equation modeling conclusions differing from the quantitative research prevalent in the extant literature on the client experience 61 this study used grounded theory to conduct an indepth exploration of the factors of client experience of residential integrated health and social care for older people in china so as to understand the experiences of older residents during the whole process of receiving integrated care services the research constructed an innovative theoretical framework of client experience of integrated health and social care for older people including dimensions of scene construction individual minds and interaction and communication specifically perception and emotion institutional functions and intimacy and trust have direct effects on the client experience of integrated health and social care for older people while social foundation and participation have indirect effects this work broadens the scope and depth of research on client experience and satisfaction to a certain extent and provides new insights into the mediating effects in client experience of integrated aged care for future quantitative studies with the above factors this study proposes an optimization plan for the improvement of a highquality aged care service system to provide a comprehensive reference for government departments and integrated aged care institutions first as the related resources and policies of integrated health and social care for older people are still fragmented and scattered among departments of civil affairs medical insurance and health care etc chinas government needs to put more effort into reducing the crossdepartmental cooperation resistance caused by uneven interest distribution and making the service delivery smoother and more seamless second the government departments should scientifically arrange the location space and facilities of integrated aged care institutions matching the actual needs of older adults by consulting and collaborating with the institutions institutions and practitioners are supposed to be more concerned about the selfreported experience of older residents and accurately identify their service needs to strengthen the personcenteredness of the delivered services finally as clients and coproducers it is necessary for older adults to participate in the policy formulation and analysis instrument development and validation and other aspects in improving the quality of institutional integrated care this however requires more authoritative institutional arrangements to guarantee data availability statement the datasets generated and analyzed during the current study are not publicly available to protect the participants confidentiality however they are available from the corresponding author on reasonable request supplementary materials the following supporting information can be downloaded at file s1 interview outlines author institutional review board statement this study complies with nationalinternationalinstitutional guidelines and the declaration of helsinki all experimental protocols have been approved by the clinical medical ethics committee of xiangya hospital central south university all data were collected on the basis of informed consent and privacy protection and did not involve coercion or inducement all respondents agreed to the followup use and publication of the interview materials informed consent statement informed consent was obtained from all subjects involved in the study

background an emerging service delivery model of integrating health and social care for older people has been actively promoted by the chinese government since 2016 but the client experience and influencing mechanism still remain unclear methods this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the chinese context so as to understand the experiences of older residents during the whole process of receiving integrated care services and on this basis put forward suggestions for the improvement of a highquality aged care service system we coded and analyzed the indepth interview data of twenty older adults and six staff members from june 2019 to february 2020 recruited from six institutions in changsha one of the ninety pilot cities for integrated health and social care in china results the findings showed that the client experience of older adults is mainly affected by factors in three dimensions scene construction individual minds and interaction and communication which are comprised of six subcategories social foundation institutional functions perception and emotion cognition and understanding intimacy and trust and participation based on the factors and mechanism consisting of six influencing paths we constructed a model of the client experience of integrated health and social care for older people in the chinese population conclusions the factors and mechanism influencing the client experience of integrated health and social care for older people are complex and multifaceted attention should be paid to the direct effects of perception and emotion institutional functions intimacy and trust in the client experience and the indirect effects of social foundation and participation on the client experience

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introduction virtual social networks are bases or a set of bases that provide facilities so that users can share their interests thoughts and activities with others and others can share these thoughts and activities with them the emergence and development of virtual social networks which generally happened in the last decade has caused great changes in human societies and has changed many social cultural economic and political structures naturally such transformations and changes have created new social personal moral and cultural issues that did not exist in the era before the emergence and development of virtual social networks the use of virtual social networks especially in the case of teenagers who generally do not have much media literacy can have unfortunate consequences teenagers generally entered these virtual social networks and started using them emotionally and without considering the rational notions of media consumption it is certain adolescents have not yet achieved a clear understanding and experience of the type of relationships and communications that exist in this space and they do not feel the contradictions in a real way the problem becomes more prominent when the target community is teenagers who basically do not know much about social networks and the internet and their media literacy is very weak for this reason teenagers have a great capacity for social vulnerability and may experience various injuries at any moment they do not have much experience in this field and for this reason the social harms experienced by them may be accumulated and finally we will face a detailed set of social harms in teenagers due to the use of the internet on the other hand more uptodate and more skill of teenagers has made them a pioneer in using new media capabilities among teenagers virtual social networks are their main communication method to maintain friendly family and academic relationships and partnerships based on this more damage will definitely be done to this group of people in the society so that excessive use of the internet and staying in these virtual networks is considered an addiction which can lead to severe psychological and social harm facing teenagers with moralsocial maturity makes them more exposed to premature puberty and identity crisis this problem is so much that some social theorists refer to it as internet addiction accordingly teenagers are influenced by this environment in fact virtual space is also one of the surrounding environments of teenagers that teenagers are involved with this issue has been different in the traditional and premetaphorical situation in this situation teenagers were most influenced by family school and friends and their socialization process was done by these social groups but today and in the era of virtual social networks these network spaces are responsible for the socialization of teenagers and due to the cultural social religious moral etc differences that exist in these networks teenagers may enter paths contrary to the cultural paths of iranian society besides that the experience of freedom without control in virtual social networks by teenagers has exposed them to all kinds of social and cultural harms in any case the social environment around teenagers plays a significant role in their lives and now with the changes that have occurred due to the emergence and expansion of virtual social networks this social environment has changed which causes numerous injuries and social issues have occurred in iranian teenagers these social harms include many things that can be called fraud and internet crimes internet pornography virtual love and emotional conflict of teenagers with virtual illusions violence and aggression and its generalization to the real world anyway these social harms are not only limited to teenagers and the space of virtual social networks but involve the whole society such damages may become widespread to the extent that they question the benefits of virtual space and virtual social networks therefore it is important to recognize these social harms and provide solutions for the proper use of these virtual social networks and the results can provide a suitable platform for better use of these networks and reduce concerns about it based on this the current research seeks to investigate the social harms caused by the presence of teenagers in virtual social networks in different areas and to provide solutions to control these social harms teenagers are of fundamental importance because they are the generation that shaped the future of the country and the development of society in all areas depends on them beside this importance there are behavioral patterns and cultural and social values of the iranian society questioning them and systematically weakening these patterns can lead to unfortunate consequences adolescents may have less stability in maintaining social values and behavioral patterns of iranian society due to emotional and irrational conflicts with various issues it is clear that questioning and deconstructing these behavioral and value patterns by teenagers has endangered their future social personality and may endanger the iranian society in the future this issue does not mean that values and behavioral patterns do not change rather these values and patterns may change over time but they have a fixed and specific core around which the changes revolve questioning this core without logical alternatives in line with iranian culture can have unfortunate consequences for iranian society many researches have been conducted on the way teenagers use the internet and virtual social networks and its positive and negative consequences but not much study has been done on the methods of controlling the consequences of these virtual social networks for teenagers in the context of media influences katz et al developed the uses and gratifications theory and concluded that audience satisfaction can come from three sources media exposure media content and social context that categorizes exposure to different media rosengren et al proposed a more developed model of the use and gratification pattern in his opinion some basic high and low level human needs in interaction with distinct sets of intrapersonal and extrapersonal characteristics and also in interaction with the structure of the surrounding society including the structure of the media and various sets of individual problems lead to a set of problems and solutions this causes various motivations to find satisfaction or problemsolving behavior and this leads to the emergence of different patterns of real media consumption and different patterns of other behavior which leads to the emergence of patterns of satisfaction or dissatisfaction and probably to the totality of the characteristics within and the extroversion of the person and ultimately affects the media structure and other social political cultural and economic structures in the society uses and gratifications theory seeks to explain how people use mass communication tools to satisfy their needs and the motivations of these people in using the media the cultivation theory also provides a model for analyzing the impact of communication media with three assumptions first that there is a possibility of influencing specific and individual types or genres and media programs on people but measuring this effect is very difficult the pervasive effect of communication media especially television happens in the long term therefore it is important to focus on the media world as a whole and on the stories messages and images that are broadcasted repeatedly second media influence is generally symbolic rather than behavioral thirdly the influence of the media is more towards maintaining the existing social and ideological order in a general view cultivation theory believed that those who are exposed to mass media will eventually see the world in a way that is more than conforming to the external reality by making the media out of reality in response to criticism gerbner revised the cultivation theory he added two other concepts of generalization and intensification with these concepts the fact that watching too much tv has different results for different social groups is considered gerbner states that normalization occurs when excessive viewing leads to the symmetry of viewpoints in groups intensification also happens when the effect of cultivation is greater in a certain group of the population many researches have been conducted on the way teenagers use the internet and virtual social networks and its positive and negative consequences but not much study has been done on the methods of controlling the consequences of these virtual social networks for teenagers based on this the present study was conducted with the aim of modeling the social harms of teenagers in virtual social networks material and methods the current research is a quantitative study that was conducted with the correlation method the statistical population included all specialists in the field of communication and modern communication media accessible sampling was used to select the sample participants were 154 people that 83 were men and 71 were women in terms of educational level 571 had masters degree and 429 had phd degree structural equation modeling was used to examine the research model for this purpose the partial least squares method in pls software was used the data collection tool was a researchermade questionnaire that was developed in a qualitative process this questionnaire has 33 questions with a fivepoint likert response scale from very low to very high questionnaire dimensions were mental and psychological injuries weakening of social values violation of sexual norms moral injuries and change of behavioral patterns index reliability by two criteria cronbachs alpha and combined reliability and convergent validity by average variance extracted and factor loadings and divergent validity are measured by the root mean value of the extracted variance of the variables cronbachs alpha values for all dimensions are greater than 07 and it indicates acceptable reliability also in table 1 the values of all average variance extracted are greater than 05 and as a result the questionnaire presented in current study has good convergent validity results the results of the firstorder and secondorder confirmatory factor analysis to estimate the factor loadings of the dimensions and items of the online social harms model were provided in table 2 the estimated values in table 2 indicate that the factor loadings related to the dimensions and items of the online social harms model are in a favorable condition in fact the correlation of this construct with the dimensions and items are estimated at a high level so the convergent validity related to the dimensions of this variable is established at the level of the items according to table 2 the factor loadings of the dimensions of model of online social harms in a hierarchical manner are also satisfactory one of the methods used to measure discriminant validity is the cross loadings method according to cross loadings a particular item should have higher loadings on its own parent construct in comparison to other constructs in the study based on the output of the software which can be seen in table 3 the correlation value between the indicators and their related structures is higher than the correlation between them and other structures which proves the appropriate discriminant validity of the model in other words the root mean value of the extracted variance of the variables in the present study which are located in the main diameter of the matrix is greater than the correlation value between them which are arranged in the lower slots of the main diameter as a result the model has the appropriate fit status the estimated values related to the fornell and larcker criteria and the different traitsame trait index are reported in the table 4 it should be mentioned that based on fornell and larcker criteria it is expected that the mean square root of the variance extracted for each construct is higher than the correlation of that construct with other constructs regarding the index of different characteristic same characteristic it is expected that the geometric mean of the correlation coefficients between the items that are related to different structures is lower than the geometric mean of the correlation coefficients between the items that are related to the same structure therefore the ratio between different characteristics the same characteristic should be smaller than 1 discussion the findings of the research showed that the average of all research variables or in other words the components and elements of the research paradigm model including among the statistical sample of the research is estimated to be above average the emergence of virtual social networks in addition to the positive consequences they have had for various societies have also left negative effects on various parts of human societies different social groups have different reactions to these new social networks and as a result they experience different consequences adolescents are one of these social groups that are profoundly influenced by virtual social networks they have lived and grown up with these virtual social networks in a way these teenagers can be considered the internet generation therefore it is not possible to prohibit teenagers from participating in these virtual social networks in a negative way but appropriate policies should be made in this field in order to control and manage the social harms experienced by these adolescents in any case teenagers experience harm as a result of being in these virtual social networks and there is no escape from it such damages can only be reduced and its consequences managed the results of this research are about the weakening of social values due to the use of social networks as a social harm among teenagers this result is in line with the theoretical approach of gerbner cultivation theory gerbner believed that cultivation is not a unidirectional process but is similar to an attraction process according to gerbner the media is the creator of the symbolic environment media is not a window to the world or a reflection of it but a world in itself cultivation theory argues that communication media have longterm effects gradual and indirect but dense and important effects they emphasize that media consumption has more attitudinal than behavioral effects high consumption of media is seen as establishing attitudes that are more compatible with the world depicted by media content than with the real world however the results of this research are in line with another part of the theory that believes that the mass media cultivate the attitudes and values that already exist in the culture and help to preserve and spread these values among the members of a society the results of the present study showed that virtual social networks help to change these patterns more than they help to maintain existing values and behavior patterns also the findings of this part of the research are in line with the research results of memon et al they have come to the conclusion that social networking leads to increased exposure to and engagement in selfharm behavior due to users receiving negative messages promoting selfharm emulating selfinjurious behavior of others and adopting selfharm practices from shared videos another part of change of social values in teenagers due to the use of virtual social networks is the change of family values which the results of the present study showed this result is in line with the research of christopherson by examining teenagers he has come to the conclusion that the variables of feeling anonymous on the internet and the amount of internet use have a negative effect on family values also the level of acceptance in the internet has had a negative effect on family values in addition the more we enter the space of intimacy on the internet this space of intimacy on the internet will cause family values to decrease and this is probably due to the substitution of the internet environment for them instead of the family the review of previous studies shows that such a pattern did not exist in previous studies and researches and most of the researches dealt with the injuries experienced by teenagers and young people in virtual social networks and the effect of various factors and the consequences of this issue in the previous lines the results of these studies should be examined in detail with the results of the present study conflict of interest the authors state no conflict of interest in the study

the current research was conducted with the aim of identifying and presenting a control model of social harms of teenagers in the use of virtual social networks the research method was of a mixed method type which was operationalized and implemented in two qualitative and quantitative parts the research method in the descriptive quantitative phase was a survey type and the statistical population included all specialists in the field of communication and modern communication media who were selected to participate in the research the data collection tool in the quantitative part was a researchermade questionnaire taken from the qualitative phase the data were analyzed in the quantitative phase using the software package for social sciences and smart pls the findings of the research showed that the convergent and discriminant validity indicators indicate the desirability of the validity of the variables and the values of cronbachs alpha coefficient and composite reliability indicated the accuracy of measuring the dimensions of all the variables the estimated values factor loading critical values and significance level indicated that the factor loadings related to the dimensions and items of all variables are in a favorable condition in fact the correlation of the variables with the dimensions and items related to these dimensions was high so the convergent validity related to the dimensions of the variables at the level of the items is established according to the results the research model included the dimensions of mental and emotional injuries weakening of social values violation of sexual norms moral injuries and changing behavioral patterns the findings provide useful implications in the control and prevention of cyberspace harms

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magical binding predestined partner cursing seer clairvoyant orthodox priest interethnic influences marriage i n this paper i explore the possibility of individuals influencing marriage by the use of magic on the basis of fieldwork conducted in a village on the transylvanian plain 2 this topic arose as part of a broader research project that focused on how residents of different ethnic and religious backgrounds related to one another in this rural community to what extent they were acquainted with the different religious cultures represented in their village and what the more serious problems were that drove them to appeal to one another as well as to religious specialists for help 3 calvinist hungarians orthodox romanians and predominantly orthodox roma live in the village 4 they belong to a wider and still strong relationship network that links them to other villages and towns in the region although a minority of people have local civil service jobs or work for local businesses most commute to town for work very few working age inhabitants earn their living from farming beef and buffalo cattle owners are becoming fewer by the day and even fewer people keep sheep with the exception of a handful of successful farmers and entrepreneurs the hungarian and romanian populations have experienced a noticeable economic decline in the past decade in contrast several roma families have prospered and have embarked upon ostentatious building projects roma mobility is significant with many people working abroad among hungarian and romanian locals only members of the younger generation seek foreign employment and typically entire families move abroad one of the most discussed problems in daily village life is the increasing rate of theft local gossip lays the blame on poor roma families but in most cases there is no evidence to back up the charges cultural and social life too have seen changes sunday dances which in earlier times happened on a weekly basis have not been held for decades and the party culture is waning instrumental music group singing and traditional dances are on the verge of disappearing only a few members of the youngest generations still learn these dances and they do so by taking lessons from dance instructors loneliness with people staying at home and watching tv is a widespread feature of village life the elderly in particular mourn the loss of their rich local culture and complain about being lonely and about the toorare occurrence of community events the transformation of those events and of the party culture in the past decades has failed to generate new forms and content that could properly fulfil the role of what has been lost the dance of old in which the entire community participated cannot be replaced by the bar frequented mainly by young lads and by men who are lonely divorced widowed or in many cases alcoholics one needs only to remember how ordered a setting the weekly dance used to provide for entertainment leisure the channelling of frustrations and communal communication it also offered a natural place for courtship and prodded young people to search for a partner i cannot engage here in a description of all the changes that have occurred in the villages social life but it is important to note the demise of the weekly dance given the positive effects this had both on courtship and on existing marriages starting a family and providing heirs remains exceptionally important for todays villagers besides the blessings that come with children parents lives are fulfilled by their childrens marriages and the birth of grandchildren today we find parents constantly worrying about their children either delaying matrimony or eschewing it altogether at the same time ethnically mixed marriages have become increasingly acceptable when members of todays oldest generation were young a mixed marriage often led to conflict and the deterioration of parent child relationships there were instances of parents cursing their children 6 and mixed marriages were also noted as motives for suicide singleness developing a relationship bad marriages and the sudden early death of a spouse all have at their root complex causes and people in the village usually consider more than one explanation plausible as an alternative explanation in many problematic cases they bring up manipulation by magic being exposed to the will and hidden interference of others in my paper i examine how locals think the making and breaking of marriages can be influenced through magic and how they appeal to magic to explain why matrimony does not happen why there are conflicts between spouses or their relationship takes a turn for the worse and to explain the death of a spouse in the following list i briefly outline marriagerelated situations in which magical intervention was considered matrimony induced through magical techniques between a free man and a single woman one of the interested parties initiates the magical intervention on a given person usually by asking for the help of a folk specialist cases of this type appear in the recollections of the elderly binding the marriage of a single young person with magical techniques to make it impossible for them to marry 7 villagers believe that seers healers and witches 8 are capable of doing this binding and that it happens even to this day causing a breakdown in or ending a marriage through magic in various ways again with the help of specialists a given couple might separate after magical intervention destroys their relationship or one spouse can be made to develop an illness and die leaving the other free to marry again while family members unhappy with a childs choice of partner generally opt for the former method the latter is often pursued by an outsider who has sexual and marital interests in the spouse of the opposite sex the coerced marriages that result from this second method are usually disastrous not only are the couple unhappy but the guilty party cannot die until they have confessed their deed examples of the second method being used occur only in the narratives of the elderly and exclusively with reference to the past after a divorce one of the former spouses or a family member of one of the former spouses may severely afflict the health of the other former spouse through magical techniques thus affecting both their chances of marrying again and their life prospects and health the spiritual and physical tribulations of someone facing a crisis after divorce are often understood by villagers as the consequence of harmful magic which can either be outsourced to a specialist or performed by a family member of the aggrieved person it is commonly believed that the trials associated with a bad marriage extend into the future and interlink with future troubles in a whole chain of unfortunate events whereas one member of the former couple has long since started a new relationship the other is on their own suffers declines has a serious illness etc in several instances in the village victims turned to orthodox priests for help and the problems were resolved my paper is structured in three parts the first part concerns the recollections of the current oldest generation and events that happened when they were young these include both wellknown cases recounted often because of their tragic outcomes but also lesserknown ones in none of the cases did the events involve the narrator directly in the second part i turn to nearcontemporary cases that occurred in the lives of people who are currently middleaged the accounts of which were shared by the afflicted person or by a member of their immediate family these examples are different from the older ones not least because it is more difficult for individuals to talk about their own experiences or those of close relatives it requires the development of a strong relationship of trust for people to open up about their deepest woes the narratives they tell are not generally known in the village apart from family members only their closest friends are aware of them in the third part of the paper i go on to compare the cases that survive in memory with those from our own times we will see that differences between them are rendered significant not only by personal involvement in the latter cases and on account of this by wider ranging more plentiful and more reliable documentation but also by a change in the methods of magical intervention in addition there are differences in the problems mentioned reflecting on the notions of marriage prevented by magical binding and of the predestined partner i will analyse the relation between r and romanian beliefs and hermeneutical possibilities building on previous hungarian and romanian research on the transylvanian plain collections of folklore and monographs i will also provide a summary of all the important data concerning the specialists involved i will round off my paper by formulating a series of conclusions i memories the following events related to me mainly by women in their 70s and 80s took place in the three decades after world war ii one of these womens major concerns revolved around the need to create suitable conditions with the use of magic that would result in marriage for a young person they feared might remain single for life if left to his or her own devices when for whatever reason marriage did not happen at the desired moment and fears arose that the young person would end up a spinster or a confirmed bachelor people would strive to induce an acceptable marriage via magical techniques usually targeting an attractive potential marriage partner of the appropriate ethnicity and social rank to be the subject of a magical rite 9 conducted by a specialist on occasion a family resorted to conducting maleficent magic themselves for example parents once fed an enchanted black chicken to the chosen lad so that he would take their daughter or niece to his home immediately after the meal which in the eyes of the community amounted to marrying her 10 more commonly they sought the help of specialists even though there was a romanian woman in the village who was known as a witch with a talent for successfully manipulating marital relations the majority of interviewees noted that people in need sought seers and soothsayers from more distant villages a seer in these areas refers to a specialist in divination who is frequently called upon to perform a magical intervention or undo the maleficent magic 11 of another witch in addition seers dispense medicinal herbs for various ailments to heal or to undo a malevolent magical spell they often also prescribe religious exercise my fieldwork involved interviewing hungarian romanian and roma villagers on this topic i learned the most from hungarians less from romanians and nothing from the roma these differences obviously stem both from the course our discussions took and from the human relationships i managed to develop as my research illustrates hungarian and romanian villagers do talk to one another about these subjects and the narratives involve people from both communities i1 manipulating marriage with the help of seers an eightythreeyearold hungarian talked about a hungarian seer in the region whose activity he was able to observe in his youth without their knowledge during the troubled period of dekulakisation the narrator was deployed to a nearby village to oversee the confiscation and transportation of grain and lodged with the chairman of the new collective farming unit in his hay loft from here on rainy days when he could not carry out his duties he could watch the chairmans wife a seer receive her clients and observe their interactions he thus learned exactly who came and why what the seer requested as remuneration and what she was given sometimes the interviewee knew the clients and was able to follow up on events and see whether the promised effect actually happened he noted that the seers earnings raised the familys income substantially one day he was surprised to see his hungarian neighbour and her sister coming to request the seers services they wanted to marry off the sister to a chosen young man the seer requested they return on sunday morning with a hundred lei and a grey hen in their presence she looked into a wooden pail of water 12 spoke into it and saw not the reflection of the things in the room but the face of the proposed bridegroom predicting that he would call on them that same afternoon according to my informant she said go now take the shortest way home for she says the boy is coming to your house and well this is what happened they started off and they arrived home by the shortest route after walking in heavy rain the whole way in the end the lad took the girl to be his wife but they had an unhappy marriage the method employed in this act of harmful magic does not appear in the narrative the narrator merely allows us to surmise that the seer not only made a prediction but also performed a magical intervention at some point we know that she used the pail of water to look into the future and that she asked for money and a hen but we do not know whether she used the hen in a magical rite given the symbolic significance of the black hen in the region she very likely did 13 two other facts support the probability of magical intervention generally speaking seers in this region conduct their divination procedure over a piece of clothing or a playing card and then perform a magical intervention and again marriages induced by magic are always unhappy as in this case information regarding a romanian seer who undertook to manipulate marriage was supplied to me by auntie róza now eighty years old and still a lively talkative woman she has been married twice her first marriage was very short but her second lasted for many decades until her husband died since she had no children she used to offer her services to relatives when they found themselves in crisis situations on several occasions she accompanied relatives to a seer acting as a sort of mediator she would outline the relatives problem ask for help and afterwards comment on the advice and the techniques the seer offered as well as negotiating the fee 14 auntie rozas decisive manner and perseverance rendered her extremely useful 15 i shall present one instance a girl in her husbands family got married with her parents consent but later they could not accept the husbands family whom they regarded as lazy domestic conflicts 16 drove the young wife to move back to her parents home several times until the couple finally divorced both spouses regretted the divorce they tried unsuccessfully to find new partners at one point the girl went into service in cluj and there an acquaintance told her about a seer in jimbor 17 whom the acquaintance had consulted about her own unhappy marriage someone told her they should go to jimbor past buza where there is that romanian community and she says that they went and the seer said to her just go home and look for your coat in the wardrobe its smeared with something for she says they had been here the person your husband is seeing and look she says what theyve done and so it was she got the young womans coat when the young divorcée heard this story about the lover who had interfered by magic and who had secretly gone to the home of her victim and had smeared something on the coat in the wardrobe she became suspicious that someone might have interfered in a similar way in her case too she contacted auntie róza and asked her to accompany her and her mother to the seer in jimbor auntie róza readily complied below i give her account from the moment when they arrived with the seer asking for the clients jacket to look at it and then retreating with it to another room while this act of divination was being carried out the poultry in the courtyard started to attack the window presumably sensing the presence of some outoftheordinary activity or power right then when she began she went into another room and asked for one of her jackets to look at it not before us lo the turkeys lo the geese they were breaking down the window she was inside and she came out and she says remember that you were at a funeral she told us how old the woman was the one who died she says your motherinlaw was there too and she picked up some of the mud that had fallen from the heel of your boot and threw it into the grave so she could prove that her son was good and you were goodfornothing and you would never get another husband ohthen her sister says oh aunty ill give you such and such just make things right and everything i say listen to me say no more she wont keep her promise who knows what they do but she says ill give you eight fasts you do them you keep them backwards thats right fasts and then she says to keep them backwards to begin saturday and come back with the money youll see when you get to the last one the man will show up and so it was well listen to that she made a phone call and the man had already gone to ask them to call ili to come home cause i want to make her my wife the seer concludes that the young woman was magically harmed by her former motherinlaw in the following manner at a funeral they both attended the motherinlaw picked up some soil from under the heel of her daughterinlaws boot and cast it into the grave with the purpose of ruining her prospects of finding a new husband showing in this way that she was a goodfornothing woman the path to lifting the magical harm lay through a fast kept backwards for eight days in the reverse order of weekdays in the first week on saturday the second week on friday and so on the fast was a strict one she was forbidden to eat anything and had to isolate herself from everyone else she could not meet with anyone nor could she give anyone anything from the house this type of isolation and abstinence is in fact a recurring feature of the fasts kept in this region to lift magical harm the unusual aspects in this case are the reverse fasting and the number of days of fasting in addition the ascetic religious exercise is extended with elements that are obviously magical in character separating oneself from the world protecting ones household goods avoiding contact and the possibility of being touched when the fast was done then she did what she did he is her husband to this day 18 she was not allowed to eat anything then just pray well thats the real fast that she should lock herself up and there locked up inside there she should pray on those occasions with no one else she has to be careful that she does not give away even a hair from her hand on that day no she is not allowed to discuss with anyone so that nobody finds out she is keeping a fast one could keep to it in a village one could keep to it she locked herself up and shes not at home the broom is at the door and no one is at home well it was like this in the old times we used to just put the broom out by the door and nobody is at home just so im telling you ive been in many places ive seen many things really the seer expected payment after the successful conclusion of the affair when the former husband reappeared but it was not delivered later when the young wife became ill the suspicion arose that the seer had performed harmful magic against her because she had not been paid her role was perceived therefore as ambivalent just as happens around the globe with other folk specialists with a similar sphere of action an attempt was then made to pay the seer but it turned out that she had died the messengers did not return home but consulted a different romanian seer who established that the young wifes illness had natural causes this conversation with auntie róza brought up another case approximately fifty years ago two hungarian girls from the village consulted the same seer in jimbor because they wanted to get married but without magical intervention the situation seemed hopeless in conversation with auntie róza the seer mentioned the bindings that had to be renewed now then she says i still have to go to your area to să reînnoiască nodurile to renew what is placed around the necks cause she had made a bond for this one as well and for another one she is now dead that little woman the seer had prepared two bindings for the girls which they wore around their necks even after their nuptials had been successfully concluded we do not know what these knots contained only that they were meant to be worn around the neck like a necklace and that their efficacy did not last for life they had to be renewed periodically and for this purpose the specialist travelled to the village since she confused auntie róza with someone else someone who evidently knew the story of the two girls she asked auntie róza to take a message about her imminent arrival to the two women this case is public knowledge by now and several people mentioned the names of the two women to me one of them has died in the meantime while the other moved away from the village with her husband a long time ago these marriages also turned out badly it is very important to note that these narratives describe every single marriage brought about by magical intervention without the knowledge of one of the parties 19 as leading to unhappiness 20 naturally we cannot know if that was the true sequence of events indeed it may be that it was only in retrospect that this explanation was employed to make sense of unhappy marriages it is important to note that the magical intervention carries negative moral connotations there have been other cases in which before a divorce the motherinlaw or one of the spouses wanted to magically harm the otherto ruin their chances of marrying again or their health or their life in general such cases occur nowadays too by now divorce has become a common phenomenon it frequently follows longer marriages blessed with several children it produces a significant rupture and it is painful and conflicting i shall return to this topic in the final part of my paper i shall also address the issue of the lover who magically harms a marriage given that this is the interpretation offered for a wellknown tragedy that took place a considerable while ago i2 marrying at the price of someones death many village residents still remember two extremely sad stories about young married couples with small children in both cases the wife died with tragic suddenness whereas the husband remarried soon after the event their contemporaries struggled to understand both the tragedy and the husbands unwontedly short period of mourning their narratives combine real and possible elements at the same time they actually articulate two foundational causes for the collapse of a marriage animosity within the family and the danger posed by the appearance of a lover respectively the following narrative appeals to a mothers curse in order to explain the death of a young wife a romanian girl and a hungarian boy fell in love the boy persuaded the girl to elope because her parents were opposed to the marriage whereas his approved their family life started very well they had good marital relations and were blessed with children the woman always sought opportunities to send their children into company where they could learn hungarian as well the familys financial position was also improving according to the villages system of values life was going very well indeed for them and then tragedy struck the woman was electrocuted the way she died evoked in the minds of the people who knew her the fact that her mother had cursed her so the boy was hungarian the young woman romanian and then the mother of the woman cursed her because she went after a hungarian she said that for her to become the laughingstock of the village just when fortune was about to smile on her the most… well something like this thats right and so it happened so she had an electric shock she was electrocuted it was the saturday before easter so she had everything prepared baking cooking and she thought she would wash the clothes they took off right away and hang them out to dry and in the cattle shed there was a wire strung out which was tied to the basket of the light bulb so there used to be a kind of basket to prevent bulbs from being knocked and breaking and there was a basket like that made of iron over the bulb there so it had been done like this in the first place the bulb was already covered like that and there was a short circuit and the power ran through the wire and she hung the clothes on the wire and that was it she died on the spot she fell there she was found lying there poor thing i saw her only when they were bringing her out but well she was stuck to the wire when they were bringing her out poor thing of course all her clothing well everybody saw that all her parts were showing so it was in a way as if she had been cursed now they were really well off they had a car the two of them got along very well and then then the curse took hold of her you see but really this is what i heard from others as well that well the curse of the parents does get hold of children i observed in various contexts that members of the older generation still believe in the power of the parental curse and that they are prone to explain even the misfortunes of peoples descendants in later generations as the outworking of their parents curse which they have inherited it is clear from this narrative that a mixed marriage still posed serious problems for the girls family the husband remarried and the children were raised by their maternal grandmother the other case may have happened earlier probably in the late fifties or early sixties according to local opinion the wifes demise was caused by a widow who had set her sights on the husband hoping that he would marry her once his wife was dead their neighbours believed that the husband had had an earlier affair with this widow the narrative states that the person who performed the magical harm appeared in the guise of a frog other possible explanations for this tragic event were also proposed well in such cases they used to say that the family was harmed where we used to live on small street our neighbour there the woman next door was burned alive she was lighting the lamp and there was a little path like so there they had a tiny kitchen and as she was lighting it back then we used to have lamps there was no electricity gas lamps she was lighting the lamp and it blew up and all her clothes were burned right up to here see the hem of her dress was all that was left and the flames went higher than her head at the time i was just a little girl and when she had almost entirely burned away then she ran to our place cause until then she kept running in the garden maybe just maybe she could put out the flames her children were quite little fourfive years old cause she had a boy and a girl her husband was out with the sheep and they were getting ready to go out there was some houseparty this was on a saturday evening at the collective back then there was the collective and in her state of nerves i do not know how she managed it but she spilled the gas from the lamp on herself and it caught fire and by the time her husband arrived what then cause my people had already called the ambulance and the ambulance came and well they took her away but seventyfive percent of her body was burned she was that burned and then as she came into the house see she lay on the bed and she kept shouting mother dearest why did you curse me so now if her mother was guilty or someone else god almighty only knows so her husband came and then the ambulance arrived and took her away and the woman died witchcraft is a convenient explanation for inexplicable misfortunes the young wife had lit that same gas lamp many times before but this kind of accident had never happened why did it happen precisely then why did it happen to her and to noone else this case reminds me of the old granary in the classic work of evanspritchard 21 it cannot be mere coincidence that a given person is standing in the shadow of the granary when it crumbles and collapses no matter how old it is and how seriously the termites have eaten it away it cannot be a matter of chance that the gas spills out of the lamp onto this woman so that this young mother with little children is consumed by fire the granary collapses over whoever is the victim of harmful magic and here fire consumes the person who was either magically harmed by the widow or cursed by her mother on account of her choice of husband carelessnessfatigue is not a sufficient explanation for an accident so banal yet with such fatal consequences to happen the curse or the harmful magic is also needed here the narrator evokes with deep feeling the harmful magic of the widow from the local neighbourhood through describing the behaviour of the frog conceived as her alter ego the frog pursues hides watches and naturally it is a toad of enormous size and when she came when they brought her home she had been in the hospital in clujand as they were bringing her home with the horse and cart they had to climb a smallish hill and a big toad kept following now under the coffin now under the cart it was keeping pace with the horse and when they drew up to the courtyard it crept there under the pig shed and when the funeral took place it was watching from under there from under the pig shed then after the burial then my folk explained that her husband was previously seeing another woman a widow and perhaps it was she who made the magic that the woman the wife should die then at last i dont even know some two months after the burial the man did in fact marry that woman he married her but then they had a bad life hard they had a hard life and when the woman was dying she had to confess that she was the one who had made the magic so that his wife would die she was not able to die until she told her husband that she had made the magic so that his wife should die im telling you that that ill never forget that but it was a big one this big look a huge huge toad it kept hopping after the coffin as they were carrying the woman up but that widow was living some two houses away and the toad came out from there and came when they were bringing her home many one sees many awful things like this hungarians hungarians but her mother and father were not here they were not at home because they had gone to iacobeni and they the couple were on really bad terms with her mother and then she kept shouting mother dearest why did you curse me so these different explanations do not cancel each other out that the family was made that is they were the victims of black harmful magic may indeed constitute an explanation this was the only narrator who mentioned such an overarching explanation from other narrators i learned only of one of the two surviving explanations the mothers curse and more often and with more emphasis the harmful magic of the widow other studies on the transylvanian plain also mention cases in which a person who sets their sights on someones spouse performs harmful magic against their marriage to enable them to marry this spouse once the current one has died 22 an important point to remember is that author of the magical harm achieves her goal but the ensuing marriage is unhappy and she cannot even pass away until she confesses the deed to her husband the toad is regarded even today as an animal that represents the magical harm committed against a marriage if it attempts to enter a house hungarians and romanians alike interpret this as someone trying to magically ruin the relationship of the couple who live there a romanian woman from the village recounted that upon finishing a fast she and her daughter were shown in a dream the identity of the person who had sent the toad and the harmful magic in the third part of my paper i shall return to these old narratives as well as to the magical techniques and specialists presented here ii marriage and magic today ii1 the binding that prevents marriage the only son of a prosperous farmer in the village is already in his forties but is yet to marry he is intelligent better educated than most people has a good job works on the farm in his free time is extremely hardworking and has a good relationship with his parents they help each other out and they all enjoy good health they have everything the parents only regret is that their son has not been able to marry and so the family has no future there will be no descendants to give purpose to their struggles in life for the past several years they have kept trying to understand what caused this and to help their son in numerous ways including enlisting the help of various specialists but nothing has worked i learned of this case from the parents and other people close to them however it was only after a long time and after i had won their trust that the parents opened up about their problem and their attempts to find a solution the mother spoke the most she had discussed the problem with hungarian 23 and romanian women from her circle of friends on their advice she had repeatedly consulted first the local priest then priests serving in neighbouring towns and finally monastery priests asking for advice and help one more experienced romanian friend tried to pass on every possibility she knew she also played an active part by accompanying the mother on her visits to orthodox priests several romanian orthodox priests agreed that the sons marriage had been bound 24 for a long time some of them said specifically that he had been the victim of binding since he was twentytwo since the binding had been done a long time ago it is difficult to undo it it was difficult to help for the most part these priests recommended fasting they fixed the duration the days of the week and the severity of the fast and occasionally they also recommended prayers the mother took with her items of her sons clothing worn in contact with the skin these were blessed and her son would wear them while she was fasting the son was usually aware of who his mother had consulted and knew that she was fasting for his sake but there were times when he did not know generally speaking the couple are handling this delicate problem with great sensitivity they are making efforts not to suffocate the son with remarks or expectations they rarely express their worries and do so with great discretion although they are getting old and feel the situation is getting more desperate by the day i would like to emphasise two points the first is that the chief adviser in this process is a local romanian woman who visits the family almost every day when the need arises it is she who phones priests to schedule a consultation since the mother is a little uncomfortable about appealing to orthodox priests the second important lesson of this case is that for this calvinist family fasting is a strange practice hard to observe the mother says that some priests acknowledge this from the start and prescribe more relaxed fasts she is doing all she can since her sons happiness is important to her and she can see that he is not happy with being single interestingly peoples offers of help are all angled in this direction with no one looking for the solution elsewhere in the sons communication skills habits behaviour attitude to girls or limited free time an interesting feature of this narrative is that the son was twentytwo years old when he had his last relationship with a girl that could have led to marriage it was he who left the girl and the specialists consulted believe that this girl bound his marriage out of revenge so that since he could not be happy with her he could not be happy with anyone else 25 the mother however recalls that her own mother had been so upset when she got married that she refused to speak to her for a whole year after the wedding she did not dare visit her parents again until she was already pregnant with her son she has begun to suspect that her mother may have cursed her for having married against her will and that perhaps her son cannot marry as a consequence of this curse she regards both these explanations as possible the problem remains unresolved she has no confidence in the techniques recommended by the specialists 26 although she has not followed every single piece of advice she does not think this or her questioning attitude has anything to do with the lack of success ii2 she wont rest until her son divorces me the course of ilonas life tellingly illustrates how difficult almost impossible it is for people of her age to fight ones environment to break out from it or to change the mentality of the village and how much bitterness a bad relationship with her motherinlaw can cause for a wife even if she has a good marriage after graduating from university ilona enrolled in a master programme in a different subject she then took a job in the village in the field of her ba degree in the meantime she was raising three children and regularly helping out her husband and motherinlaw as well as her own parents she worked incredibly hard one gains the impression that she used to go to her job to get some rest the truth is that she successfully carried out all her work assignments and even contributed many innovative ideas however her superiors either cut her off short when she was presenting them or laid claim to the results of her projects without explanation she finds peace in her home and immediate family her children and husband and her parents who have always supported her and surrounded her with love not so her motherinlaw who assumed from the start of the marriage that her daughterinlaw would take over a substantial part of her household chores in spite of ilonas compliance she continues to behave with animosity and to hurt ilona on a daily basis by systematically taking credit for all her household work the couple have been married for twentysix years the husband still has a close relationship with his mother and his parental home every single day ilona would help with her motherinlaws household chores before doing her own chores and in the meantime she raised her children difficult though it was to get everything done it would be hard to explain why things turned out the way they did ilona accepts the situation and does not ask too many questions her motherinlaws animosity is a different story it troubles her profoundly and she does not understand why she deserved this almost every day when all the work is done and ilona is about to leave the house her motherinlaw keeps shouting after her that she will not rest until she has made her son divorce her still the marriage is flourishing and their offspring are given plenty of love even though ilona has never been happy with her motherinlaws treatment of her she did not sense any particular danger until one of her husbands childhood friends a romanian man who had moved away came home for a visit and told them that ilona was in peril it seems that in the meantime this friend had endured a long period of suffering and as a result had become a clairvoyant 27 able to see when magical danger was looming over others and to recognise if someone was about to be harmed by magic this good friend first warned ilonas husband who simply laughed it off since he did not believe in these things then he sought ilona out and warned her that her life was in danger on account of the machinations of her motherinlaw and sisterinlaw who wanted to destroy her she learned the story of his suffering his former wife had sought to magically harm him after their divorce but the package that served as the vehicle of the magical harm was picked up by their toddler and so the intended harm fell on him for years afterwards this boy suffered from symptoms normally associated with possession father and son regularly sought help at monasteries and visited the tombs of the saints meeting many priests who provided relief after some years the boy was released from his symptoms and in the meantime the man discovered his clairvoyant abilities which he was now trying to put to good use by helping others ilona was so impressed by the story that she agreed to visit the nearby monastery with the clairvoyant and ask for help they were received by the stareț abbot 28 who explained in great detail what ilona should do and among other things how to write a pomelnic 29 correctly an important aspect of her narrative is the cultural hesitance she felt towards the orthodox church space and cult and the reserves which she had concerning the rituals or at least certain elements of those rituals as a believing churchgoing calvinist she found it difficult to kiss the wonderworking icon of mary and it was a strange experience to be covered with the patrafir stole 30 while the abbot was praying for her while they were in church the good friend who accompanied ilona noticed that light was descending on her a sign of her strong faith ilona has been prone to sickness in recent years and these periods of illness have matched the predictions of her clairvoyant friend in addition the family have experienced many problems he had foretold this has not only strengthened her confidence in his powers but has made her more and more afraid that her motherinlaw may indeed harm her by magic when not long ago the motherinlaw described with a wealth of detail how she had gone with a neighbour to a seer in town because the woman concerned did not love her daughterinlaw and wanted to get her son to divorce her ilona understood this not as a random piece of news but rather as a statement of fact clearly her motherinlaw had not gone merely as a companion rather she must have been seeking a similar result then she began to fear the consequences and to view her serious health problems as the result of the alleged magical harm in reality simple exhaustion would have been sufficient to account for all her problems yet people in her family are reluctant to admit that so many years of loyal service and an excessive workload do wear one out although ilona is aware of her exhaustion she is almost ashamed to treat it as a problem in ilonas narrative we are confronted with two distinct attempts to magically harm a marriage both attempts supposedly enlist seers to separate the spouses given her illnesses and the clairvoyants predictions ilona assumes that her motherinlaw may even be plotting her death not just her divorce she agrees for a short period to seek the help of orthodox priests yet is evidently reluctant to accept this solution soon she finds another explanation and turns elsewhere 31 as with the previous case that of the unmarried son of the farming family here too it should be mentioned that a certain reluctance regarding some aspects of romanian orthodox religious practice occurs in my opinion more often among educated hungarians the two women in the narratives above share a strong hungarian protestant identity and therefore think it very important to distance themselves from orthodoxy iii1 love magic or changing ones position in society through magic two monographs on love magic written at almost the same time by the romanian academic tudor pamfile and by bronislaw malinowski 32 analysed cultures situated at considerable distance one from the other yet the subtypes of love magic discussed in these studies show that there are surprising similarities between the two cultures in northwest melanesia malinowski identified the following methods of influencing as most typical through dreams through eating andor food through touch and smell according to his observations love magic forms an integral part of a wider system of magical techniques and ideas also employed in other areas of life pamfile has finished his monograph on love magic in 1915 he presents a rich arsenal of methods of influencing attraction and love as well as methods of divination the use of plants food and drink singing and dancing as well as the importance of dreams are important similarities with love magic on trobriand islands we can notice the importance of the idea of the predestined partner among romanians ursita ursitul as well as the possibilities of spoiling a relationship or the destiny in love matters of a person young girls and their mothers have an active role in influencing marital status writing on magic in late antique egypt david frankfurter elaborates on the broader connotations of binding spells pointing to a kind of continuity between magical procedures that constrain or incite the actions of others frankfurters approach supersedes the research tradition that classified magical binding according to technique and aim the horse spell he examines belongs to the larger category of spells that bring about a change in competitive situations apart from love these may include sport or judicial political or financial affairs another interesting aspect is that the girl who had been turned into a mare was restored to human form by the monk macarius through prayer and sprinkling with holy water in other words macarius was the one to undo the spell just like the romanian orthodox monks of the transylvanian plain and transylvania in general all this reminds us that in christian culture there is continuity in the way churches relate to magic and certain traditions have survived to this day albeit not in every historical church in this paper i consciously avoid making explicit use of the concept of love magic this choice of terms was informed by what i experienced in the village i tried to pay close attention to the way in which locals narrated discussed the topics concerned indeed in the village in which i conducted my research the concept of love did not even arise in this context feelings were very rarely mentioned the aim of the magical interventions analysed here was not to generate intense emotions or a passionate physical and spiritual relationship rather they sought to affect the socially accepted institution of marriage and family life forming a relationship with a partner and through them a family that is changing ones marital status 33 and demonstrating ones success in securing a partner this partner was meant to come from a family of the same ethnicity and suitable social status in the eyes of the parents i would not go so far as to state that in this village tender feelings do not matter or that they did not play an essential role in the relationships discussed here only that as these villagers perceive it the actions of the specialist who implemented the magical intervention and of the client who commissioned it were not motivated primarily by love none of the narratives referred to the magical inducing of a love affair 34 it seems that in local understanding sexuality and physical relations do not belong to the sphere of magic for instance extramarital affairs were often talked of but only by way of prosaic acknowledgement and narrators mostly spoke about cases involving their priests since they expected them to set an example of morality given that some priests had illegitimate children in certain cases more than one and with different women this would become the talk of the village however neither the priests nor the women involved were seen as workers of magic nor were the priests said to have fallen in love the heart of the issue at least as i understood their words was inconstancy and weakness of character it is only in certain situations that magic is invoked to explain matrimony the second marriage of a widower occurring too soon after the death of his first wife and marriages that had been opposed on account of differences in social status or which had taken a turn for the worse proved particularly liable to be given such an explanation the cases presented in this paper offer ample evidence of how this can be achieved on the one hand by causing the wifes demise and on the other hand by binding feeding also serves to bring about a relationship even though the magic lasts for only one night in other cases it is difficult to pinpoint the technique employed 35 often we know only that it was preceded by a prediction in the course of my fieldwork the concept of binding 36 emerged only in relation to matrimony even though the village did have a resident specialist in influencing marriage a romanian witch vrăjitoare 37 locals stated without exception that when the need arose they travelled elsewhere to more distant experts no doubt the local witch too must have been consulted by clients travelling from afar just like the local bonesetters in the village as in the entire region the experts in binding and generally speaking in manipulation through magic were the socalled nézőnék seers clairvoyants and jósnők soothsayers it is important to note that all these were exclusively women 38 it seems however that people have appealed to them for help less frequently since 1989 nowadays they continue to provide services of magical intervention but demand for preventing or neutralising the effects of harmful magic or undoing magical binding has decreased warding off trouble is nowadays more the province of romanian orthodox parish and monastery priests and the techniques employed are therefore drawn from the sphere of religious experience as we have seen in the narratives presented in detail above religious elements can also be found in the advice of lay experts they too prescribe prayer recommend fasting or request that items of the victims clothing be brought to them however there are twists in what they require the fast that must be kept backwards the need to isolate oneself during periods of fasting the specialists in the magic of binding and unbinding came from all the regions ethnic groups clients consulted them irrespective of their ethnic background just as they do nowadays with romanian orthodox priests again the assistance provided by religious specialists is evidently not related to their ethnicity or even to religion but much more to the fact that it is they who traditionally assume and perform such duties as the orthodox church continues to encourage this the number of people turning to them is increasing rather than decreasing peoples attitudes to every kind of specialist display ambivalence the common belief is that where intervention for the good is possible it is also possible to interfere for evil purposes he who helps may perhaps also harm in the case of the services offered by seers we have seen that the client or their family member occasionally expressed doubts regarding the outcome even though they were expected to pay a considerable sum which was usually handed over beforehand it is important to note that the rules of the orthodox church only allow it to accept charity with everyone giving in line with their judgement and financial resources i did not hear narratives that presented orthodox priests in a bad light of the only priest in the region who has gained notoriety in the local media 39 the residents of this village have nothing negative to say they view him not as a magician but rather as someone they know well from a different context who alongside his ecclesiastical service also fulfils a function of assistance when we consider the magnitude of the change marriage produced in the status of women and men in village society it becomes easier to understand why they resort even to something as drastic as magical methods and techniques to achieve it it is also possible that some have appealed to magic with harmful selfish intentions it would be hard to determine to what extent specialists actually interfere actively in cases of harmful magic and whether they do indeed attempt to induce someones demise suffice it to note that we are faced here too with the same ambivalence uncertainty and blurring of boundaries between rumour beliefs and reality that characterise theories and discourse related to magic all over the world 40 here i merely observe based primarily on the village narratives i collected that the reality is uncertain and the attitude to specialists ambivalent for a clearer picture we would need to be acquainted with each and every case in minute detail a task bordering on the impossible we can scarcely interview every party involved we have no way of knowing the activity of the given specialists in its entirety or their thoughts about each and every case the ambivalent attitude mentioned above has to do most often with doubts related to the use of knowledge the community passes unequivocal judgement on the aims of the magic employed if it interferes in a marriage or induces someones death even the actor presents it as negative the narratives presented in full here and those used as background material show that women play a very active role both in the manipulation of marriage by magic 41 and in attempts to release a family member from the effects of magic men do not usually appear as clients of such specialists if they encounter problems it is normally their mother wife or sister who sets out to ask for help in many cases the men concerned are not even aware of this but occasionally a mother confides in her son about what she is doing especially if the rites to be performed require the sons active participation 42 this is what is happening with the son whose marriage was bound in his youth and on behalf of whom it is chiefly the mother who prays and fasts on the advice of priests this son appears in the role of a child not only because his mother is taking the initiative to try to lift the magical harm but because he is actually living his life like a child in his parents home despite no longer being young using magic as a convenient explanation for a mans failure to marry absolves him in a way from personal responsibility the assumption that magical harm was done directs attention away from some immediate issues 43 that could be the real reason why matrimony has never occurred these might include such possible factors as poor communication skills insufficiently developed emotional intelligence fear of commitment and poorlymasked immaturity but equally valid reasons could be workaholism or simply an excessively restrained attitude to spending even in todays consumer society an experienced priest from the region was making an important point when he told a mother that her son was unable to marry because girls nowadays prefer to live in town agriculture and animal husbandry are not the most attractive occupations for a girl in contemporary romania or for young people in general in some cases problems of addiction add to the difficulties though one has to admit that addicts can be found among married people too although a mans failure to marry might have other explanations even a fraction of those mentioned above would be enough to account for it along with magic the inherited family curse is another explanation that absolves the unintentionally single young man and assigns the cause to a different realm one in which he has no decisionmaking capacity in other situations like that of ilona harmful magic for example may be the easier more comfortable explanation were she to refuse some of her daily tasks stop doing everything she is expected to do and deal with her ill health by resting this would cause even greater turmoil in the family since the problem seems to stem merely from her motherinlaw life goes on as usual and as we have seen her husband cannot even be bothered to take the danger seriously and yet danger there is albeit perhaps not from a magical source iii2 interethnic influences matrimony prevented by magical binding and the idea of the predestined partner given the close network of relationships between people of different ethnic and religious backgrounds one cannot realistically hope to examine hungarian or romanian ideas and practices in isolation 44 in villages in this area hungarian and romanian residents talk to one another about every aspect of life in my experience their communication with roma fellowvillagers is less wideranging but i may have simply missed the opportunity to observe friendly and neighbourly relationships of similar depth between hungarians and roma and romanians and roma respectively beliefs and magical practices of hungarian and romanian origin are inextricably intertwined as too are other features of the culture of the transylvanian plain 45 strong relationships have also developed in the area of popular religiosity but here i witnessed a onesided orthodox effect 46 these days it would be hard to find a hungarian or roma family members of which have not visited orthodox monasteries and have not asked monastic priests or other local or regional priests to pray for them or their relatives individuals and families react in different ways to advice given by orthodox priests while they do not always show unconditional trust or persevere in the recommended religious practices it is a fact that conforming to the established model is more common than having reserves and in most cases people appeal to these priests more than once in their lifetime in many cases the problems are resolved and the positive outcome encourages further such resolutions by becoming a paradigm for future problematic situations i chose to present the two contemporary cases discussed above not because i find typical the more than usually cautious and doubting attitude to orthodox religious assistance they display 47 but because i know these cases from very many angles and in great detail and because they exemplify two specific concerns related to marriage therefore when examining villagers views on the manipulation of marriage by magic one has to cope with an amalgam a combination of hungarian and romanian traditions that is a kind of hybrid system of beliefs and an equally heterogeneous practice while the origin of certain elements can be discovered from an overview of hungarian and romanian ethnographic scholarship it is only in the rarest of cases that i venture to advance a suggestion of this kind and even then only by way of hypothesis i will however develop one of these assumptions because in this case the effect can be identified with great probability it concerns the ideas of marriage being bound through magic and of the predestined partner both beliefs are copiously documented in romanian collections of folklore and in academic monographs as well as in recently published anthropological research these concepts also appear in hungarian scholarship about the transylvanian plain occasionally with interesting nuances binding marriage that is making it impossible by using a magical binding for it ever to happen leads to a tragic situation in the family of the unmarried man or woman as they grow older i suspect this idea originated in romanian folk culture whence it entered the imagery of local hungarians so that by now it has been internalised as a legitimate explanation for the existence of confirmed bachelors and spinsters in hungarian circles as well while the idea is absent from earlier collections of hungarian lore and magical practices 48 romanian studies discuss it most recently alexandra tătăran presented a series of similar cases in which appeal was made to a village priest residing in bistrița county this priest was famous in the region for his ability to undo harmful magic that prevented matrimony 49 tătăran encountered at the site of her fieldwork the expression the wedding ceremony is bound a synonym for the romanian expression used in the village i studied the marriage is bound tătărans the wedding ceremony is bound sharpens the interpretive frame by focusing on a characteristic symbolic instrument of matrimony galina lindquist too met a similar idea during her fieldwork in moscow the crown of celibacy which in turn stems from russian popular belief she linked this notion with the crowns held over the heads of the bride and groom in orthodox religious wedding ceremonies if the crown of celibacy floats above a young mans head it must have been placed there by the harmful action of an expert in magic and although invisible it is all the more efficacious in condemning the victim to remain single lindquist adds that the experts she researched in moscow also dealt with cases in which the victim was afflicted by the seal of loneliness and as a result lived in absolute loneliness with no significant other romanian popular belief also has another notion to explain why a person is unable to get married spiteful deed 51 to discuss this concept and other important related beliefs and practices i draw on tudor pamfiles monograph dragostea în datina tineretului roman love in the traditions of romanian youth 52 pamfile states that personal enemies may perform magical harm against a young individual so as to render him unattractive to everyone he meets this type of harmful magic can be undone with the assistance of experts in magic this fapt de urât can happen not only in the life of unmarried people but also in that of married couples in which latter case the marriage is harmed on the initiative of a third person a frequent occurrence in romanian folklore collections is the idea of the predestined partner it is believed that when things are going well partners predestined for each other find each other get married and live happily together but the fated partner may be compelled by magic to marry someone else which means that the other partner is left on their own they are unable to marry since there is no one for them to marry the only solution is for them to interfere by magic and separate the married couple two possibilities emerge from the sources i consulted on the one hand the magical harm may affect only the marriage that is the relationship between the spouses not the wellbeing of either this would be the abovementioned fapt de urât applied to a married couple in this case the couple separate and the person who enlisted the help of magic becomes the new spouse the truly shocking cases however are those in which a person finds out through the divination of an expert in magic that someone else married their fated partner and asks the expert to induce the death of the spouse who usurped the partner predestined for himher 55 narratives record various courses of action some have committed this fatal act without remorse others are tormented by a guilty conscience until the day they die in hungarian collections from the transylvanian plain i found narratives in which the bride told the groom that she had killed his former wife when they were already walking into the church to be married 56 in the village of my research the moment of truth is characteristically the one we saw in the first part of this paper women who have changed the course of events by magic confess their deed on their deathbeds a recurring element of ursitarelated harmful magic 57 is the frog that appears as the alter egofamiliar or the representative of the witch it keeps appearing it returns every time it is thrown out of the house it is difficult to get rid of 58 the toad is frequently invested with this kind of role in both romanian and hungarian narratives from the village several narrators spoke of how people had tried to dispose of it and what meaning they gave to its appearance here too there was a woman who still remembered that when she was a girl her mother had taught her to tie the toads legs together with red thread so that she could take it somewhere a long way away from the house in several other places in the transylvanian plain toads tied up like this used to be hung upside down in smokeries on such occasions the suffering witch would appear and beg for a stop to the torment a widespread witchrelated belief in the region is that there are ways to take revenge on the witch who harms by magic she can be tormented by striking stabbing etc her image or alter ego the witch not only feels these torments but is left with physical marks so that even if she does not reveal herself while being tormented she can be identified later from these marks largebellied toads appearing in someones house are interpreted as alter egos of pregnant women such toads with large bellies are attested in the collections of vilmos keszeg according to one narrative for instance a single woman consulted a wise woman who used to walk with the devil to find out whom she would marry the wise woman looked into a bucket of water and showed there that she would marry a father of seven she told the single woman that a bigbellied toad would come to her house and if she killed it the pregnant wife of the man with seven children would die and he would come to get her to propose when the toad appeared in her home the woman hurled a piece of redhot iron into its mouth a few weeks later the mans wife died she did not die by hot iron but her mouth was on fire two weeks after that the widower proposed to the woman the narrator claims that this woman very much regretted having killed the toad and having also murdered the wife she committed sin for herself and looked after the seven children 59 it is very important to bear in mind that irrespective of ethnicnational and religion to coerce or dissolve a marriage through magic is regarded as a sin even when it does not result in death the ensuing hardship and unhappiness are viewed as actual penance finally i would like to mention a small but significant fact a number of monographs mention the belief that the toad has to be sent back to whoever sent it in the first place together with the harmful magical bundle 60 i also encountered this advice during my fieldwork in the village a romanian acquaintance became aware of the fact that a toad kept trying to enter her house no matter how many times they drove it away it came back she suspected that someone was trying to attack her daughters marriage but was at a loss what to do being a regular churchgoer she confided in the orthodox priest and asked for his advice to her surprise he told her to scold the toad and send it away which showed that he had the same understanding of the phenomenon as she did since orthodox village priests meet many problems of this and similar kinds in the course of their daytoday pastoral duties it goes without saying that they are extremely knowledgeable concerning popular beliefs and all the practices that go with them they also know that these beliefs play a significant role in the daily life of their parishioners and generally manage to adapt to this state of affairs which puts them in a position to offer professional advice when troubles arise conclusions in this paper i have presented based on my fieldwork in a village on the transylvanian plain what members of the older and middleaged generations know about manipulating marriage through magic naturally the elderly spoke of their memories these included events that happened to their relatives and in which they also played a part at least as mediators in addition they narrated widely known tragedies that had not affect them personally by contrast the relevance of the narratives told by the middleaged subjects extends without exception to the present as well these are very personal stories and i had the opportunity to collect significantly more detail accordingly the possibilities for manipulating marriage then as well as now can be reduced to a set of fundamental patterns using magic to prevent or induce matrimony or to dissolve a marriage nowadays even tensions or conflicts between divorced spouses can generate accusations of magical harming the recent stories which are still ongoing are firmly rooted in the fertile soil of the stories of earlier generations what kind of relationship can we glimpse between these layers how do changes that have taken place in the region and in the history of the families concerned influence the interpretation of life events and the quest for a solution an idea that spans the generations is the power of a parental curse and its being inherited by children family prestige is also inherited and it is significant that the post1989 restoration of land confiscated under communism led to the reappearance of the old village hierarchy as well all this affects matrimony who marries who which marriages are met with approval and in what kinds of circumstances the suspicion of magical manipulation arises as far as existing marriages are concerned i observed in several cases that the relationship between motherinlaw and daughterinlaw is fraught with danger the former may not only make the latters life miserable but according to local belief may even endanger it previously marriages either took place by consent or the bride and groom eloped if there was no agreement between the two families the marriage could fall under a curse which affected peoples ideas about the couples future happiness and their interpretation of misfortunes a familys rank financial position and prestige strongly influence marital choices this can be observed since the fall of communism too based on what i have seen in other parts of transylvania i can say that it has never ceased to be the case in the region the comparatively modest family background of the bride can often be the spur to a motherinlaws enmity in such rural environments this happens first and foremost in olderestablished large farming families the narratives that live on in the memories of the elderly suggest that in the old days matrimony was regarded as important even when one had enlisted the assistance of a seer that is when the natural course of life was disrupted through magic although such marriages never turned out happily parents of daughters still gave in to the pressure they felt to prevent the girl being left on the shelf or failing to secure the desired husband often the girl was treated like a mere object with the actively engaged person being the mother who commissioned the intervention but we have seen that two girls could also team up to visit a specialist supporting one another the community unanimously condemned and continues to condemn such intervention regarding it as a sin and a source of unhappiness contemporary narratives tell a different story the rising number of confirmed bachelors is a new phenomenon it seems that manipulating the chances of unmarried youth through magic is no longer practised nowadays the angle of approach is different a close relative assumes that someone has bound his her marriage through magic and strives to undo this binding to which end the assistance of orthodox priests and of seers is called upon hungarian villagers usually accept the proffered explanations and problemsolving methods even though these are culturally alien to them the narratives discussed above allow us to observe a change from old to contemporary methods of influencing matrimony these days binding feeding etc are no longer customary instead orthodox priests and seers usually recite prayers over the clothing of the individual who wants to get married or mothers undertake fasts on behalf of their sons in other words magic has been replaced by religious methods there has certainly been a change in the role of seers but it is clear that they survived socialism and continue to be present in todays postsocialist reality one seeks them out in nearby villages and towns they have approximately the same sphere of action and interestingly they typically prefer modest surroundings and simplicity the role of romanian orthodox priests has certainly increased considering that before 1948 most romanians in the region were grecocatholics a common feature of the two narratives from the present is that in both cases the men come from betteroff farming families who are attempting even today to farm extensive lands compared to other villagers and who own more cattle than the average the labour that comes with such large farms costs these families substantial effort they work extremely hard they operate farm machinery and they also supervise their labourers farming consumes their entire day in one narrative the relationship between the wife and the motherinlaw is growing increasingly strained presumably the mans parents did not approve of his choice of wife but in the other case too word has it in the village that the mother did not approve of her sons youthful relationship the claimed source of the problem it seems that nowadays local young men can only enjoy healthy relationships andor a happy balanced marriage if their parents refrain from interfering in their lives at the same time we have seen that even a supportive helpful understanding attitude towards the young man woman is by no means a guarantee of success matrimony is highly valued in many cases it is unattainable and if a marriage does take place the course it takes depends to a very great extent on the wider family context regardless of sex ethnic background or religion magic provides a readymade explanation for numerous puzzling woes and difficulties the true causes of which it is seemingly in no ones interest to explore i should add that a common element that transcends boundaries of time and ethnicity is the frog as the envoy that channels the harmful magic or as the alter ego of the witch it appears in both earlier and contemporary narratives both hungarians and romanians spoke of it and gave it the same meaning and sought to remove it in the same way at any rate it is important to emphasise that hungarians and romanians in the village do speak to one another about disturbing occurrences and problems that romanian neighbours and friends frequently offer their advice establish contact with specialists and on occasion even accompany the person in trouble on visits to them many narratives feature hungarians and romanians alike but in different roles irrespective of who the narrator is these explanations and solutions offered when certain problems arise are part of the shared heritage and so they circulate in the village interethnic relationships are continually transforming this can be measured first and foremost in the frequency of and reception given to mixed marriages whereas in former times interethnic marriage was considered shocking nowadays hungarian romanian marriages occur frequently and enjoy acceptance and one finds romanian roma and hungarian roma mixed marriages as well in 2018 alone five mixed marriages were celebrated in the village nowadays there is no longer a need to posit magical interference as an explanation for mixed marriages the issues raised here are viewed only from one specific perspective the manipulation of marriage through magic further advanced research will be needed to explore the depth and complexity of social problems such as the sharp increase in recent decades in the number of confirmed bachelors the inheriting of social status as conditioned or not by political regime the changes that have taken place in social prestige and their effects on matrimony and attitudes to magic all likewise demand further research each of the narratives examined answers a whytype question just as in azande witchcraft why this spouse why did the wife die why is the man unable to marry in the local perception the social institution of marriage can be influenced through magic local interpretive networks facilitate a magical understanding of matrimony divorce and the death of a spouse 4 to protect the privacy of the people concerned i will not disclose the name of the village all names given in the paper are fictitious i provide only approximate data regarding population and ethnic percentages since precise data would allow the settlement to be identified the village has around 1500 inhabitants around half are hungarian with one quarter romanian and one quarter roma 5 the expression used in the village is vénlegények it denotes lads or men who are not yet married but are no longer young 6 parental cursing also took place in situations in which parents had other reasons for not accepting their childrens choice of marriage partner 7 the expression used in the village is meg van kötve a házassága 8 in this context the concept of witch was used only in romanian and for persons of romanian ethnicity in the past there was a vrăjitoare living in the village and she specialised precisely in inducing and binding marriages 9 i am using the concepts magic and magical rite based on the study by mauss the term used in the village for harmful magic is csináltatás the specialist in magic is known locally as soothsayer or seer and i therefore use this term instead of mauss concept of magician 10 although both the region and the village were famous for their spectacular wedding traditions many stories attest to the fact that such weddings often did not take place with nuptials taking a more modest form thus in several cases merely moving in together or possibly a more festive dinner marked the beginning of the marriage if a relationship induced by magic broke apart early on the spouses were considered divorced and any future partner they found needed to have had a similar past a divorce that follows a short period of marriage does not seem rare in this period many older women admitted that they left their first husband shortly after getting married and moved back to their parents and later took a new husband 11 cf eg kós according to károly kós in the transylvanian plain néző seer is a synonym for the terms kuruzsló healer javas shaman and jós soothsayer the most commonly used word in the locality of my research is nézőné seer other occurring terms are jós jósnő soothsayer and in a single case in reference to a romanian woman from the village boszorkány ro vrăjitoare witch 12 looking into the pail was a widespread procedure of folk divination all over this region and was used especially for identifying a thief or finding out how the theft had been committed vilmos keszeg has published a study on this subject and eleonora sava a monograph 13 i learned of a very interesting use of the black hen from a research paper on witchcraft in the region of maramureș the village is multiethnic the witch romanian and she is a widely soughtafter specialist among other things she kept fasts on behalf of others during the socalled fast of the sun she herself fasted on wednesdays and fridays and on tuesdays thursdays and saturdays she locked a black hen in a cage and made it fast in this way every day except sunday was a fast day the hen replacing the witch for three days a week 14 in one narrative the mother who is worried about her daughter gives the seer a sum equivalent to a whole months pay the amounts are perhaps no longer remembered accurately but it is certainly implied that the sums of money were large meaning that these specialists made a significant financial profit 15 auntie róza had personal experience of soothsayers and seers she had repeatedly visited such specialists both in her youth and also later on when she was already married as a girl she had gone notes to the seer in town with another girl they questioned the seer first and foremost concerning their marriage prospects and their future husbands the payment consisted of homebaked bread and bacon which one of the girls carried with her as a wife at a spa resort she had consulted a seer of roma descent who was vacationing there in the latters hotel room she presumed that the woman was a soothsayer simply on account of her ethnic background but it turned out to be true she first spoke to the seer in the dining room and then visited her in her room one had to be discreet since soothsaying was in that period an officially persecuted activity 16 in one such conflict the husband slapped his wife in the words of the narrator the silly woman immediately ran to her parents home i would like to draw attention here to the fact that the narrator finds physical aggression against a wife acceptable there was much more bitterness ahead for the wife to swallow among other things she heroically bore with her husbands infidelities smiling to the world even though he had just cheated on her with her best friend while she was lying sick in hospital 17 jimbor is a village in the region of buza the seer was the mother of the head of the local collective farming unit when they sought her out she committed to the task reluctantly for fear she would get her son into trouble in spite of this she was known throughout the region her fame and address not to mention the stories involving her spread by word of mouth this seer had romanian nationality both romanian and hungarian seers were sought out by romanians and hungarians alike 18 i have indicated in brackets the questions i asked in the course of the interview 19 cf if someone is made through harmful magic to love someone it is an unfortunate thing what if they were not meant for one another yet the women bring them together they used to say till god takes note two old women got them together ha valakit megcsinálnak hogy szeressen valakit nem szerencsés dolog hátha nincs neki rendelve összerakják az asszonyok szokták mondani még az isten észreveszi két öregasszony összeteszi the quotation is taken from the collections of gabriella vöő cluj i shall return to a popular belief mentioned here which i have not yet discussed namely that the person to whom someone is married was not destined for them 20 alexandra tătăran also comments on marriages brought about in a similar way though binding once the nuptials have taken place every spell is lifted and the spouses start to hate each other this is the secret behind their unhappy life 21 evanspritchard 22 such cases will be addressed later on cf the belief in the predestined partner 23 the hungarian friend had faced a similar problem at one point in that case too they had gone together to the romanian orthodox priest her son had married and had children and the problem was solved 24 both the romanian expression and its hungarian counterpart are confusing nevertheless given that this is the local term for this phenomenon i need to use it it means that magical binding prevents marriage from happening and consequently the victim remains single 25 on the harmful magic of the abandoned lover see eg canianu 26 the father had also consulted a seer and they had followed her advice as well again without results 27 i give the hungarian and romanian terms for the clairvoyant as used by ilona 28 stareț is the romanian term for the monk in charge of a monastery 29 a pomelnic is a piece of paper on which the faithful write down the names of relatives alive and deceased on behalf of whom they wish to have prayers recited in a church or monastery the word is cognate with the verb a pomeni meaning to mention to remember 30 the term patrafir refers to a stole a scarflike piece of priestly clothing worn around the neck and mandatory during services since it signifies divine blessing priests began the habit of holding it over the head of the believer during certain rites 31 she is now undergoing bioresonance therapy to treat her illnesses but that part of the story is not relevant to the topics discussed here 32 cf eg malinowski pamfile on ancient greek love magic and its aggressive terminology shaped by competition and frustration see faraone 33 aurora liiceanu gives a similar account she emphasises that in the practice of experts called in her case vrăjitoare the most frequent request is for the inducing of marriage to which end the witch and the client work together the village she studied put enormous pressure on people to marry liiceanu too believes that the magical intervention sought to effect a change in someones marital status 34 by contrast such events and magical techniques have been widely reported in the arieș valley on love and love magic in other parts of transylvania see also balázs balatonyi the cases published in lajos balázs study are all ones of love magic they seek to increase someones desire or an attraction one cannot resist or magically harm an unfaithful partner to gain revenge there is only one exception a case in which a motherinlaw committed magical harm against her daughterinlaw because she did not like her she sewed an eggshaped harmful magical object into the pillow of the bed in which the couple spent their wedding night and the bride became incurably ill this narrative also states that the victims consulted monks to find a cure but without success 35 in the case of one romanian couple it even happened that the grooms parents placed a harmful magical bundle in the trousseau the harmful magic eventually caused the death of both spouses the bundle consisted of a red cloth and feathers braided together and sewn into their pillow 36 in a research paper éva pócs mentions in the category of bindings that influence bodily functions both binding the luck of a girl to make it impossible for her to get married a lány szerencséjének megkötése hogy ne mehessen férjhez and causing impotence by binding in the same paper pócs quotes from andor komáromys account of witch trials some information taken from a case in bihor county for the girl to be rendered unable to marry she is bound thus a lock of her hair is wound around the leg of a hen which is buried under the hearth hogy a lány férjhez ne mehessen úgy kötik meg hogy hajának egy fürtjét tyúk lábára tekerik és azt elássák a tűzhely alá pócs komáromy 245 i did not encounter practices of a similar kind in this village however the correlation between girl and hen clearly existed there as well since wedding traditions included an episode in which the bride was replaced by a hen liiceanu describes the selective binding of potency in such cases a woman binds the potency of the man who is important to her in such a way that he is rendered impotent for everyone else except her 37 i would like to note here that the village had another expert in influencing matrimony one who employed different techniques the socalled hear ye the matchmaker 38 narrators mentioned only one male specialist the clairvoyant good friend who discovered his abilities precisely by frequenting orthodox priests monasteries and the tombs of saints by doing so he was granted a miracle an important difference is that people in need do not seek him out but rather he seeks out those he deems to be in need 39 since the accusations published in the media are unproven i refrain from giving the name of the priest my impression is that people who live in his neighbourhood and know him well value him whereas those living further away gossip about him as a black magician with supernatural powers i believe we are face to face with a charismatic personality who clearly divides opinion and is extremely controversial 40 on the ambivalence of magic see eg malinowski evanspritchard kieckhefer komáromi 41 on the active role of women in magic see also liiceanu 42 liiceanu concludes that unmarried men never go to the witch vrăjitoare alone but if they are aware of the intervention and participate in it the results will be better 43 on the strategic use of witchcraft accusations see argyrou 44 research on the transylvanian plain that publishes hungarian and romanian material side by side thereby systematically comparing knowledge and practice alike such as aurél vajkais work entitled népi orvoslás a borsavölgyében counts as a rarity 45 györgy martin june folkszemle hufolkszemlemartinmezosegifalvaktanckulturajaindexphp here the intertwining and mutual influence of the hungarian romanian gypsy and saxon cultures brought the wealth of the thesaurus of transylvanian dance and music to its pinnacle as a consequence of the constant interchange of dances and dance tunes the boundaries of hungarian and romanian specificity are completely blurred in the transylvanian plain and a veritable musical and dance bilingualism manifests itself a magyar román cigány és szász kultúra összefonódása kölcsönhatása itt fokozta a legmagasabbra az erdélyi táncés zenekincs gazdagságát a táncok és a táncdalok állandó csereberéje következtében a mezőségen teljesen összemosódnak a magyar és román jellegzetességek határai s valódi zenei és táncbéli kétnyelvűség érvényesül 46 this relationship must have been strong even when the romanians in the village and the area belonged to the grecocatholic church nevertheless completely new research is needed to identify what it consisted of which elements were common and whether orthodox influence became stronger after the second world war and the banning of grecocatholicism 47 both cases involve educated women which means they identify more strongly with their religious identity which is strongly linked with their ethnic identity 48 judit balatonyi encountered this idea in ghimeș see the tying away a marriage 49 village priest solving marital deadlocks tătăran 50 cununie is a romanian term denoting the orthodox religious wedding ceremony it alludes to the crowns held above the heads of the couple at one point in the ceremony 51 fapt de urât means a harmful magic that renders a person ugly or hated 53 pamfile 54 pamfile their fated man is taken away by trickery and charms 55 tătăran calls this type of harmful magic ordaining spells they seek to compel the man widowed after the induced death to marry the perpetrator of the magic according to tătăran in todays romania a lifeanddeath struggle is being waged around marriage especially in country areas the deathcausing interference mentioned above can be recognised by three signs sudden illness and death the widower remarries soon the new spouse does not suit him from a social point of view and is noted for knowing those things 56 keszeg 57 see eg pamfile and liiceanu vrăjuri de ursită fate charms 58 pamfile olteanu the frog as the alter ego of the witch is also attested in international scholarship see eg mauss 59 keszeg 60 this method is practised not only in the transylvanian plain but elsewhere too see also pamfile

she carried out three different longterm fieldworks in romania and russia her research areas the social significance of the ideology of witchcraft based on historical sources and contemporary research magical and religious healing interethnic and interreligious relations in transylvania contemporary russian and romanian orthodoxy orthodox religious communities monastic communities communities formed in the sphere of influence of priests churches postsoviet conversion stories demonic possession exorcism contemporary orthodox demonology

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introduction mediatization affects the ways of conceiving culture from its conditions and methods of production to habits and valuations arising from its recognition conditions if mediatization is considered a longterm process it is possible to observe how specific formats endure over time even when the media and technologies that gave rise to them have disappeared some structures therefore acquire relative rigidity over the years from list and repertoire to playlists playlists have become a primary format for discovering ordering and sharing music in contemporary culture occupying a central role in the strategy of platforms such as spotify to attract advertisers the concept of a playlist has been defined as a sequence of songs meant to be listened to as a group however different authors have dealt with playlists and their actantial capacity inside and outside musical life among others as a means to communicate political opinions and selfpresentation playlisting the practice of collecting music files inside the playlist format is one of the main features of streaming platforms it has multiple uses and has varying degrees of importance to playlist curators regarding the morphological attributes of its evolution the playlist inherits traits from both the list and the repertoire these notions are related and extensively studied in the social sciences list the study of the list as a semiotic phenomenon acquires importance insofar as it is a cultural practice that fulfills different functions both in the ordering and systematization of textual corpus and the mutation of cultures in their points of explosion umberto eco deals with the morphological multiplicity of the list as part of the modes of artistic and everyday representation in this sense the list is a semiotic device that gives order to a specific accumulation process that is when one does not know precisely how many elements comprise a macrocosm or when it is complex to encompass also when we are not able to offer a definition based on essential features one goes on to enumerate its properties in order to translate it into something intelligible eco distinguishes between practical or pragmatic lists and poetic lists the practical list can be exemplified by the shopping list the guest list for a party the catalog of a library the inventory of objects in any place the list of goods in a will the invoice for a commodity that requires payment the menu of a restaurant or the list of places to see in a tourist guide following eco pragmatic lists have some specific properties they have an exclusively referential function that is they refer to objects or concepts and have the practical purpose of nomination and enumeration secondly they are finite and thirdly they cannot be altered from this perspective practical lists confer unity to a set of objects that however different they may be from each other fulfill a contextual requirement ie they are related by their immanent features by being grouped in the same place or by constituting the objective of a specific project as we will see below poetic lists however deal with any artistic purpose they are made for and any art form that employs that format to express it repertoire far from the cumulative nature of ecos view of lists the notion of repertoire is associated with the idea of collection namely it has a more active meaning than the practice of accumulation the notion of repertoire refers to the use of language for operational purposes specifically communication and is generally associated with collaborative interaction practices unlike the list the repertoire serves the constant creation of performative competencies this is described by diana tylor who also recalls that the notion of repertoire is intrinsically linked to the idea of the archive tylor attributes unalterable features to the archive be they documents maps books extension books written texts objects or any type of instrument supposedly resistant to transformation instead the repertoire requires the presence of actants who participate in situ in a specific type of production in other words contrary to the supposedly stable objects of the archive the actions that make up the repertoire do not remain unalterable the notion of playlists brings together in its etymology aspects immanent to both definitions list and repertoire while the prefix play reminds us of the actantial weight of its meaning the suffix list synthesizes the subjectivized form in which a playlist is cognitively presented in general playlists comprise an extensive range of interactive modalities and thus ways of generating transference and enunciation cultural media coevolution the mediatization of everyday life forms particularly in music encompasses practices that exemplify its subtle but penetrating influences on global culture as well as its variable assimilation across the planet in the digital age the relationship between arts and media has been codetermined more intensely than ever before analyzing some of the features of this coevolutionary process enables us to order and classify the novelties permanences or mutations that occur in current technologyrelated social practices and uses through the sociosemiotic and therefore cultural processes taking place in the textual metatextual and transpositional discursive levels one of the interesting aspects of the semiotic study of formats is that perceived from a metalevel they operate as affordances in different spheres of everyday life thus playlists integrate specifically media affordances aimed at shaping the conditions of music listening and enjoyment but also musical affordances affecting the interaction between musicians and shaping aspects of the performative this doubleedged character of playlists is echoed in our epistemological framework ie understanding mediatization from a sociosemiotic perspective that comprises both mediatic affordances and musical affordances the sociosemiotics of mediatization uses the concept of affordances to explain how the material aspects of media can influence and costructure symbolic representation and social interaction on the other hand the fields of musicology and popular music studies employ the notion of musical affordances to mean sound production actions and their effects 1in other words our epistemological framework allows us to conceive affordances as an operational tool that encompasses the full range of potential uses facilitating limiting and structuring mediated communication and interaction in specific contexts as cultural configurations they possess a diachronic character with each stage in their evolution crystallizing in particular discursive systems regarding the present conjuncture for example we may think of the semiosphere of black music and contemporary formations of the macrostructure such as trap reggaeton hip hop or neosoul one of the fundamental concerns of mediatization studies whatever their geographical perspective is their concern to understand contemporary and future culture ie mediatization studies produce knowledge by constructing qualitative quantitative or qualiquantitative descriptions of the particularities that characterize the synchronic stage of culturalmedia processes this involves building metatextualities that explain or can establish dialogues with similar processes in other areas of the semiosphere on a micro meso or macro scale an innovative viewpoint in mediatization theories is to examine daily media life not only from the listeners perspective but also from the perspective of the actors who produce transpositions in the musical universe list and repertoire through mass media during the second half of the twentieth century the role of the list and repertoire formats became evident in radio or television formats structured on the basis of song lists or video clips for example television programs such as mtvs the 10 most requested or el mundial del video broadcast by much music argentina the role of the ranking programs format in music mediatization and configuring a discursive genre must be acknowledged the same is true for television and radio station programming schedules or record labels and distribution companies catalogs which played a central role in the second half of the twentieth century considering such precedents we can perceive playlists as the evolutionary result of other intangible media formats long present in the mass media meta musical affordances lets take jazz as an example of the popular music of the twentieth century we find that its repertoire has been canonized at least partly thanks to fake books and real books this repertoire of archives in scriptural format crystallized from scores played a crucial role in the canonization of jazz and the consolidation and evolution of the semiosphere of black music during the twentieth and twentyfirst centuries jazz became popular between 1900 and 1950 due to the enormous amount of music published at the time by the american industry toby wren asserts that the distinctive features of jazz as a musical genre are intrinsic to the repertoire of standards and even the very practice of musical improvisation in the genre is structured by that repertoire the specialized literature considers it essential to analyze the diachronic adaptive capacity of global jazz practices and how racial ethnic and cultural differences are expressed through music to recognize how different cultures assimilate the same cultural code hence wren concludes that a jazz standard has no precise definition debates over which pieces can be considered standards are contentious in part because the criteria for a jazz standard change over time and geographies wren refers to those melodies and harmonic structures that are considered common knowledge among jazz musicians and appear in the pages of the various real books and fake books this is the raw material the saussurean langue from which musicians engage in parole on any given stage in 1975 students at berklee college of music in boston compiled the best versions of the standards being played at the time they added new compositions listed and published in a single edition resulting in the new real book this book failed to be legalized due to the difficulty of obtaining copyrights for all the pieces also noteworthy is the case of the great american songbook comprising popular songs written for broadway and hollywood musicals and tin pan alley another relevant precedent is when the hal leonard corporation publishing house was in charge of compiling the copyrights of almost all the songs that appear in the original the real book of 1975 surprising the jazz guild with the release of the first legal version in september 2004 with similar features to the original version in terms of typography and organization real books were consolidated in the semiosphere as a series of handwritten scores alphabetically ordered in which the melody of each standard is found in different keys accompanied by its harmonic nomenclature their fame is partly due to the many versions of standards transposed to different instruments this aspect facilitated their performance since it allowed musicians to have a repertoire to read in ubiquitous mode the specialized literature defines these musical forms as pieces of distinctive songs of american culture combining africanamerican influences and european conventions what is interesting about the jazz standard and thus real books is that they were usually situated and defined in both the academy and the musical realm as repertoire for improvisation samuel floyd asserts that jazz is more about improvising new texts it is a communal and cooperative process as a cultural format the standards were also referred to as a symbolic resource by damond phillips as they function as the glue that connects the different styles within jazz individually standard tunes have distinctive characters that performers try to highlight in their interpretations including their improvisations paul berliner for example describes in detail how musicians have varied chord progressions and improvised on standard repertoire although berliners book expresses multiple viewpoints the general characterization of the repertoire conforms to european notions of working in music the standard is preexisting and the musicians offer an interpretation and use it as a basis for improvisations at present both popular music and semiotic studies point out that from the midtwentieth century onwards the score is no longer used as a language for archiving musical texts this began with analogical mediation and deepened with digital technology playlists in radiooooo radiooooo is a french platform born in 2014 based on collaborative playlisting it is a project in which each user can contribute files with sound text and a visual cover each contribution or discovery implies an act of selection and inclusion in at least one of the playlists offered by the platform depending on the decade to which each song belongs the number of contributions of each user and the level of acceptance of each contribution counted in likes each community member accumulates points that position in a general ranking radiooooo allows a previously nonexistent experience of musical fruition in which the user can choose any country from the world map that occupies the central place of the interface then select a decade within a timeline that goes from the early twentieth century to the present and even making future representations from current songs once we choose geography and a decade the platform plays a list of songs automatically generated from the collaborative contributions of the users in other words mediatization is based on a wikitype of interaction where the files are organized in playlists according to the geographical and temporal characteristics of each piece and their stylistic attributes in addition to spatiotemporal coordinates other technical devices function as vectors that individualize the user experience the shuffle mode for example offers a more unrestricted experience in terms of spacetime as the option dispenses with user interaction by choosing geographic and temporal locations for music listening next it allows the choice of a stylistic range of the music among three main vectors slow fast or weird in semiotic terms these vectors are inadequate to define the criteria underlying listmaking in contrast the first two effectively allude to the musical pieces tempo or bpms on the other hand given the temporospatial variety the concept of rarity does not seem to offer more than opacity another essential feature of radiooooo is that unlike platforms like spotify there is no manual generation of playlists the process is automatic or assisted and based on the intrinsic characteristics of the texts each user contributes figure 2 is a screenshot of the user interface of radiooooo in 2018 and aims to show some visual and vector features that have remained or disappeared in its evolution at the time for example there was an option called taxi which metaphorically alluded to the experience of moving through different landscapes while tuned to a city radio in effect taking a ride in the sound landscape of some other country and decade the platform also has a shuffle mode moving randomly between countries and decades making the sound experience even more unpredictable following eco the generation of playlists by the application occurs pragmatically a priori is about users scattered around the globe who motivated by their love for music and perhaps for the pleasure of appearing in the sites ranking collaborate with sound fragments collected in a digital space if one considers the aesthetic dimension of the playlists especially the most recent ones it is possible to recognize the enunciative role of the platform through the playlists insofar as there are certain stylistic attributes shared among the selected files a clear example is the representation of future sound landscapes from a selection of past or current texts to risk an aesthetic conception of the year 2070 in different parts of the globe as shown in the picture below this actantial feature of playlists endows the platform with an enunciative identity given its interactive properties the platforms identity is always shaped by its community of users which generates narrative processes and aesthetic identification we need to underline that the radiooooo experience offers a type of musical fruition based on interactions resulting from the practice of playlisting interactional attributes are unthinkable outside the spatialtemporal malleability provided by digital technology in sum radiooooos description highlights some aspects that show how a virtual community establishes its ties based on the encoding and decoding processes of global music where the playlist format is the platforms practical and enunciative proposal spotify playlists as repertoire in black music jam sessions our research framework includes ethnographic work and more specifically participant observation in contemporary circuits of jam sessions across different geographical latitudes these circuits are characterized by exceeding the jazz sphere in the interpretative field embracing a broad spectrum of the black music semiosphere given these peculiarities we have called this type of jam sessions jbms jam sessions are forms of cultural life that originate in the field of jazz given the practices that characterize them with musical improvisation as one of their distinctive aspects we can say that they represent instances where the langue becomes parole where the repertoire is placed at the service of the improvisational and transformative action of a text initially archived in a repertoire the real books the jbms are usually open to languages with a higher degree of minimalism and economy of technical means than the language of jazz this makes them attractive to many musicians but it is also relevant to understanding the proliferation of jbms in different countries despite the nuances they acquire in each case one of the jbm circuits studied is located in the city of buenos aires and presents noteworthy mediatic issues in the shaping of its repertoire unlike in jazz jam sessions where as we have seen the repertoire is dictated by the real books the jbms studied interact with repertoires through the use of playlists within the spotify platform 2 but what are the implications of such a media substitution 2 swe refer specifically to circuits circumscribed to buenos aires argentina which have also begun to be mapped and studied in europe as part of the broader research that includes this work a priori the replacement of the book format by spotify playlists allows an individualized creation of repertoires composed of sound files selected and ordered through their user profiles which can be official or belonging to the profiles of actants in the role of curatorship of the jbms the replacement of formats has wideranging implications jbms encompass a spectrum of musical genres beyond jazz reaching all genres and styles contained in the semiosphere of black music they encode both the type of performance and the interactions between the participants from the affordances that each media moment imprints from the use of spotify playlists influencing both the configuration of the repertoires and the performative practices that characterize the type of performance in each historical period the substitution of one format for another has also implied the disappearance of solfège3 as a recurrent practice to use the repertoire encouraging the learning and interpretation of the pieces through listening in other words there are cognitive implications resulting from the media substitution that regulate the ways of learning and interaction among the players the following images belong to the playlists of two jbms with different degrees of development the image on the right belongs to the playlists of a jbm called skill session which is generated from the personal profile of one of its curators its content prioritizes local artists some regular musicians within the circuit over black music from international and consecrated worldwide artists the image on the left shows a segment of the afromama4 playlist a spotify jam session that interacts with musicians and followers through its verified artist profile its official profile curates a playlist that integrates black music classics with pieces by local artists and regular participants in their live performances the comparative relationship between both playlists allows us to describe how the individual styles of the repertoires are built according to particular features in each case for example the difference in the degree of presence of established black music artists in each repertoire or the nature of the profile from which the playlists are created and mediatized as well as how each repertoire includes texts by the musicians who participate in the circuit while in the first case the sound files are selected and ordered from individual user profiles the second case takes advantage of the virtues of a verified artist account to focus on the production edition and circulation of sound texts belonging to musicians of the circuit afromamas verified artist profile shows in its playlist phonograms belonging to musicians who are part of its staff and regularly participate in live performances in addition each phonogram produced and edited by afromama has a cover image that contains the same identification logo with minimal variations between each file distinguishing them from those files that the user profile did not produce but have only been selected for the repertoire the background colors on each cover change from dark burgundy to purple the inscription below the logo allows reading the name of the phonogram and below it the name of the jbm together with the name of the works author the uniformity of aesthetic features in the covers together with the visualization of the works in list format offered by the playlist generate an effect of homogenization among the phonograms giving them a sense of identification with the profile of the user that contains them playlists in the context of jbms have a triple function the fruition of listening in a ubiquitous context they function as the repertoire for the musicians participating in the performance the edition and circulation of new phonographic texts produced by the artists participating in the live performances thanks to the facilities offered by the platform and the digital technology of music production creating repertoires in jam sessions through playlists implies a more dynamic interaction flow than the real books in the jazz sphere the playlists offer the possibility of putting into play a type of media capital not available to the participants in previous media moments that is to say the possibility that the jam sessions put into circulation discographic material of the participating musicians when in jazz jam the actantial potential of the musician passes through the capacity to modify a canonized work at the moment of the performance but the archives are not modified and remain crystallized as part of a canon this means that the change in media format is also related to the type of performances each type of jam session offers in the case of jazz it is a type of performance where each execution of a sound piece has an aesthetic value regardless of the works identity in the repertoire in musicology this type of performance is called simpliciter on the other hand in the jbms the interpretations tend to reproduce the texts in their original form or with previously rehearsed variations restricting the moments of improvisation to minor lapses and where the artists seek to make their repertoire known and stimulate the circulation of its contents in platforms in the jbms the enunciative character of the repertoires does not depend on the type of interpretation made of the sonorous texts instead the enunciative and actantial value resides in the fact that the jam session participants can include their songs within a repertoire that includes established artists in the semiosphere the possibilities of editing and circulating sonorous files offered by the jbms are practices that in other media belonged exclusively to production companies and record labels final considerations this paper has described aspects inherent to the formation and maintenance of virtual and nonvirtual communities based on the use of different types of playlists which in a temporal trajectory crystallize in discursive styles belonging to the contemporary synchronic plane of the semiosphere the description of the radiooooo platform allows us to account for the formation of a virtual community based on an interactional flow guaranteed by the platforms playlists radiooooo bases its media proposal on collaborative playlisting in this way it is possible to distinguish a musical experience aimed at showing exotic artists and songs from the desire to explore music in different geographies and periods it is a nonalgorithmic way of getting to know new artists and musical styles based on user collaboration the platform organizes the operation of various playlist types with files automatically ordered by default but generated by each users contribution opening playlists in countries and eras previously blocked on the platform due to lack of files radiooooo also shows the enunciative capacity of the playlist as it guarantees stylistic attributes that generate a collective identity in this context the playlists actantial potential is seen both in the collecting impetus of its users and in the search for unknown moments and strange places for the listener as for the alternative uses of playlists in spotify we refer to implementing the playlist to guarantee the repertoire and its individual enunciative features in a circuit of black music jam sessions the playlists work by codifying the aesthetics of black music in individual styles offered by each jam session that is by attending to individual enunciative modalities adopted by each space the playlists as a repertoire of the jbms influence cognitive aspects linked to the learning of the musical pieces and the interaction between the musicians for their interpretation an example of this is the elimination of solfège as a necessary practice to access the repertoire this aspect modifies the musical competencies put into play among the circuit musicians all these highlight the emergence of a mediatic capital previously nonexistent in these contexts the possibility of including sonorous texts and putting them into circulation within a broad user community through the playlists of the jbms prioritizes exposure and reproduction over the extempore modification of the archive at the moment of the performance it is noteworthy finally that the mediatization of the playlist format in the cases analyzed reinforces the song format as a type of textual organization as opposed to other ways of conceiving musical pieces

his paper analyzes the notion of playlists as a sociosemiotic category in the context of the mediatization of contemporary popular music by studying its uses in virtual and nonvirtual communities we propose that the digital mediatization of playlists affects contemporary cultural forms shaping social modes of conceiving music as they enable new forms of interaction in the present moment our investigation focuses on different ways digital mediatization of playlists contributes to creating virtual communities and transforming performative practices in nonvirtual communities of musicians in our analysis we consider the playlist as a format a category of action that encodes cultures in different social groups in a diachronic trajectory it may involve the evolutionary development of musical genres or practices of production and recognition in which the use of playlists and their interactive possibilities as repertoire affect how the digital memory of the semiosphere is encoded

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introduction infectious diseases are a major contributor to racial and ethnic mortality disparities in the united states with inequities in social vulnerability factors being considered key contributors 12 in areas populated by a majority of racially and ethnically minoritized individuals these inequities may impact patients ability and perceived need to access health care differences in healthcare utilization inevitably translate to an increased reliance on higher acuity resources within rem communities such as emergency departments and urgent care 3 urinary tract infections are one of the leading outpatient indications for antimicrobial therapy and while associated morbidity may be low injudicious antimicrobial use represents a risk of inappropriate prescribing 45 there is a paucity of literature that explores racial ethnic and sv differences in the outpatient treatment of uti 4 here we attempt to describe racial and sv differences in the utilization of ed and uc resources for the treatment of uti with a focus on uncomplicated cystitis as a first step to improving prescribing and treatment practices in vulnerable communities methods study design patient population and location this retrospective observational study evaluated adult patients with a diagnosis of cystitis treated in the ed and two uc centers associated with loma linda university health from january 1 2021 to april 30 2021 patients were included if they had a urine culture collected in the ed or uc and were diagnosed with acute cystitis by international classificaiton of disease code n30 patients were dichotomized to rem and nonracially and ethnically minoritized groups based on patientreported race and ethnicity rem groups include selfidentified race as black or african american asian or pacific islander middle eastern or hispanic origin or latin race as well as selfidentified ethnicity of hispanic or latino and the nrem group only included selfidentified race as white with an ethnicity not defined as hispanic or latino this study was approved by the institutional review board of loma linda university data collection and study definitions patient demographic information and comorbid conditions were collected by chart review urine culture microbiologic results were recorded only for initial cultures collected in the ed or uc admission and discharge dates were collected and a length of stay longer than 2 days was selected to identify patients likely requiring inpatient admission antibiotic susceptibility was defined by clsi m100 encounter antimicrobials were defined only as antimicrobials given during ed or uc encounter discharge antimicrobials were recorded results study population during the study period 250 patients with either an ed or uc encounter with a diagnosis of acute cystitis were screened and 114 rem patients and 73 nrem patients were included patients identifying as female were most represented and most patients were overweight or obese in the rem group 79 patients identified as hispanic or latino 20 patients identified as black nonhispanic and 13 identified as asian rem patients were significantly younger than nrem patients despite differences in age there was no statistically significant difference in comorbidities between rem and nrem groups with similar rates of diabetes and chronic kidney disease rem patients were also significantly more likely to be at the highest level of sv group when compared to nrem patients microbiology and treatment the most commonly isolated primary organism was escherichia coli followed by klebsiella spp and 55 patients had only mixed flora isolated on urinary cultures ceftriaxone was the most common antimicrobial administered during ec or ud encounters while 89 patients received no antimicrobials during their encounters on discharge 168 patients were prescribed oral antibiotics most commonly cephalexin or nitrofurantoin consistent with local antimicrobial susceptibility rem patients were less likely to have documented susceptibility and more likely to have documented resistance to the agent prescribed on discharge when compared to nrem patients although these differences were not statistically significant only eight patients across both groups had antimicrobials adjusted after discharge when culture susceptibilities resulted rem patients were also less likely to have a length of stay longer than 2 days when compared to nrem patients although this difference was also not statistically significant discussion in this study our findings identified no significant differences in the treatment approaches or outcomes between these rem and nrem groups however notable demographic differences were appreciated including age differences in comorbidities which may contribute to the increased likelihood of required readmission and significant svi disparities in the rem cohort these results denote a potential area for the development of edor ucspecific clinical pathways for rem patients who present with suspected utis to hospital centers that primarily serve vulnerable communities recognizing the significance of age as a potential factor in healthcare disparities efforts can be directed toward tailoring educational materials and interventions specifically for this demographic by considering the unique needs and health literacy of this population healthcare providers and organizations can potentially engage patients in lifestyle changes to prevent uncomplicated cystitis microbiological distribution of uropathogens was similar between rem and nrem patients however rem patients were more likely to have been prescribed antimicrobials on discharge with documented inactivity against their uropathogen which may have collateral effects and result in a need for continued ed and uc utilization and incurred costs 78 these study results highlight opportunities to improve both institutional empiric and culturedirected antimicrobial use this study has several limitations to consider the retrospective nature of this study and reliance on icd10 diagnosis rather than clinical presentation likely limits the accuracy of uti diagnosis although these diagnosis codes likely indicate provider perception it is important to note that the study aimed to describe differences between rem and nrem patients with uti and outcomes were not available for comparison assessments of health literacy were also missing which is a recognized independent predictor of health behaviors and could further impact outcomes 9 finally our institution serves a predominantly hispanic population within an area of high sv to gain a more comprehensive understanding of health disparities in uncomplicated cystitis future studies should include patients from low to moderate svi and evaluate the impact of both deprivation and health literacy on clinical outcomes

racially and ethnically minoritized rem patients are disproportionately impacted by infectious diseases in our study rem patients were more likely to receive care for urinary tract infections in the emergency department or urgent care were younger and were more likely to have higher social vulnerability

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introduction violence against women is a major public health problem a gender inequality issue and a human rights violation there are significant serious and longlasting impacts of violence on womens physical and mental health including injuries unintended pregnancy adverse birth outcomes abortion hiv and sexually transmitted infections depression alcoholuse disorders and other mental health problems 1 2 3 4 5 the 2030 sustainable development goals sdgs include as one of their targets under goal 5 on gender equality the elimination of all forms of violence against women and girls indicator 521 measuring intimate partner violence ipv proportion of everpartnered women and girls aged 15 years and older subjected to physical sexual or psychological violence by a current or former intimate partner in the previous 12 months is proposed to track the measurement of progress in achieving this goal the indicator does not include an upper age limit and data on older women including but not limited to intimate partner violence are needed to support national and global monitoring of violence against women of all ages including for monitoring of the sdgs the majority of existing violence against women surveys and data have focused on women of reproductive age as they suffer the brunt of intimate partner violence and nonpartner sexual violence 6 a growing number of surveys are now including women older than 49 years however globally there is sparse evidence concerning patterns of and types of violence against women aged 50 and older and limited understanding of barriers to reporting and helpseeking amongst older women who are subjected to violence 7 compared to women of reproductive age women aged 50 and above may experience different relationship dynamics which influence forms of abuse 89 and some evidence indicates that older women experience different types of violence for example psychological violence and verbal abuse compared to younger womens experiences of physical and sexual violence 10 for older women recent exposure to violence may be interlinked with violence victimization at different stages of the lifecourse 1112 dynamics of ageing may shape experiences of violence for example provision of care to a dependent partner may influence decisions to disclose or report abuse 10 they are also more likely to experience violence from other family members including children and from carers currently the evidencebase of qualitative and quantitative data concerning violence against older women is limited and a better understanding of these differing patterns and dynamics is needed to ensure appropriate policy or programmatic responses to violence against older women and service development and provision for older women affected by violence 1011 to address these gaps in the evidence we conducted a systematic review of qualitative literature on violence against older women current frameworks on violence against women and existing evidence gaps in research and evidence stem in part from conflicting theoretical approaches definitions and conceptual frameworks concerning violence against older women the dominant theoretical frameworks are the older adult mistreatment framework and older adult protection framework 71314 the older adult mistreatment framework conceptualizes violence against older women as a form of elder abuse focusing on age as the primary factor influencing vulnerability to exposure to violence the older adult protection framework specifically understands violence within the context of caregiving and institutional arrangements where older adults often be gender neutral and the adult protection framework can result in a framing of older adults as inherently impaired and vulnerable in addition the ipv framework primarily understands vulnerability to violence in terms of gender inequality and partnership dynamics which may neglect analysis of how ageing and partner violence intersect these differing frameworks inform multiple aspects of research including study design data collection and analysis and reporting resulting in fragmented data and evidence for example some research utilizing the older adult mistreatment framework lacks a focus on the gendered dimensions of violence 1415 and other studies have solely focused on women in institutional settings neglecting measurement of violence perpetrated by intimate partners and other family members 13 existing syntheses of evidence on violence against older women often reflect these differing conceptual frameworks employing an older adult mistreatment framework a systematic review of quantitative studies of elder abuse found that the global prevalence of elder abuse in community settings is 157 in the past year with psychological abuse and financial abuse as the most prevalent forms of abuse reported 16 this review reported prevalence by type of violence but did not report on perpetrators analysis of studies conducted in institutional settings found women aged 60 and above to be significantly more vulnerable to abuse with psychological abuse as the most prevalent form of violence followed by physical violence neglect financial and sexual abuse 17 this analysis included data reporting stafftoresident abuse analysis of quantitative data of women aged 60 and above in the systematic review of quantitative studies of elder abuse found a global prevalence of elder abuse against women of 141 in the past year with psychological abuse reported as the most prevalent form of violence followed by neglect 16 the focus of this review was prevalence of different subtypes of violence and type of perpetrator was not considered another systematic review of quantitative data on interpersonal violence against older women in community dwellings primarily employed an ipv framework finding prevalence of reported interpersonal violence ranged from 6 to 59 over a lifetime from 6 to 18 since turning 50 and 08 to 11 in the past year however results indicated that definitions of violence vary widely and affect prevalence estimates 18 syntheses of quantitative literature have identified prevalent forms of violence against older women highlighting limitations in the evidencebase due to variations in definitions and methodology and a primary emphasis on populations in highincome western countries these reviews have captured a wide range of types of violence however have not considered type of perpetrators or patterns of cooccurring types of violence alongside these systematic reviews of quantitative data some reviews have included qualitative and mixed methods studies an empirical review of ipv in later life examined 27 quantitative 22 qualitative and 7 mixedmethods studies finding that forms of ipv amongst older women in later life shifted from a higher prevalence of physical and sexual abuse during reproductive years to a higher prevalence of forms of psychological abuse 19 a review of qualitative research on ipv amongst older women identified a number of relevant themes including patterns of abuse that were continuous and consistent with previous experiences of abuse in families of origin and previous relationships 20 a systematic review and metasynthesis of qualitative studies of ipv and older women focused on how previous exposure to ipv influenced healthseeking behaviours specifically mental health care 21 an empirical review of quantitative and qualitative studies of sexual violence against older people identified widespread variation in prevalence rates across studies and a range of perpetrators primarily intimate partners or adult children 22 a recent narrative review of quantitative qualitative and mixed methods studies of ipv against women aged 45 and above concluded that womens age and life transitions mean that they may experience abuse differently to younger women they also face unique barriers to accessing help such as disability and dependence on their partners 23 however amongst these existing systematic reviews of qualitative literature none have focused specifically on older women while also being inclusive of any form of violence in order to improve understanding of violence against older women it is important to explore patterns dynamics and experiences through examination of the qualitative literature qualitative data on violence against older women complements quantitative evidence not only by offering insight into lived experiences of older women subjected to violence but also by expanding and clarifying types of violence perpetrators linkages to particular risk factors and physical mental and social impacts of violence against older women in the present review we aimed to build on previous systematic reviews and strengthen the evidencebase by i including studies and evidence focused specifically on women ii including any form of violence against women rather than adopting a specific theoretical framework on what types of violence or perpetrators should be included from the outset iii focusing on women aged 50 and above and iv focusing specifically on qualitative studies to explore the nature and dynamics of violence against older women from the perspective of women we aimed to identify evaluate and synthesize qualitative studies from all countries exploring violence against women aged 50 and above identifying types and patterns of violence perpetrators of violence and impacts of violence on various outcomes for older women including physical and mental health and social support and womens responses to experiences of violence we include the following forms of violence elder abuse family violence and intimate partner violence elder abuse is defined as single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person 24 intimate partner violence is defined as behaviour by an intimate partner or expartner that causes physical sexual or psychological harm including physical aggression sexual coercion psychological abuse and controlling behaviours 25 family violence is often used interchangeable with intimate partner violence however also encompasses abuse and violence perpetrated by other family members for example adult children or inlaws while there is no universal agreedupon definition of older women for the purposes of this review we define older women as women aged 50 and above while recognizing that aging and age are social phenomenon and definitions vary across organizations cultures and communities the protocol was preregistered with prospero registration number crd42019119467 phpidcrd42019119467 methods search strategy in this systematic review we searched 11 electronic databasespubmed psycinfo embase cinahl pilots eric social work abstracts international bibliography of the social sciences social services abstracts proquest criminal justice and dissertations theses global from 1990 we conducted searches that combined the following domains as part of the research question 1 age and 2 women and 3 violence and 4 qualitative methodology for each of these domains we identified the relevant keywords and search terms which varied by database the search strategy was appropriately modified for each database including syntax and specific terms topics and or headings the search strategy for pubmed is included in s1 file searches were conducted in april 2018 and updated in july 2019 we did not limit the search by year of publication or language we also hand searched reference lists of relevant existing systematic reviews which we identified both through background research and through the formal database searches and reviewed relevant references we consulted with 49 experts on violence against older women or older adults including researchers practitioners and policy makers from all regions globally all experts were contacted and followedup with a minimum of 2 contacts 26 experts responded with 424 articles 64 of which were duplicates we reviewed the full text of 43 articles and ultimately included 2 in the full review grey literature was not systematically searched grey literature submitted by experts was initially considered for inclusion however conducting comparable data extraction and quality assessment for grey literature alongside the peerreviewed literature was not possible we identified 18 nonenglish language articles for fulltext review for 17 of these articles we identified a native speaker external reviewer who was provided with inclusion and exclusion criteria and consulted with authors regarding final inclusion one nonenglish article was not reviewed as the research team could not engage a farsi speaker to review the article the external reviewers consulted with srm to decide on inclusion of full texts and conducted data extraction and quality assessment on 3 articles identified for inclusion 27 28 29 study selection and data extraction after removing duplicates study selection proceeded in two stages in the first stage two authors reviewed titles and abstracts of all identified manuscripts we included studies that met the following criteria i focused on women aged 50 and older ii employed qualitative methodology and iii focused on womens experiences of any type of violence perpetrated by any type of perpetrator studies including men or also including women aged younger than 50 were included if specific and separate sex and agespecific analyses were included we included studies employing any type of qualitative methodology and mixed methods studies were included if qualitative data was presented separately studies were excluded if the whole sample was children adolescents or adults under the age of 50 if the sample only included men if the methodology was quantitative or in the case of mixed methods studies if the qualitative results were not separately presented and if the data only included the perspectives on violence against women as reported by care providers health professionals legal professionals and nursing home managers after the first stage of title and abstract review we reviewed the full text of any manuscript considered relevant by either of the authors in the second stage two authors independently reviewed all articles selected for full text review for eligibility to reach consensus on inclusion any discrepancies were resolved with the input of an external reviewer we designed a data extraction excel spreadsheet specifically for the purposes of the review including characteristics of included studies methodology characteristics of the sample types and nature of violence we extracted main findings participant quotations where possible and study limitations if reported data extraction was conducted by one author and checked for accuracy by a second author with discrepancies resolved by discussion to reach consensus quality assessment all included studies were assessed for quality using an adapted version of the critical appraisal skills programme casp scale the adapted scale included the following questions 30 1 was there a clear statement of the aims of the research 2 is a qualitative methodology appropriate 3 are the setting and context described adequately 4 was the research design appropriate to address the aims of the research 5 is the sampling strategy described and is this appropriate 6 is the data collection strategy described and justified 7 is the data analysis described and is this appropriate 8 are the claims madefindings supported by sufficient evidence 9 is there evidence of reflexivity two authors assessed the quality of the studies assigning a 1 for each affirmative response and 0 for each negative response for a final score out of 10 disagreement was resolved by discussion between the two authors quality assessment was not used to determine if any studies should be excluded but rather to assess the strength of each study synthesis an excel spreadsheet to compile all relevant findings and quotations from the studies for thematic analysis was developed two of the authors coded the main findings extracted from each study we used linebyline coding on a subset of articles developing a set of overarching themes and subthemes for a draft codebook the coding proceeded as an iterative process with the two authors each separately coding the main findings using the draft codebook discussing coding results and refining the codebook based on overlap and redundancies identified after all data were coded we tallied all occurrences of each code and further explored areas of overlap and merged subthemes with low numbers of codes finalizing the broad themes and focused subthemes for nonenglish articles included the external reviewer translated primary quotations into english and thematic analysis on these articles was conducted alongside the english language articles reporting the synthesis and all aspects of the systematic review process are reported following the 21item checklist provided in the enhancing transparency in reporting the synthesis of qualitative research statement 31 and the prisma checklist s2 and s3 files results studies identified and characteristics our searches of 11 databases yielded 9318 articles with an additional 468 articles identified through crossreferencing and expert recommendation after removing duplicates 7834 articles remained we identified 417 articles that were potentially eligible and included in full text screening two of these articles had not yet been published additionally 1 farsi language study was unable to be translated and assessed against the selection criteria fiftytwo articles met criteria for inclusion in this systematic review the 52 included articles represent data from 31 studies overview of study characteristics study setting most studies were conducted in highincome countries including the united states of america israel canada the united kingdom hong kong and australia six articles were from uppermiddle income countriesbrazil mexico and iran and three articles were from lowincome countriesuganda and ethiopia one article came from india a lowermiddle income country quality assessment application of the adapted version of casp scale yielded variable results across the 52 articles assessed see table 2 ratings of research methodology statement of research aims and selection of appropriate research design were overall high the majority 29 descriptions and patterns of types of violence older women described ipv family violence and elder abuse of various types perpetrated by a range of perpetrators 80 older women described ongoing instances of neglect verbal abuse and financial exploitation in a study conducted in india 41 in other cases physical violence characterized earlier and ongoing experiences of violence within intimate partner relationships 37404754 ipv in particular was described by older women as occurring throughout different stages in the relationship spanning their youth and into older age older women often experienced an escalation of ipv and controlling behaviors despite the age and or illness of their partner 364046616977 changing relationship dynamics due to ageingincluding a husbands retirement children leaving the home women wanting to engage in activities outside of the home or diagnosis of a chronic or terminal illnesstriggered escalating ipv 364046475669 shifts in types of violence from predominantly physical violence to predominant psychological abuse and neglect were commonly described in studies that encompassed previous and ongoing ipv 3451 studies focused on ipv commonly described both previous and ongoing violence and a smaller number described only or primarily violence experienced while aged 50 or above 6469 violence occurring within the family was discussed in 15 articles 353943444648495563666869717679 with perpetrators including family members not including children 27434448495963686971 and adult children 353948667679 studies captured instances of physical and verbal aggression by mentally ill adult children against older women 66 violence enacted by elderly with dementia against older women who were caregivers 46 and forms of neglect financial exploitation and emotional abuse enacted by family members including children 44 the majority of these studies focused on violence experienced in older age while one study explored dynamics of abuse between children and mothers across the lifespan 3539 10 articles reported on experiences of elder abuse 283235434455 57 58 59 78 with perpetrators including community members 4344 caregivers 5759 nursing home residents 58 and health care providers 28 types of elder abuse included verbal abuse physical assault and inappropriate sexual advances 58 and sexual assault 59 financial control spanned instances of elder abuse family violence and ipv 435362647678 and was described as cooccurring with and resulting in other forms of violence financial exploitation could result in emotional and or physical violence if older women resisted control 6264 an older woman explained that in the context of her relationship with her husband if i did not follow his control over money he would be verbally abusive 64 themes and subthemes identified through coding are displayed in table 3 there was violence along with suffering for many years it was a suffering but i had a goal behind all this suffering to have my children grow get married and get an education i dont know if the suffering was worthwhile for me i dont know if it was worthwhile as it was very difficult today i look and say that i was a heroine i was a heroine myself with all the things i went through during the 40 years 42 when i was bringing up the children i thought of nothing else i just wanted to bring them up actually my forgiveness was for the sake of the home and the children without any consideration for myself i did not value myself at all i was the doormat of the entire household when there was anger and quarrelling none of the children came to ask about it they never said anything when he raised his hands they did not go and ask him why he was hitting their mother nothing perpetratorrelated factors ageing perpetrators and continuity of abuse although mrs v had not been hit in many years she was submissive to her husband and distraught about the continuing marital rape among the tactics used by mr v to control his wife were prohibiting her from driving working outside of the home or managing money 59 treat him well take care of him and everything will be ok 47 if i complained about him he said that when i called the police before the police arrive id be dead i did not know that there is help for intimate partner violence cases i did not know because i had no friends i did not talk to anyone my life was from home to work and from work to home he beat me sometimes 81 perceptions of abuse and violence as normal i mean i suppose you could say i have been abused ive never been badly beaten but i have been hit and with all the temper and that sort of thing but then there was never anywhere to go and im really not aware that theres anywhere specifically for older people and im not aware that they even do anything 55 272932415570717475 most of the time they physicians think you are just getting a little carried away you are a little highstrung you are very nervous you have always been this way so calm down so i didnt go to the doctor when he beat me so badly its a little embarrassing at my age 74 lifelong ipv continuation of patterns of ipv in old age he started beating me on the second day of our marriage hes been hitting me all these years 71 33404959 70 71 72 77 earlier experiences of violence he started beating me on the second day of our marriage hes been hitting me all these years 71 48495761707180 cumulative impacts of violence the worst thing is that so many years of abuse caused me many health problems especially with my nerves and depression this was due to mistreatment no one can have happiness or live well dealing with so much trouble i also have other health problems but the worst for me are those related to my nerves depression and lack of sleep i have back problems high cholesterol ulcers anemia and i have a liver problem a lot of problems it never ends even after getting divorce we still suffer the consequences 81 343741475051546768 i have a problem with my stomach i did five tests and nothing was found it is the anger i swallow i have this pain in my stomach because the anger i feel of him 68 bruises heal in time but words last forever when you are told over and over how stupid ugly and insane you are you really believe it i am not financially or physically capable of going anywhere 51 intersection of ageing and violence a number of subthemes emerged emphasizing the interconnections between the experience of ageing amongst older women and dynamics impacts experiences and perceptions of violence suffering loneliness regret and guilt older women emphasized suffering loneliness regret and guilt in their accounts of living and coping with violence particularly psychological violence 34 37 38 40 42 44 45 47 5052 54 56 62 66 75 78 79 within the context of ipv women described experiences of loneliness in terms of detachment from family members including abusive partners and adult children who often criticized older womens responses to violence 33343738404256 respondents linked regret with time and age emphasizing previous decisions lost opportunities and wasting time due to living with an abusive partner 33343745 one respondent said i was an idiot woman no woman lives like that cooking and serving him after the beating i say that i was an idiot 42 older women expressed feelings of guilt over the abuse they experienced and regret and guilt for exposing theme subtheme illustrative quotation s supporting references needs of older women affected by violence social and community support if my friends knew the truth about who i was living with then they would become really angry with me i was losing contact with my friends because they were saying how could you let him treat you like this particularly when you are in such dire need of support it was easier for me to just be quiet but its very difficult to go through such an abusive situation without having friends to talk with though i did lose some friends 64 41 4552646568 75 76 77 78 i never invite any of my friends or relatives to come home because of the fear that he will insult them none comes to visit me because i have stopped calling them 41 i coping mechanisms leaving a relationship i didnt like the way my daughterinlaw treated me so i asked my son to find me another place to stay another son of mine was here so he found a place for both of us to stay 76 33 34 37 38 42 4548 57 65 69 70 73 76 isolation substance use and emotionbased coping strategies i coped by going into my own private world i took valium i saw myself as a failure and felt sorry for myself 50 why would i need this kind of life how can a man do things like that why did i agree to that what do i have inside me today it is all empty an empty shell what am i left with nothing all together my entire life was for nothing a big loss i destroyed it all i gave up on myself became nonexistent i think i am a lost case i am the loser in all this what is left i am all eaten up i have no emotional strength left i dont feel like doing anything 47 behaviors to enhance safety the two years were coming up for the restraining order i start getting these nightmares hes going to be at my door wanting to move in i was living here and he was living in place about a mile from home so i go back to court and apply for renewal of the restraining order and i am told there is no such thing as a renewal you just apply again 70 3667697075 their children to violence 38455052546679 several studies linked suffering regret and loneliness specifically to psychological violence which was described as more prominent in older age pervasive and damaging to social relationships and selfesteem 5156 the studies that explored these themes primarily encompassed accounts of violence experienced throughout intimate relationshipswhile women were younger and through to older age these experiences were described and conceptualized by older women as interlinked and continuity of victimization by intimate partners was emphasized rather than viewing womens experiences of violence in older age as distinct or separate violence ageing and vulnerabilities older women described that ageing diminished their physical and emotional capabilities to cope with experiences of violence 33373947 this subtheme appeared in 12 manuscripts 333739404347485355596276 and was expressed in relation to various forms of violenceipv 333747 including violence perpetrated by a spouse due to dementia 40 violence in the context of a new relationship or second marriage 4853555962 violence perpetrated by a mentally ill child 39 violence perpetrated by childreninlaw 76 and elder abuse 43 these studies primarily focused on current experiences of violence of older women as changes in physical and emotional capacity to cope was described in relation to present victimization as a result of diminishing physical and cognitive capacities of ageing old women experienced vulnerabilities and dependency dynamicswith partners adult children and caregiversthat exposed them to situations of abuse 4447525657616466 a mother of an adult son with schizophrenia explained when i was younger i could overcome him faster save myself now that im old and i have diabetes now i have to be faster now im afraid for my life afraid he will kill me 39 women reported that lack of financial autonomy often compounded by years of controlling behaviors perpetrated by a violent spouse was a central factor in women remaining in abusive spousal caregiving and family relationships 4447525664 perpetratorrelated factors some included studies reported on perpetratorrelated factors that initiated or exacerbated forms of violence against older women ageing perpetrators and continuity of abuse older women emphasized contexts surrounding ipv in which the perpetrator continues to exercise control power and violence despite their failing health and old age 41 4749 51 56 59 72 76 77 women also described shifting forms of violence predominantly from physical and or sexual to psychological violence and controlling behaviours 364550516172 while sometimes the experience of physical and or sexual violence declined psychological violence persisted and sometimes escalated 505172 while describing the impacts of continual and intense psychological violence one woman said he destroys you you are not even a person anymore 72 controlling behaviours were also experienced in the context of cultural norms for example in a study of sri lankan immigrant women in canada older women described forms of control enacted by children and childreninlaw one older women reported h e the soninlaw thinks that i am a widow and why should i have anything on my own name and why cant i give everything to them and just be a slave to them 76 perpetrators illness as a cause of violence this subtheme only emerged in three manuscripts 404669 however it is the only instance among the included studies in which older women described first or new experiences of ipv in older age older women who provided care for spouses with dementia reported aggressive behavior physical violence and verbal abuse 4069 in one study a woman reported i dont know whats going on with my husband hes never been like that never hit me before im really worried about him hes been changing so much we have been married for 47 years he seems another person 46 another study found that women who had experienced lifelong ipv understood dementiarelated violence as a continuation of aggression dominance and abuse whereas women who had only been exposed to dementiarelated violence took solace in a diagnosis felt grief over the loss of their spouse as he used to be and tried to maintain intimacy and affection in a previously caring and loving relationship 40 social and gender norms regarding response to violence older women described the ways in which social and gender norms shaped their experiences of and responses to violence silence stigma and family descriptions of social and gender norms that encouraged women to stay in abusive marriages and prioritize childrens needs above their own were common across studies 3335 38 4042 46 48 57 6569 71 7376 79 80 older women described several social norms that shaped their past decisions in response to violence including silence surrounding violence and the reporting of violence 4180 fears of shame and stigma related to leaving a marriage 656973 and ideals of being a good mother by putting up with violence for the sake of her children 384274 one woman explained there was violence along with suffering for many years but i had a goal behind all this suffering to have my children grow get married and get an education i dont know if the suffering was worthwhile for me i dont know if it was worthwhile as it was very difficult 42 remaining in a relationship as a strategy was often employed due to older women feeling obligated to care for an abusive partner who was now sick or unable to live alone 33 one respondent explained if i leave him its not good my conscience wont allow it at his age 76 its not nice to leave and neglect him i dont have feelings for him i respect him because hes old and because hes my husband i have to care for him 33 these studies primarily focused on previous and current experiences of violence social norms predominant when women were younger shaped prior and current responses while one study of sri lankan immigrant older women focused on social norms governing current decisions relating to womens responses to abuse from children and childreninlaw 76 in several cases remaining in the relationship was a coping mechanism of last resort given the multiple barriers present to women leaving the relationship whether with an intimate partner other family member or caregiver 48 women also described strong beliefs in social norms that supported staying with a sick or frail abusive partner or abusive child 33354046576676 many women viewed seeking help and confiding in others as embarrassing and unacceptable one woman explained i was ashamed i just didnt want to admit thats the situation i was in 80 perceptions of abuse and violence as normal in some of the included manuscripts older women perceived violence as normal sometimes explaining that they preferred not to term their experiences as abuse or violence 32415570717475 older women infrequently perceived verbal and emotional abuse as violence 32 and some women did not identify as a victim of violence 5571 one woman described her process of realizing that her experiences were forms of abuse well i really didnt recognize it as abuse and as soon as i got that message i felt that i got on a very clear track now i know what im dealing with and i can do something about it 74 moreover service providers and the legal system often failed to recognize financial exploitation or verbal abuse as abuse 4174 or that older women could be affected by ipv 75 in rural kentucky usa older women explained that the longer they were in the relationship with their abuser the more the violence became more normalized and accepted 70 studies also emphasized how ageist attitudes normalizes forms of coercive control enabling abusers to take advantage of older womens age frailty and illness for example appropriating part or all of the victims property 434457 lifelong ipv many older women described experiences of ipv throughout their lifecourse several subthemes were identified related to lifelong patterns of violence cumulative consequences of ipv and linkages of violence in older age to earlier experiences of violence continuation of patterns of ipv in old age older women described experiences of ipv in older age as a continuation of the patterns of violence experienced throughout the relationship 33404959 70 71 72 77 several articles described years to decades long relationships characterized by ipv 40707177 for example older women living in rural kentucky usa explained that the longer they were in the relationship with their abuser the more the violence became more normalized and accepted 70 earlier experiences of violence associations between older womens earlier experiences with violence including witnessing of violence as a child and current experiences of ipv were discussed in several articles 484961707180 for example in a study by roberto and colleagues many women who had experienced physical abuse as a child or young woman interpreted controlling behaviors as love and did not recognize emotional abuse later in life until the abuse became physical or affected their health 61 linkages were also uncovered between experiences of abuse as a child or young woman with current abuse by their adult children 5771 cumulative impacts of violence older women described several consequences of experiences of lifelong ipv in one study older women related the impacts of lifelong violence to that of a chronic illness which alters or limits ones quality of life 47 older women frequently linked experiences of violence with physical health consequences including bodily pain reduced mobility and hearing problems 37475467 as well as mental health and emotional impacts including depression 4150515467 anxiety 5467 panic attacks 54 suicidal ideation 41 loneliness 3451 and loss of selfesteem 34505154 needs of older women affected by violence older women who reported exposure to violence described various needs in terms of social support access to services and issues accessing these services due to their age social and community support older women commonly described isolation from family and friends and a lack of social and community support as a result of violent and controlling behaviors from an intimate partner 4145526465 75 76 77 78 one older woman stated i cannot remember not one time not having the hell beat out of me black and blue i wasnt even allowed outside i couldnt open my mouth i couldnt talk i couldnt have friends i had neighbors and they didnt know me he threatened to kill me if i ever told anyone what was going on 70 additionally factors that were reported to impede access to social and community support included being an immigrant with limited language skills 676876 and living in rural areas with strong norms against reporting ipv 52 barriers to accessing services several articles identified specific barriers for older women to access services and for health care utilization including lack of awareness of services 525455577476 older women reported several concerns when interacting with health care providers including health care providers assumptions that older women could not be experiencing violence due to their age minimization of forms of abuse common to older women and lack of confidentiality when using the same provider as their spouse 74 one respondent explained and when you go to the doctor they run down the list and then its always you know well is it abuse well yes emotional well what kind of emotional verbal oh ok and they mark it and thats it 74 coping mechanisms older women reported various approaches to coping with the experience and impacts of different forms of violence often employing several different coping mechanisms such as leaving relationship with an abuser and emotionbased coping strategies such as alcohol or drug usage in order to navigate difficult decisions maintain their health and wellbeing and protect other family members in the context of exposure to violence leaving a relationship in 11 of the included manuscripts older women described remaining in an abusive relationship family context or caregiver relationship as a form of coping 3334384245464857657073 and in six manuscripts leaving a relationship was employed as a coping mechanism 424561697677 in one study older women explained that they had previously not been able to leave a relationship with an intimate partner for the sake of their children whereas once their children had left the house they felt freer to reject violent behavior 42 older womens own health problems were described as a trigger for choosing to leave an abusive relationship 61 isolation substance use and emotionbased coping strategies older women described isolating themselves from family friends and social support using alcohol or drugs to cope with experiences of violence and reframing experiences of violence often through minimizing experiences 33 34 3739 47 50 51 61 68 69 73 79 older women explained that if they were to seek support family or friends would blame them for their experiences of violence leading women to choose social isolation as a coping strategy 5069 older women also described using drugs and alcohol as a means to numb themselves to their daily experiences of violence 50 one woman explained he got his medical partner to prescribe valium for me in the 1970s and i am still taking it especially when i feel hopeless and in despair i know that i am addicted to it and worry that at 68 years i will never be able to survive without them 50 older women also reported employing forgiveness of violent and controlling intimate partners as a coping mechanism 3438 older women who remained in a relationship with their abuser often described employing emotional detachment as another coping strategy 33374769 lastly older women described how they reframed their experiences of abuse by excusing abusive spouses for their actions or employing strategies to deliberately diminish the severity of abuse such as forgetting experiences of abuse 3438616873 while emotional detachment was described as causing isolation and loneliness older women also perceived it as a form of inner resistance 37 a vital means of opposing intimacy and connection with an abusive partner and as particularly vital in the case of ipv where the safety of a womans home is threatened by violence 47 behaviors to enhance safety older women described taking actions in order to enhance their own safety in the face of violence 3667697075 in some instances older women first called police or applied for formal legal support such as a protection order in the face of violence in one study a woman explained i called the police because he my partner pushed me down on the countertop and poured a cup of tea over me it was as though he wanted to strangle me they took him into custody for 24 hours 36 in several instances legal authorities including police provided limited support leaving women unable to find longterm solutions to the violence they experienced 70 discussion this systematic review was motivated by a need to improve understanding of similarities and differences in dynamics patterns and experiences of violence against older women in a context whereby the vast majority of research evidence policy and service provision is targeted towards women of reproductive age we reviewed available qualitative studies on violence against older women in order to address existing gaps in evidence and data we also sought to provide insight into the lived experiences of older women experiencing violence and an understanding of the types and patterns of violence perpetrators of violence and health impacts of violence among older women the included studies primarily address ipv with fewer emerging from the older adult mistreatment framework most research examined specific types of violence in isolation for example ipv or abuse from an adult child and there were no examples of studies that included polyvictimization or experiences of any type of violence against older women the strong emphasis on older womens experiences of ipv gives voice to the experiences of older women subjected to violence and shows how it can persist over time however some sites perpetrators and types of violence against older women may be excluded from view including that of violence enacted by other family members and nonfamily caregivers and of women living in institutional care the findings in our review confirm results from prior reviews systematic and otherwise of similar bodies of literature for example pathak et als review of ipv against older women noted a decline in physical violence against older women whereas other forms of violence remained stable or increased a finding that was reflected in our data 23 some of the studies included in the present review also confirm partners retirement and children leaving home as precipitating factors for increase of ipv against older women indicating points for potential intervention and support for older women in a review of qualitative literature on ipv against older women finfgeldconnett noted that older women actively choose coping strategies that enable them to make the best of their situations 20 a conclusion that is also supported by some of the results of our review in other cases staying in a relationship with an abuser appears to be driven by gender norms and feelings of duty towards a partner in addition 3438 coping strategies such as use of alcohol and other harmful substances appeared to result in poor health and lack of wellbeing 34 3739 47 50 51 61 68 69 73 79 recurring themes emphasizing the pervasive impact of violence against older women on physical and mental health relationships social networks hope and sense of wellbeing in our systematic review and other previous reviews indicate the importance of taking violence against older women in all its manifestations seriously as a public health and human rights issue as was identified in previous reviews there is relatively little evidence concerning the emergence of violence in later life particularly in the case of ipv in the case of the majority of studies included in our review older women described shifting but continuous patterns of violence throughout the lifecourse although a small sample of studies identified new relationships and dementia of an intimate partner as factors precipitating the violence 4046485355596269 comparing the ipvspecific evidence generated in this review to the existing evidencebase on ipv against women of reproductive age some notable continuities and differences are evident firstly our findings confirm the extensive impact of ipv exposure on physical and mental health which has been widely researched amongst women of reproductive age 2 82 83 84 85 however our data indicate that ipv amongst older women is commonly experienced in the context of exposure to lifelong ipv and that the physical and mental health impacts are cumulative compounded by ageing processes and often exacerbated by changes in social situation also triggered by ageing ability to employ physical or cognitive coping mechanisms that had been effective earlier in life may diminish for older women 33373947 in addition alongside depression anxiety and posttraumatic stress disorder which are the most commonly measured and reported mental health impacts of ipv amongst women of reproductive age 86 87 88 older women discussed hopelessness and regret as pervasive and important psychosocial impacts of ipv in older age there may be some similarities between younger womens experiences of shame and stigma 89 90 91 92 93 and older womens feelings of regret however regret and hopelessness may be specifically central to older womens experiences of violence particularly ipv secondly our results confirm that exposure to ipv is often linked to experiences of violence in childhood older women in studies included in this review indicated that growing up in families where violence was commonly witnessed and experienced was interlinked with exposure to ipv in adulthood and through to older age a finding that is evident in data on women of reproductiveage 94 95 96 thirdly there appear to be common challenges for women of reproductive age and older women in leaving an abusive relationship including perceptions of the importance of remaining in a relationship for the sake of children indicating the commonality of the importance of social and gender norms in driving decisionmaking 97 98 99 100 101 implications garnered from research with women of reproductive age experiencing ipv are relevant here similarly it should not be assumed that older women want to or can leave an abusive situation and services provided should recognize and be sensitive to this finally our findings highlight specific issues for consideration in the case of violence against older women including changes in type and prevalence of controlling behaviours 36455051617277 and forms of financial control that occur alongside ipv 4353626478 these behaviours have the potential to significantly restrict options and limit ability for older women experiencing violence even more than in younger women currently however these may be underrecognized as specific risk factors for older women global research on violence against women has increasingly explored the significant influence of social and gender norms on prevalence of and risk factors for violence against women of reproductive age 102 103 104 105 our findings indicate that social and gender norms also continue to strong influence older womens responses to and experiences of violence older women described social and gender norms as shaping their decisions to stay in relationships to provide care for an abusive spouse and often as reinforcing shame and social isolation there is substantial overlap between norms identified in this review with the existing evidencebase on social and gender norms on women of reproductive age for example the norm of keeping violence victimization private and overall injunctions concerning silence surrounding ipv some evidence indicates positive impacts of violence prevention interventions focused on changing social and gender norms 106 however these programs have not been specifically tested for feasibility and acceptability with older adults and careful consideration of how and if addressing social and gender norms amongst older adults could result in reduced violence perpetration is needed our review identified significant gaps in the evidencebase concerning older womens experiences of violence in low and middleincome countries within studies conducted in highincome countries with a few exceptions 5261707680 the focus of the included studies was on older women from western cultural backgrounds the sparse coverage of several regions globally and low and middleincome populations overall indicates that our findings cannot be generalized to older women globally and that there are likely important influences on and impacts of violence against older women that are currently missing from view while we can assume that older women in low and middleincome contexts also experience violence the existing evidence base for both qualitative and quantitative data fails to adequately shed light on patterns and prevalence 1617 in addition as found in our quality assessment included articles contained very little detail on the contexts in which the research was conducted 32 3442 4547 4951 53 54 56 57 59 6166 69 70 7275 7779 which makes it difficult to link the evidence from this review to specific contextual factors further exploration of contextspecific issues such as living conditions and associated norms for example norms governing that older widows live with children and childrens families is needed in addition exploration of perceptions of capabilities and appropriate social roles for older women in different sociocultural contexts is warranted perceptions and experiences of ageing processes and specific issues such as widowhood differ significantly in different cultural contexts and existing qualitative and quantitative data do not include these diverse factors or account for their relationship with violence against older women our findings indicate that older women affected by violence need social and community support to help them cope and address the anxiety and stress associated with threats to their safety older women affected by violence may be particularly isolated with social isolation concomitant with ageing compounded by social isolation due to violence victimization some of the studies indicated that older women do not understand or define their experiences as abuse or violence but do seek support regardless as such there may be potential for services and interventions designed to address social isolation and targeted for all older women to address violence against older women various interventions that have been found to be effective in reducing social isolation and improving social outcomes for older persons such as group support through discussion groups individual support through home visiting and psychosocial education programs could be effective in improving social support for older women affected by violence 107 currently services for older persons are overall extremely limited in low and middleincome contexts and dynamics of social and community support for older persons vary considerably in nonwestern cultural contexts the current qualitative evidencebase does not indicate if older women affected by violence in low and middleincome contexts would benefit from similar interventions or if integrating response to and support for violence against older women into agedcare services are a feasible way to reach older women affected by violence in the limited number of included studies that addressed older womens experiences with and expectations of healthcare providers concerns were raised including lack of confidentiality and health care providers not taking womens abuse seriously 74 health care providers are in a unique position to provide support and response for women who have been affected by violence the world health organizations clinical and policy guidelines and clinical handbook provide guidance for health care providers in providing womancentred care compassionate firstline psychosocial support and linkages to multisectoral services 108 in the case of older women women may come in contact with primary secondary or tertiary health care services for reasons related to chronic disease and ageingrelated injuries for example or as caregivers for spouses or children there is a need to explore how and where violence prevention and response for older women in the health system could be feasible and acceptable for example gerontologists and other specialists providing eldercare specific services could be provided tools and skills to identify and support women who may be subjected to violence in addition as identified in this and other reviews of violence against older women there are factors that may act as precipitating factors for increase or initiation of violence including changes in caregiving dynamics or retirement of a spouse and these could be points of potential intervention and additional support for older women especially if there is a history of past violence limitations and strengths several strengths and limitations should be considered while interpreting the findings of this systematic review in contrast to previous systematic reviews we included all qualitative evidence concerning violence against older women regardless of type of violence and perpetrator allowing insights into the overall focus of the evidencebase which revealed limited engagement with elder abuse against women and family violence perpetrated by nonpartners for example children additionally we followed a rigorous protocol adhering to a preregistration protocol in line with entreq guidelines 31 we carried out an extensive systematic review across 11 databases supplemented by hand searched references lists and article recommendations from 49 experts on violence against women or older adults and therefore it is unlikely that published articles would have been overlooked in this review we reviewed all articles in any language apart from farsi in order to minimize selection bias or for relevant articles to be missed two authors screened all titles and abstracts and all articles at the full text review stage at the data extraction phase only mel extracted relevant data introducing the possibility of transcription errors despite this limitation all extracted data was double checked by srm to minimize potential of missing descriptive data and both completed independent quality appraisals to minimize potential for biased assessments additionally during the analysis phase both authors coded article main findings and key quotes and developed descriptive and analytical themes to strengthen the interpretation and synthesis of findings another limitation of the findings of this review is the concentration of studies in higherincome contexts which greatly limits the transferability of findings to lowand middleincome populations in addition the small number of studies conducted in low and middleincome countries entailed that comparison of patterns between highincome and low and middleincome contexts was not possible this review was also limited by the quality of included articles many articles did not clearly report on study setting and context sampling procedures data analysis reflexivity and research ethics moreover many articles included samples of older women across wide age ranges the available evidence does not disaggregate findings to enable understanding of whether or how women in different age groups experience violence differently despite significant variation in living conditions employment and health status of women aged 5064 vs 65 and up for example this lack of specificity limited our ability to understand the differential causes experiences and impacts of violence among specific age groups of older women implications for future research in light of the findings from this review as noted above there is an urgent need to address the scarcity of research on violence against older women in low and middleincome contexts and to expand research in highincome contexts to diverse populations and age groups who may have different risk profiles for violence in older age our results indicate that the focus of the existing qualitative evidencebase is primarily on ipv in older age it is unclear whether this research focus reflects the actual burden of ipv compared to other forms of violence against older women and if the evidencebase currently adequately includes accounts of types of violence and perpetrators that are most significant for older women as noted assessment of polyvicimization in the evidencebase is lacking as such further studies of violence against older women that are inclusive of any type of violence by any perpetrator or take an openended approach to older womens accounts of violence are needed in the quantitative evidencebase systematic reviews have focused on elder abuse and on ipv a review of quantitative evidence on ipv identified 19 studies 15 and the review of elder abuse against women included 50 studies as such the quantitative evidencebase appears to capture more in terms of forms of violence against older women our findings indicate that for older women who had experienced violence throughout the lifecourse aspects of ageing such as frailty injuries chronic disease and cognitive decline make coping with different forms of violence more difficult than earlier in life qualitative and quantitative research does not currently shed light on associations between types of violence chronicity of violence and physical and mental health outcomes for older women and additional research in this area is warranted other themes that emerged in our review call for further research regret and hopelessness were commonly described as significant issues for older women these factors appear to significantly influence wellbeing psychosocial health and physical and mental health however these outcomes are rarely measured and these may further impact other specific mental health and psychosocial issues for older women subjected to violence further research could explore if and how regret and hopelessness amongst older women differs from shame and stigma as currently measured and reported amongst women of reproductive age and further elucidate its impacts on psychosocial wellbeing in addition economic and financial abuse appeared to be correlated and interlinked with older womens experiences of violence and barriers to leaving abusive relationships terminology and definitions of these forms of abuse are varied and often unclear and measures often cover several constructs 109 while there is some growing consistency in how economic and financial aspects of abuse are conceptualized and measured there is more work needed on how to assess economic or financial abuse and understand its linkages with physical and mental health outcomes conclusion the current qualitative data available on violence against older women has important limitations including that it is predominantly derived from highincome countries often does not address context is focused on ipv to the exclusion of other types of violence and perpetrators and does not disaggregate by age group however our findings highlight some important issues ipv persists into older age and shares characteristics and impacts as in younger age groups in some cases there may be factors such as a partners retirement or illness such as dementia which can precipitate or increase violence as shown in quantitative reviews physical violence tends to decrease with age while psychological abuse and controlling behaviours increase and financial and economic abuse are important elements of older womens experiences of violence and control older women described being strongly influenced by social norms that dictate a sense of duty to stay in a relationship with an abusive partner a desire to protect children and shame and silence surrounding experiences of violence more research is needed particularly from lmics to fill in the many gaps in the evidencebase however it is clear that action to support older women in abusive relationships is needed services for older people need to be aware of the prevalence and forms of violence against older women and know when to identify and respond in a sensitive and nonjudgmental way to improve prevention of and response to violence against older women all relevant data are within the manuscript and its supporting information files supporting information

the majority of the existing evidencebase on violence against women focuses on women of reproductive age 1549 and globally there is sparse evidence concerning patterns of and types of violence against women aged 50 and older improved understanding of differing patterns and dynamics of violence older women experienced is needed to ensure appropriate policy or programmatic responses to address these gaps in the evidence we conducted a systematic review of qualitative literature on violence against older women including any form of violence against women rather than adopting a specific theoretical framework on what types of violence or perpetrators should be included from the outset and focusing specifically on qualitative studies to explore the nature and dynamics of violence against older women from the perspective of women following preplanned searches of 11 electronic databases two authors screened all identified titles abstracts and relevant full texts for inclusion in the review we extracted data from 52 manuscripts identified for inclusion and conducted quality assessment and thematic synthesis from the key findings of the included studies results indicated that the vast majority of included studies were conducted in highincome contexts and did not contain adequate information on study setting and context thematic synthesis identified several central themes including the intersection between ageing and perceptions of experiences of and response to violence the centrality of social and gender norms in shaping older womens experiences of violence the cumulative physical and mental health impact of exposure to lifelong violence and that specific barriers exist for older women accessing community supports and health services to address violence victimization our findings indicated that violence against older women is prevalent and has significant impacts on physical and mental wellbeing of older women implications for policy and programmatic response as well as future research directions are highlighted

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introduction the internet is extending research designs 1 and transforming data generation techniques 2 revealing ethical and methodological issues around recruitment 34 a core tool in this transformative process is email which is routinely used in research 5 emails leave an audit trail of volunteerresearcher interactions and record priorities and concerns of volunteers 6 they also offer insight into the context of a volunteers daily life and illness experience therefore providing a prospective record of why or how volunteers decide to participate in health research email communications may influence volunteerresearcher relationships kvale 7 suggests that email interviews potentially alter the power imbalance of participantresearcher interactions by offering opportunities for a more respectful and symmetrical relationship due to a shared context of communication this potential shift in the dynamics of research relations may extend to email communications during the recruitment and consent process for example email correspondence may extend beyond straightforward recruitment information exchange volunteers may disclose negative illnesshelpseeking experiences and see volunteering as a way of accessing otherwise unavailable medical advice role boundaries can be blurred in these circumstances and researchers need to be sensitive to the context of participation but be clear that they cannot offer therapy or medical advice also as emails contain sensitive and personal details secure and confidential storage is important all of these factors highlight the skill requirements needed by research workers whose role is often seen as purely administrative 8 recently internet recruitment and email interviews have been the focus of research that has identified ethical methodological and practical issues 9 the potential of routine email correspondence in health research however remains unexplored we addressed this gap by focusing on the content and context of email communications to explore their role in the recruitment and informed consent process and their implications for the volunteerresearcher relationship methods study design and participants this research formed part of a larger qualitative interview study early rheumatoid arthritis helpseeking experience rheumatoid arthritis is a chronic musculoskeletal condition and a major cause of disability the main symptoms are pain stiffness joint swelling and fatigue characterized by exacerbations and remissions 10 if treatment is delayed damage can occur in other organs including the heart and lungs onset can be sudden or gradual and the focus of care is to control the symptoms and limit disease and debility timely treatment is crucial to avoid irreversible joint damage which may lead to permanent disability increased personal suffering and medical cost 11 individuals who had a diagnosis of rheumatoid arthritis in the previous 12 months lived in the province of british columbia canada and were english speakers were eligible volunteers were recruited via information leaflets through local arthritis clinics and websites of the provincial arthritis organizations recruitment documents were also sent to eligible persons by their family practitioner or rheumatologists office the information leaflet invited people to share their experiences of early rheumatoid arthritis in an interview study data collection the information leaflet provided phone numbers and email addresses for 2 members of the research team who would conduct interviews out of a sample of 38 participants 29 used email as their main form of communication email was used to confirm eligibility provide consent forms discuss queries and schedule interviews typically email communications continued over a period of 1 or 2 weeks however in some cases email correspondence extended to several weeks or months due to practical difficulties of scheduling illness or life events the emails were password protected and stored securely on the server of the arthritis research centre of canada factual information and general comments were recorded in field notes due to the number and content of emails we recognized they were a rich source of data we subsequently sought permission to analyze the correspondence of 15 participants who had engaged in the most email contact overall the analysis presented here is based on the email communications of the 12 who provided consent ethical approval was received from the university of british columbia behavioral research ethics board volunteers were invited to choose their own pseudonyms which have been used data analysis the analysis was iterative a thematic approach informed by a constant comparative method was used at and za read and coded the emails independently after discussion and repeated readings of the emails three initial themes were identified compared with field notes and examined for consistency across data types focusing on emails further discussion led to agreement on higherorder themes constant comparison across data types and scrutiny of all data independently prior to team discussion added rigor to the analysis contributing to validity of the datadriven claims results volunteer emails varied in number content length and style most volunteers noted their diagnostic status and willingness to take part some indicated an interest in participating in the erahse study but requested more information about research tasks and the potential risks and benefits of participation the majority elaborated on their illness situation beyond the eligibility criteria several gave richly contextual accounts of their symptoms medication use interactions with health professionals and navigating the health care system 12 13 14 15 here we focus on four main themes arising from the data research participation as reciprocity volunteering as selfmanaging and helpseeking ambivalence around participation and informed consent and practical considerations of participation research participation as reciprocity mutual benefits volunteers expressed mutual benefits of participating in describing their experiences and contributing to the knowledge base they wanted to help the research initiative and others with early rheumatoid arthritis at the same time they hoped to benefit from sharing their stories and securing advice or information about illness management the email below illustrates the perceived twin benefits of participation for the volunteer and the research endeavor nicole volunteers to help the research in the face of frustrating symptoms she anticipates that sharing her story might help herself and the research and hopes to gain insight into disease and pain management hello anne my name is nicole i am a 33 yearold woman who was diagnosed with rheumatoid arthritis in about september of last year i have just in the last few weeks made contact with the arthritis society and received the emailed newsletter in which i read about the information you are gathering from newly diagnosed patients i would be happy to talk with someone about my experiences if it would be helpful i suggest that as i have been frustrated lately with the disease and with managing pain that it would help me to talk about it and hopefully gain some insight that i have been missing nicole during the subsequent interviews several individuals elaborated on their email disclosures they expressed hope that their experiences could help our research and future rheumatoid arthritis patients and assist medical professionals in offering care at the same time they hoped to benefit through gaining advice and information about available resources in contrast some participants reflected on how they made contact solely as a helpseeking strategy in the face of frustrated attempts to access timely care for worsening symptoms volunteering as selfmanaging and helpseeking in their initial emails some volunteers expressed helplessness about their symptoms and frustration at formal health care making no mention of our study some had gained a diagnosis from their family physician and were waiting to see a rheumatologist for effective medications several had sought information online and recognized the need for but were unable to gain prompt treatment these volunteers had been induced to contact us in the face of unpredictable severe debilitating or abnormal symptoms and rising anxiety about their situation the email below illustrates uncertainties around symptoms and concerns about obtaining a timely meeting with a rheumatologist nicolette described the context in which she had emailed us she had suspected she was in the early stages of rheumatoid arthritis due to previous knowledge about the disease and an internet search which identified the importance of a prompt diagnosis and early treatment given this knowledge and being told by her family physician that there would be a delay of 12 months prior to seeing a rheumatologist she felt frustrated and sought further information on the internet she then found our study and contacted us to talk to someone and gain advice regarding as illustrated above some individuals were prompted to volunteer for our study due to frustrated attempts at formal helpseeking they viewed research participation as a way of accessing much needed support and advice in their quest for prompt treatment emails raised questions such as what should i do and included comments such as i might learn something if i take part indicating volunteer need and perceived benefits of participation this posed potential ethical problems for free and informed consent ambivalence around participation email correspondence revealed questions about informed consent and offered some insight into the decisionmaking process rain made contact hoping for help in navigating the health care system and was in two minds about participating in his initial email he described his frustration with the health care he was receiving and did not refer to the research study subsequently he asked a series of questions about accessing care while considering whether to take part rain emphasized that his primary motivation for making contact was his hope for a speedy rheumatologist referral which was difficult to obtain in his rural community his ambivalence about participating was apparent in his questions about the informed consent document as he asked explicitly about the risks and benefits rain elaborated in his interview that he went on the internet to look for some support 15 p 23 the email record offers a glimpse of the prospective decisionmaking process from the volunteer perspective rather than through hypothetical or retrospective concerns around consentfor example when eliciting responses during an interview this is a vivid illustration that informed consent is a 2way flow that extends beyond ensuring volunteers have received the consent form prior to interview to review at the time of interview it also highlights the need to be flexible regarding communication formats in this example the volunteer agreed to a phone conversation regarding his concerns and any potential risks burdens or benefits of participating for him compared with potential benefits for others and the research more generally hi anne practical considerations of participation after receiving the recruitment documents several volunteers focused on practical aspects of participation they reported busy lives characterized by symptom management and hospital appointments and gave insight into the research experience as they negotiated a convenient time and place for interview the emails also offered volunteers the opportunity to set out the parameters of participation in the correspondence below teresa notes her preferred location and three suitable times for the interview asking the researcher to let her know what works best hello i looked over the attachments and everythings ok after consideration i think it would be too long a day for me to add the interview into a appointment the occupational therapist appointments tend to go on for 1 ½ hours or more my rheumatoid arthritis is very active right now and im easily fatigued i would prefer a home interview which would be more relaxed and give better insight into the impact of my rheumatoid arthritis possible dates are monday april 7 1pm tuesday april 8 10 am or friday april 11 10 am let me know what works best teresa this email records a daily life compromised by symptoms and treatment and adds context to the data generated at interview it records the potential burdens and costs of the research task for this participant in real time it also highlights the importance of a convenient time and place for collecting data for the comfort of the participant and the quality of the data gained discussion principal results the email communications offered insight into the perspectives of volunteers in our study they generated prospective data on motivations to take part recruitment and informed consent first we found there was a reciprocal element to participating some volunteers felt they could be of help to research and at the same time hoped that participating would be of help to them second others were prompted to volunteer due to their acute need for information in the face of troublesome symptoms and frustrations with the health care system for these individuals volunteering was solely a selfmanagement or helpseeking strategy third some ambivalence was illustrated when deciding to participate regarding the difference between potential benefits for the volunteer and benefits for the research in general fourth practical difficulties of participation arosefor example scheduling an interview in the context of a daily life organized around symptom containment and medical appointments finally the emails also revealed rarely discussed dimensions of the volunteerresearcher interactions and the invisible work of researchers overall our findings contribute new knowledge to the scant information on the ethics involved in email communications 1617 context of volunteering experience of early illness and helpseeking in common with those in other studies our volunteers hoped to gain health benefits 18 people who are in the early stages of a chronic illness may well experience uncertainty and anxiety about their condition 121415 such feelings may be exacerbated when people are not provided with a firm diagnosis or prompt treatment 12 in this context people who feel that they are unheard in the health care system and are aware that they require timely treatment may be inclined to volunteer for research about their condition our recruitment materials described an interview study and an interest in personal experiences this may well suggest an outlet for a personal illness story to be heard and promise hope of advice or support in a patients quest for a speedy diagnosis or effective treatment more research is needed to identify how far people volunteer for research to access information or advice as part of their selfmanagement and helpseeking strategies recruitment informed consent and volunteerresearcher interactions the emails provided prospective records of aspects of recruitment consent and volunteerresearcher interactions and as such generated data on an underinvestigated dimension of the research process emails facilitate a 2way flow of information exchange in a shared context of communication 7 and have the potential to contribute to a more collaborative health research relationship in the era of the informed epatient 19 the volunteers in our study had the opportunity to interact in their own time and space at their own convenience rather than in a facetoface situation or via the more immediate and intrusive telephone this may have shifted the balance of control and offered the possibility of an active volunteer 6 participating in a more meaningful and involved recruitment and informed consent process for example individuals may have been more inclined to enter into a prolonged dialogue about participation and to broach sensitive issues when deciding whether to take part the volunteer emails in our research recorded reasons for taking part and doubts reflections and questions about benefits and risk volunteers may also share emotional stories and frustrations or on a practical basis take the initiative in terms of when and where the interview should take place in future research projects it would be instructive to ask the participants their views on the role of email communications with researchers and research workers during recruitment potential for rapport building through email communications the opportunities for building more collaborative and dynamic relationships in electronic health care 20 applies equally to the qualitative health research process the emergent nature of many qualitative studies makes the achievement of rapport with participants and feelings of interpersonal trust crucial to the generation of questions considered important or interesting by both parties 21 p3 for this community of volunteers with newly diagnosed rheumatoid arthritis emails offered a way to engage in dialogue at an anxious and frustrating time and provided opportunities to foster trust and rapport 14 this potential benefit mirrors what childress 22 describes as proximal benefit both the participant and researcher can potentially gain from building an appropriate but respectful relationship during the research process the invisible work of research workers the volume and content of emails surprised us motivated this analysis and highlighted the undocumented or invisible work of researchers and research coordinators 8 given the context of some volunteers illness stories and navigating the health care system such communications may create expectations regarding the nature of the response although we needed to be sensitive to volunteers circumstances and emails offered opportunities to build trust and rapport we also needed to negotiate the boundaries between acting as therapist and acting as sensitive researcher this necessitated time for prompt careful and informative correspondence as we attempted to achieve a careful balance between pragmatism and empathy in the context of multiple tasks and deadlines also given the context of some volunteers illness stories and their reported frustrations at not being heard research workers need perhaps to consider how volunteers are informed that they do not fulfill study criteria practical obstacles to participation the emails pinpointed the practical costs of participation for the volunteers the realtime communications suggested that for these participants the burdens of taking part in interviews held some practical obstaclesfor example the potential to aggravate symptoms such as fatigue more research is needed to assess whether such considerations are relevant beyond this dataset and for volunteer patients in all types of health research limitations our findings are limited in scope as in all qualitative research we do not claim to make generalizations but to gain a more indepth understanding of social phenomena we drew on a small number of emails from study volunteers with newly diagnosed rheumatoid arthritis who perhaps were particularly keen to participate due to their helpseeking and illness experiences we highlight that this analysis of the email communication included 1 male and 11 females and could not undertake a gender comparison in the future it would be preferable to study a genderbalanced sample it would also be beneficial to include all of the emails from volunteers rather than a selection we suggest however that the findings can be usefully explored in a range of research settings and designs below we offer some observations regarding practice future research and educational initiatives practice standard operating procedures created at study inception are one way to ensure all research staff approach communications in a thoughtful and consistent way these procedures should include mechanisms for secure handling and storage of emails and it should remain clear that study participants be informed of the risks to privacy when using email and that they may prefer alternative means of communication suggestions for research to better understand the role of email use in health research we need more evidence on emails and how this form of communication may influence recruitment informed consent and volunteerresearcher relationships as well as the skill set needed by research workers exploratory research questions could include what is the nature and extent of routine email communications in different research populations and what are the potential challenges and benefits educational aspects on the basis of our findings we cannot recommend extensive educational interventions however we suggest that educational workshops which focus on emerging ethical issues in the use of new technologies could include sessions on email communications workshops could engage those involved in research such as ethicists health research participants and researchers to identify and reflect on emerging issues comparisons could be made between phone and email communications in terms of ease of use content form and language and interpersonal relations topics could include issues around using emails as data and securing consent to do so conclusion we are unaware of other studies that have been based on the analysis of volunteer recruitment emails the emails tracked part of the decisionmaking process in real time recording volunteers hopes concerns and practical contingencies in the context of their illness experience because emails can be a rich prospective data source researchers may wish to include them as data which has implications for consent although this is a small sample from which we cannot make general statements volunteers in other contexts may see health research participation as a way to access care information and advice research workers should be aware of this during the recruitment and informed consent process emails are not only a technological development but also a reformulation of recruitment and informed consent offering the potential for increased dialogue during routine communications in health research a key implication of this study is how email communications revealed the invisible work of research workers during recruitment and informed consent using the emails as data improved our understanding of the decisionmaking process the context in which people volunteered for our study and the practical obstacles involved there was a suggestion that emails fostered opportunities for meaningful and thoughtful dialogue over time but more research is needed to investigate this and perhaps their capacity to shift the dynamics from a traditional to a more symmetrical relationship as well as a more considered informed consent process conflicts of interest none declared authors contributions at had the original idea and led data collection analysis interpretation and writing at guided za in the early drafts and subsequently wrote all later drafts of the paper za wrote the first draft of the paper and worked with at on subsequent early drafts za participated in data collection analysis interpretation and writing cb commented on all drafts of the paper and contributed to conceptual development and structure sc commented on all drafts of the paper ll was principal investigator of the erahse project commented on all drafts of the paper and contributed to conceptual development and structure ©anne townsend zubin amarsi catherine backman susan m cox linda c li originally published in the journal of medical internet research 13102011 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 the journal of medical internet research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included abbreviations erahse early rheumatoid arthritis helpseeking experience

background while use of the internet is increasingly widespread in research little is known about the role of routine electronic mail email correspondence during recruitment and early volunteerresearcher interactions to gain insight into the standpoint of volunteers we analyzed email communications in an early rheumatoid arthritis qualitative interview studythe objectives of our study were 1 to understand the perspectives and motivations of individuals who volunteered for an interview study about the experiences of early rheumatoid arthritis and 2 to investigate the role of emails in volunteerresearcher interactions during recruitment methods between december 2007 and december 2008 we recruited 38 individuals with early rheumatoid arthritis through rheumatologist and family physician offices arthritis internet sites and the arthritis research centre of canada for a facetoface qualitative interview study interested individuals were invited to contact us via email or telephone in this paper we report on email communications from 12 of 29 volunteers who used email as their primary communication mode results emails offered insights into the perspective of study volunteers they provided evidence prospectively about recruitment and informed consent in the context of early rheumatoid arthritis first some individuals anticipated that participating would have mutual benefits for themselves and the research suggesting a reciprocal quality to volunteering second volunteering for the study was strongly motivated by a need to access health services and was both a helpseeking and selfmanaging strategy third volunteers expressed ambivalence around participation such as how far participating would benefit them versus more general benefits for research fourth practical difficulties of negotiating symptom impact medical appointments and research tasks were revealed we also reflect on how emails documented volunteerresearcher interactions illustrating typically undocumented researcher work during recruitment conclusions emails can be key forms of data they provide richly contextual prospective records of an underresearched dimension of the research process routine volunteerresearcher interactions during recruitment emails record the context of volunteering and the motivations and priorities of volunteers they also highlight the invisible work of research workers during what are typically considered to be standard administrative tasks further research is needed to fully understand the role of routine emails what they may reveal about volunteers decisions to participate and their implications for research relationshipsfor example whether they have the potential to foster rapport trust and understanding between volunteer and researcher and ultimately shift the power dynamic of the volunteerresearcher relationship

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introduction hispanicserving institutions are among the fastestgrowing types of higher education institutions in the united states hsis are notforprofit degreegranting institutions with an enrollment of undergraduate fulltime equivalent students that is at least 25 percent latinx students and are eligible for federal designation and grant programs such as the title v program 1according to the hispanic association of colleges and universities there were 559 institutions with hsi designation in 2020 enrolling about two thirds of all latinx undergraduate students which is an increase of 248 institutions since 2010 geographically hsis are mostly located in the western and southwestern united states yet 80 of them are located in california florida illinois new mexico new york texas and puerto rico hsis have a growing importance in advancing college access and success for latinx students since the latinx collegegoing population is rapidly increasing that increase in turn has contributed to the growth of eligible hsis 2 many scholars have documented the historical origin of hsis which dates back at least 30 years a large majority of hsis were initially predominantly white institutions that became latinxserving as a result of significant increases in latinx students college enrollment commensurate with demographic changes yet unlike other minorityserving institutions such as historically black colleges and universities or tribal colleges and universities both of which were founded as a result of de jure segregation and with an explicit mission to serve their respective student populations hsis were not founded with a specific mission of serving latinx students rather hsi designation has been largely defined by an enrollment threshold after an intensive period of advocacy and activism that began in the early 1980s from stakeholders concerned with latinx students access to higher and an opaque concept that lacks specific federal guidelines for promoting strategies to serve latinx students spring 2023 volume in this study we used garcia et als framework of servingness to investigate the extent to which hsis serve latinx students in doing so we focused on latinx students 6year graduation rates specifically we longitudinally examined an overall trend in latinx students 6year graduation rates at notforprofit degreegranting institutions by control and hsi designation status we further investigated how various institutional characteristics vary between hsis and nonhsis and how these characteristics facilitate or hinder institutions servingnessthat is the 6year graduation rates of the latinx student population to answer our questions we conducted a panel analysis of multiple years of integrated postsecondary education data system data from 1266 institutions literature review and conceptual framework research on hsis has increased since their formal recognition in 1992 as a distinctive type of institution research has focused on the origins and evolution of hsis on latinx and other minoritized groups of students access to higher education and on hsi students experiences and outcomes while some studies solely examined hsis other studies comparatively studied hsis with nonhsis or emerging hsis that were approaching the 25 enrollment threshold to date existing studies have documented successes and transformative changes opportunities for improvement and capacity building about hsis the findings of the literature however appear inconsistent given the differences in how analytic samples of hsis were constructed variables examined or conceptual frameworks and theories used meanwhile scholars have consistently stressed that hsis have contributed to improving latinx students access to higher education and degree attainment for those who might not otherwise have had an opportunity to enroll in college the ability to articulate what it means for an institution to be or to become latinx serving or minority serving in the absence of a clear mandate or mission remains a perennial challenge for higher education research policy and practice as garcia et al on the other hand racialized experiences such as racism discrimination or microaggressions connote negative experiences within the organization we incorporated the concepts of validating and racialized experiences in this study by accounting for the compositional diversity of students as well as of instructional staff and examined how these types of student experiences are associated with latinx students 6year graduation rates according to garcia et al the organizational structures of hsis not only influence student experiences but also shape hsis capacity to address the needs of latinx students in their framework structures for serving are for instance development of an institutional mission that highlights serving adoption of diversity plans or applying for grants to serve latinx students not all structural constructs are measurable according to garcia et al but they can be observed and studied through case studies or documentation given the significance of structural characteristics with respect to serving the needs of latinx students we investigated various types of organizational structures including the types of student services offered financial aid offers at the institutional level and institutional expenses that could play significant roles in serving latinx students and that could impact their 6year graduation rates garcia et al moreover highlighted that there are external influences on the servingness of hsis including various historical political or social influences for instance these influences might be federal state or local legislation or political advocacy for the latinx community or institutional governing boards or alumni at hsis in a much broader sense garcia et al emphasized that there is a systemic influence of white supremacy on hsis we discuss how we attempt to account for these external influences in the methods section most importantly by adopting garcia et als multidimensional framework for servingness we spring 2023 volume move away from a tendency in prior studies to frame hsis in binary terms as either serving or nonserving we instead seek to illuminate the complexity of hsi identity and the diverse institutional characteristics that can contribute to their performance as marin noted instead of asking whether an institution is latinx serving it may be more appropriate to ask about the extent to which an institution is latinx serving recognizing the ongoing identity development that may be required and the many ways latinx serving can be conveyed in this regard we investigated to what extent organizational and structural traits of higher education institutions serve latinx students success research questions in this study we aim to identify the types of institutional characteristics related to latinx students 6year graduation rates with a particular interest in hsis we address the following three methods data and sample we used multiple ipeds survey components to create a panel data set for this study ipeds data are aggregated institutionlevel data collected by the us department of educations national center for education statistics from institutions that participate in the federal student financial aid programs we also used the digest of education statistics information to gather data about the hsi status of an institution in particular we used data from table 31240 which provided a list of hsis their enrollment and their awarded degree data since data on hsi status were not available for years prior to 2015 we focused our analysis on the years 20152018 the final sample for this study was limited to 4year notforprofit institutions that were title iv eligible we restricted our analysis to doctoral universities masters colleges and universities and baccalaureate colleges we excluded associates colleges and special focus institutions as defined by the carnegie classification of institutions of higher education our aim was to keep the sample of institutions comparable in terms of the student population they serve the final analytic sample included a total of 1266 institutions measures all measures included in this study were aggregated at the institutional level and come from multiple spring 2023 volume survey components of ipeds 12month enrollment admissions finance graduation rates human resources institutional characteristics and student financial aid 3 the outcome variable we examine is the 150 graduation rates for latinx students who enrolled at the institution as fulltime firsttime degreeor certificateseeking students ipeds defines 150 graduation rate as a students completion of their program within one and a half times the normal period of time in our study the outcome represented 6year graduation rates since we focused on 4year institutions that outcome served as an indicator measuring the impact or quality of attending an hsi the key covariate of our interest was an indicator for hsi status of an institution since our analysis included both hsis and nonhsis an institution was defined as an hsi by having an enrollment of undergraduate fulltimeequivalent students that is at least 25 percent latinx who are us citizens or permanent residents since hsi status is subject to adjustment due to yearly changes in latinx student enrollment an institutions hsi designation is considered as a timevarying feature which also varies across institutions furthermore our analysis included various other institutionlevel measures to account for the latinx student experience of an organizational environment as well as for the organizational structures for serving latinx students first to reflect how latinx students may experience the organizational environment we included measures of racial and ethnic composition of the student body and the instructional staff due to the small number of observations we collectively referred to american indian natives and pacific islanders as indigenous we also controlled for six dichotomous measures of student servicessupport financial aid offers and six measures of institutional expenses to address the structures that impact institutions organizational capacity to serve student needs an example would be the percent spent on instruction out of the total institutional expense 4 for financial aid we accounted for the average grant aid per fte undergraduate student and we accounted for the average loan amounts per fte undergraduate student these characteristics are considered timevariant characteristics meaning not only that they are different at each institution but also that they vary across time empirical strategy we first conducted descriptive analyses to examine the trends in latinx students 6year graduation rates by institutional control and hsi status as well as to examine the similarities and differences in institutional characteristics between hsis and nonhsis ttests and chisquared tests were also performed to confirm if the differences across institutions were statistically meaningful by their hsi status to answer our primary research question about the types of institutional characteristics related to latinx students 6year graduation rates we conducted a panel analysis of ipeds data from 2015 to 2018 we considered each of the participating title iv institutions as the unit of analysis measured at different points in time and we identified the panel structure of the data accordingly we estimated a fixed effects model given the result of a hausman test which indicated that it was the preferred model rather than a random effects model in our analysis we used the xtreg command in stata that demeans the variables and we estimated the standard errors correctly accounting for the fact that the cases are not independent of each other given the continuous outcome variable our linear regression panel model with fixed effects can be written as y it β 0 β 1 x it a i λ t ε it y it is the outcome a continuous measure of latinx students 6year graduation rate for each institution at time point β 0 is an intercept term that can vary at different time periods x it is a set of timevarying covariates such as the proportion of latinx students facultystudent ratio institutional selectivity financial aid offers or institutional expenses a i is an institution fixed effect that controls for all timeinvariant unobserved institutionspecific characteristics that might affect the outcome such as institutional climate this means that a i absorbs the impacts of all timeconstant institutional characteristics that have not been included in our model λ t is a timefixed effect that controls for unobservable covariates that vary over time but are fixed across institutions finally ε it is an error term that is different for each institution at each time period and represents the effects of all timevariant variables that have not been included in our model limitations there were some aspects of garcia et als framework that were not observable through our data mainly we were not able to account for some of the structural factors that unlike other outcomes and experiences are not necessarily measurable in traditional ways such as mission and value statements or diversity plans we attempted to mitigate this limitation by accounting for institutional characteristics such as control or institution type since these characteristics reflect institutions orientation or diversity goals to some extent those characteristics do not vary over time in most cases we also could not account for any external influences such as white supremacy discussed by garcia et al yet all institutions we examined were domestic institutions that were potentially being impacted by such external factors to a similar extent and so should not impact our estimates significantly spring 2023 volume findings trends in 6year graduation rates for latinx students table 1 and figure 1 illustrate the trends in 6year graduation rates for latinx students by institutional control and hsi status we found that between 2015 and 2017 the average 6year graduation rates for latinx students were steady without any significant change the rates however suddenly dropped in 2018 with greater changes among private institutions which generally had higher 6year graduation rates for latinx students than public institutions had we also discovered that on average private nonhsis had the highest and public hsis had the lowest 6year graduation rates for latinx students throughout the years differences in institutional characteristics between hsis and nonhsis as shown in table 2 hsis and nonhsis appeared to have meaningful differences in their institutional characteristics in terms of the outcome hsis on average had between 5 to 7 percentage points lower 6year graduation rates for latinx students than nonhsis this trend held for the years 2015 through 2018 hsis and nonhsis we also found several differences between the sector and size of hsis compared to nonhsis hsis were larger on average enrolling about 5000 more students at each campus than the nonhsis in our sample enrolled while the majority of nonhsis in our sample were private colleges and universities fewer than half of hsis were private the level of degree offerings also differed between hsis and nonhsis hsis included fewer baccalaureate degreegranting institutions but more masters degreegranting institutions when compared to nonhsis institutional characteristics and 6year graduation rates for latinx students table 3 presents the findings from the panel analysis of the relationship between institutional characteristics and latinx students 6year graduation rates for all institutions hsis only and nonhsis only the first column reports the estimates for the full population of colleges and universities in our sample we found that hsi status of an institution was not a statistically significant predictor of latinx students 6year graduation rate all else being equal however among the other institutional characteristics student demographic characteristics and institutional services offered were predictive of the latinx graduation rate for each additional percentagepoint increase in the proportion of multiracial students the 6year graduation rates for latinx students decreased by 083 percentage points controlling for all other covariates among the student services offered both remedial classes and academiccareer counseling were predictive of lower latinx graduation rates with the provision of remedial services associated with a 512 percentage points lower latinx students 6year graduation rate holding all else constant and academic counseling associated with a 2273 percentage points lower rate career placement services were predictive of higher latinx students 6year graduation rates with this student service offering associated with 504 percentage points higher rate all else equal we also found that institutional expenditures were predictive of latinx students 6year graduation rates higher 6year graduation rates were marginally associated with higher spending on research and institutional support and on central facilities and space management spending on academic support was associated with higher latinx students 6year graduation rates with each additional percentage point of spending predicting 185 percentage points higher graduation rates holding all else constant discussion and conclusion the primary goals of this study were to better understand the meaning of servingness in the context of hsis and to determine the extent to which hsis serve latinx students in terms of their 6year degree attainment at notforprofit 4year institutions using a multidimensional conceptual framework of servingness proposed by garcia et al we defined our outcome and the key institutionlevel factors that could be associated with the outcome we first examined trends in 6year graduation rates for latinx students from 2015 to 2018 findings showed that public hsis had the lowest 6year graduation rates for latinx students over the years while private nonhsis had the highest rates more broadly public institutions on average had lower 6year graduation rates for latinx students than private institutions by hsidesignation status even after accounting for all other characteristics the average latinx students 6year graduation rates were significantly lower for hsis than for nonhsis moreover latinx students 6year graduation rates were generally lower than 50 at private hsis public hsis and public nonhsi institutions from 2015 to 2017 while private nonhsis had graduation rates slightly higher than 50 our overall findings were consistent with previously reported rates intriguingly we also observed that 6year graduation rates for latinx students suddenly we further delved into understanding the similarities and differences between hsis and nonhsis regarding the organizational environment that impacts student experiences and moreover how these institutional characteristics were associated with latinx students 6year graduation rates our results demonstrated that hsis had significantly larger proportions of asian and latinx students and lower proportions of white and black students than did nonhsis in particular the percentage of latinx students at hsis was nearly 54 times higher than at nonhsis however all else being equal the spring 2023 volume ratio of latinx students had a marginally significant and negative impact on latinx students 6year graduation rates at hsis although previous scholars have emphasized the importance of student experiences with samerace or sameethnicity peers our result suggests that peer effects might not apply in the same way for this outcome although we did not examine other academic outcomes such as grades or retention the data in our analysis do not show a statistically meaningful relationship between the proportion of latinx students and their 6year graduation rates at nonhsis this might be attributable to the fact that nonhsis have a much lower proportion of latinx students which limits the impact of latinx student body on latinx student outcomes hsis had a significantly higher percentage of latinx instructional staff than nonhsis however contrary to expectations the proportion of latinx instructional staff did not have a significant association with latinx students 6year graduation rates either among students at hsis or in the full sample while prior studies showed that a representative faculty could have positive effects on latinx student outcomes our findings suggest that at hsis with a large proportion of latinx peers a larger proportion of latinx instructional staff might have a limited contribution to latinx students 6year graduation rate this result could show the nuances of validating experiences for latinx students latinx students at hsis may find more profound validating experiences through peer interactions than through staff interaction because the former interactions occur more frequently using garcia et als framework of servingness this study also focused on the impact of institutions structural capacity to serve latinx students we investigated student services offerings financial aid and institutional expenses at hsis and nonhsis and analyzed how these factors were associated with latinx students 6year graduation rates we discovered that a greater proportion of hsis offered remedial education employment services and oncampus day care than did nonhsis and that the average cost of attendance was covered by higher percentages of pell grants and loans at hsis than at nonhsis the offering of remedial services was a significant and substantively large predictor of lower latinx graduation rates in both the hsi institutions and in the full sample however this was not a causal effect in which remedial services led to poorer academic outcomes instead this likely reflects the fact that institutions serving students with high levels of need for academic support are both more likely to offer remedial support and more likely to have lower graduation rates for all students among the other student services for the full sample we also found that academiccareer counseling was associated with lower latinx students 6year graduation rates while placement services were associated with higher rates a finding that was consistent for the nonhsi sample career placement services could increase students motivation to complete their degrees given the promise of gainful employment awaiting them after graduation hsis expenses on instruction research student services and institutional support also accounted for significantly lower percentages of the total institutional expense than nonhsis our findings demonstrated that hsis were distinguishable from nonhsis in various aspects such as the types of student support or institutional spending emphasized by institutions in addition our findings highlighted that it is inappropriate to compare the two types of institutions without context in terms of the predictive capacity of institutional spending measures we found that additional spending on research and academic support was associated with higher latinx students 6year graduation rates at hsi institutions that was not the case in the overall sample overall we conclude that these structural features are generally associated with institutional selectivity as well as with the financial capacity to provide an academic environment and support for student success these features have an important impact on latinx students 6year graduation rates at 4year institutions in summary framing servingness at hsis as an organizational and structural issue allows for focus on institutions as the unit of analysis to identify needs for strengthening their capacity to serve latinx students to that end leaders decision makers and policymakers must be clear in their words and actions about what it means to serve latinx students and to identify the types of resources needed for their success for instance securing financial resources such as federal or state funding to support latinx students should continue to be a key focus for institutional leaders moreover such support should result in greater capacity for serving latinx students to improve and sustain positive academic and nonacademic student outcomes namely hsis must recognize that these students are the reason why institutions are designated as such and why they are eligible for targeted federal funding

this study builds on the body of research on hispanicserving institutions hsis and latinx student outcomes and uses garcia et als 2019 conceptual framework of servingness using multiple years of data from the integrated postsecondary education data system ipeds we examined the extent to which hsis serve latinx students in terms of 6year graduation rates at notforprofit 4year institutions key findings suggest that the average 6year graduation rates for latinx students are lower at hsis than at nonhsis

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despite the rapid growth in the latino population in the united states little developmental research has included children in mexican american families the present study addresses this issue by evaluating a theory proposed by portes and rumbaut to help explain differences in academic development for children of immigrants specifically we investigate the degree to which differences in language fluency between parents and children predict the quality of family relationships and school performance during the developmentally challenging transition from late childhood to early adolescence mexican american immigrant families face many significant challenges including languagerelated difficulties involving the shift from spanish to english parents and children in mexican american families often gain fluency in english at different rates researchers have argued that although parents may want to learn english their employment and social surroundings often do not facilitate development of english fluency in contrast children are enrolled in school which both requires and facilitates fluency in english in addition younger children are at an age when language acquisition is relatively easy compared with the adult years intergenerational differences in english fluency form the basis of a model proposed by portes and rumbaut to identify different trajectories of cultural adaptation that children of immigrants follow according to portes and rumbaut social and academic trajectories of secondgeneration children of immigrants depend on both parent and child adaptation to the host culture their model seeks to explain in part why mexican american adolescents often lag behind their white and asian american peers in reading and math portes and rumbaut hypothesized that the achievement lag might be partially explained by patterns of interaction between immigrant parents and their children specifically their model proposes that parents and children who are similar in their english fluency will experience more healthy patterns of interaction characterized by increased communication due to fluency in a shared language preservation of parental authority and relatively little conflict families with these patterns of interaction were described as demonstrating either consonant or selective acculturation two possible patterns in which both parent and child experience similar levels of adaptation to the host culture in terms of language use in contrast parents and children who do not share fluency in english experience dissonant acculturation according to the theory possible consequences of dissonant acculturation include decreased parentchild communication role reversal and increased parentchild conflict these consequences in turn place children at heightened risk for social and academic problems in this article we extend the portes and rumbaut model by proposing that differences in spanish fluency should have similar effects though we also would note that these intergenerational language differences exist among all immigrant families regardless of language country of origin or languagecountry of destination consequences of differences in language fluency family processes in their research with children of immigrants portes and rumbaut demonstrated the prevalence of language differences in this population they found that almost no firstgeneration parents in their study met their criteria for fluency in english and almost no secondgeneration youth could be considered fluent in spanish based on these results portes and rumbaut proposed that the marked differences in english fluency would lead to relatively low levels of parentchild communication secondgeneration youth in their study retained some knowledge of their parents language enough for limited exchanges at home and most parents learned at least some words of english leading to constrained but not ruptured intergenerational communication this hypothesis has received additional support from other qualitative studies and martinez noted that clinical experience working with latino families suggests that differential family acculturation often interferes with effective communication and problem solving among all family members based on these observations and theoretical reasoning in the current study we predicted that when both parents and children are fluent in a common language either english or spanish the quality of parentchild communication will be higher portes and rumbaut also hypothesized that intergenerational language differences would lead to the development of role reversal or power differences atypical for parentchild dyads this role reversal occurs when childrens familiarity with english and the host culture has moved so far ahead of their parents familiarity that key family decisions become dependent on the childrens knowledge portes and rumbaut suggested that parents who cannot speak fluent english often rely on their children to assist in interfacing with the englishspeaking institutions that surround them because secondgeneration youths speak the language and know the culture better than their parents they are often able to prematurely free themselves from parental control although portes and rumbaut had no direct quantitative measure of role reversal the qualitative data collected for their study provided preliminary evidence consistent with the hypothesis literature on children as cultural brokers for their parents suggests that regardless of the benefits associated with cultural brokering shifts in power may result when children act as mediators between their parents and englishspeaking others the result of this process is that the child accrues greater power in the parentchild relationship than is desirable and becomes less dependent on the parent for guidance and instruction that is the child can become more dominant whereas the parent may become more passive in the current study we expect that language differences between parents and children will be associated with higher levels of child dominance and parent passivity as an extension of the portes and rumbaut model we propose that differences in spanish fluency also will lead to this power imbalance inasmuch as parents will be less influential in terms of guidance and instruction when they are not fluent in a common language with their child the final hypothesized consequence of intergenerational language differences considered here involves increased levels of parentchild conflict knowledge of the language is the most elemental kind of common ground on which communicators rely especially during conflict when language differences are added to all the other problems with communication during conflicts the chances for misunderstanding and escalation are extremely high portes and rumbaut reported that children who shared a common language with spanishdominant parents reported lower amounts of parentchild conflict joint fluency between parents and children may in part promote greater agreement on a common perspective that reduces the likelihood of parentchild conflict moreover the absence of joint fluency may make it harder to resolve conflicts when they occur thus leading to escalation in conflicts over time thus we expected that language differences in either english or spanish would be associated with higher levels of parentchild conflict portes and rumbaut proposed that these elements of the parentchild relationship link language similarities and differences to academic outcomes like achievement school dropout and educational aspirations and expectations consistent with their expectations they found that parentchild conflict was negatively related to academic aspirations and educational achievement they did not have quantitative measures of communication or role reversal but they found anecdotal support for a link from communication and role reversal to academic outcomes through qualitative interviews with study participants consistent with their view other research has found an association between parentchild relationship quality and academic success in high school school performance the current study based on the preceding review we expected to find differences in language fluency between parents and children in our community study of mexicanorigin children during the developmentally challenging transition from late childhood to early adolescence in the following analysis we first test this expectation we also expected that differences in language use between parent and child would be associated with the family processes hypothesized by portes and rumbaut poor communication role reversal and conflict in turn are hypothesized to predict poorer academic achievement more school problems and lower academic aspirations and expectations that is language differences are expected to be indirectly linked to school outcomes through their influence on these family processes the current study extends prior work in several ways portes and rumbaut used only child fluency in english as a predictor of their family process variables and academic outcomes however their theory emphasizes the benefits of linguistic and cultural shifts occurring at the same pace across generations that is their theoretical model anticipates moderation or a unique effect of the cooccurrence of both parent and child fluency in english accordingly figure 1 includes the interaction between parent and child fluency as a predictor of the family process variables in the model for the reasons noted earlier we propose that parentchild differences in spanish fluency will have similar effects as differences in english fluency this study also extends prior work by testing the theory for both mothers and fathers in their test of the model portes and rumbaut only included one caregiver per family and thus could not evaluate whether the model operated similarly for mothers and fathers we followed the suggestion by parke who advocated explicit tests to determine if theoretical predictions hold equally well for mothers and fathers finally because socioeconomic status is associated both with language use and with many of the family process elements included in this study we controlled for both parent education and family income in tests of study hypotheses method participants data for the present report come from a community study of mexicanorigin children and their parents the 674 families were recruited via telephone if staff were unable to establish contact over the phone a staff member went to the familys house and made facetoface contact to invite participation in the study the focal child in each family was selected at random from the cohort of all fifthgrade students in two cities in northern california who were enrolled in public schools during the academic years for 2006 to 2007 and 2007 to 2008 the first criterion for inclusion in the study was that the childs biological mother lived with the child and identified herself as mexican or mexican american second we included both singleparent and twoparent families but if the father was in the household he had to be the biological father and identify as mexican or mexican american third for fatherabsent households the mother had to report that the focal childs biological father was mexican or mexican american sixtynine percent of eligible families agreed to participate in the study similar to recruitment success in other community studies that recruit multiple family members families in the study lived in urban or in suburban areas and all were of mexican origin eightyeight percent of the fathers were born in mexico as were 84 of the mothers and 28 of the children eightyone percent of the fathers completed the interviews in spanish as did 78 of the mothers but only 15 of the children completed them annual family income ranged from 0 to 5000 to over 200000 with an average income between 30000 and 35000 fathers education ranged from 0 to 20 years for mothers the range was from 1 to 20 years of education the fathers ranged in age from 27 to 65 years mothers ages ranged from 26 to 57 years family size ranged from 2 to 9 at study initiation children averaged 109 years of age and were approximately evenly split across gender procedures all measures were assessed when the focal child was in the fifth grade and academic outcomes were assessed a second time during the seventh grade during these assessment periods each family was visited twice in their homes for data collection usually during a 1week period on average each home visit took 2 to 3 hr each participating family membermother father and focal childcompleted a set of computerbased interviews focusing on family processes individual family member characteristics and socioeconomic circumstances interviews were conducted in either spanish or english depending on the preference of the participant all interviewers were proficient in both spanish and english and most were of mexican descent all measures not already available in spanish were translated to spanish by bilingual staff members and then back translated to english by another group of bilingual staff members to confirm that the original meaning remained clear parents were each paid 100 dollars for their participation and children were each paid 50 for their participation during the second home visit children were video recorded while engaging in a 20min parentchild discussion task the child completed this task separately with each parent interviewers explained the task gave prompt cards to parent and child and then left the room while the parent and child discussed issues such as how the family spends time together enjoyable experiences they have had and household rules these interactions were scored by portes and rumbaut raters using an adapted version of the iowa family interaction rating scales this revised coding system represented the first attempt to apply the iowa scales to a mexicanorigin sample changes included combining overlapping scales and adding a small number of codes that were believed to be especially helpful in understanding family dynamics among this population raters were staff members who received several weeks of training on rating family interactions were blind to study hypotheses and specialized in coding one of the interaction tasks before observing tapes raters had to independently rate precoded interaction tasks and achieve at least 90 agreement with the standard for purposes of assessing interobserver reliability 20 of the tasks were randomly selected to be observed and rated by a second observer different observers rated the childs behavior and the parents behavior measures language fluency language fluency was assessed during fifth grade by asking each participant how well do you understand spoken english and how well do you speak english parallel questions were asked with regard to spanish these four questions were answered on a scale from 1 to 4 ϭ and were combined for each participant into ratings of fluency in each language selfreports of fluency are uniformly relied upon in this field and these questions were similar to those asked by portes and rumbaut average fluency in english was m ϭ 346 for children m ϭ 256 for mothers and m ϭ 270 for fathers in contrast average fluency in spanish was m ϭ 295 for children m ϭ 346 for mothers and m ϭ 346 for fathers in order to facilitate interpretation of the path coefficients fluency scores were standardized for primary analyses and product terms were created to test for moderation parentchild communication parentchild communication was measured during fifth grade using two scales from the observed parentchild interaction observed communication included use of explanations and clarifications reasoning soliciting the others views or in some way demonstrating consideration of the others point of view coders independently rated on a 9point scale the quality of parent communication with the child and the quality of child communication with the parent intraclass correlations between observer ratings averaged 56 and ranged from 47 to 71 role reversal parentchild role reversal was measured during fifth grade using two scales from the observed parentchild interaction coders independently rated on a 9point scale the degree of child dominance with the parent and the degree of parent passivity with their child observer agreement averaged 62 and ranged from 43 to 70 conflict parentchild conflict was measured during fifth grade using two scales from the observed parentchild interaction coders independently rated on a 9point scale the amount of hostile behavior displayed by parent toward child and the amount of hostile behavior displayed by child toward parent observer agreement averaged 62 and ranged from 54 to 69 academic outcomes first math and english scores from the california standards test as reported by the school were used as indicators of a latent variable called academic achievement second the number of unexcused absences and whether or not the child was suspended were used as indicators of a second latent variable called school problems to provide a more stable estimate of unexcused absences data were winsorized such that any child who had more than 10 unexcused absences received a score of 11 which reduced skewness from 256 to 109 third children reported on their academic aspirations and expectations by answering the questions how far would you like to go in your education and how far do you expect to go in your education these two questions were used as indicators of a third latent variable called academic aspirations fifthand seventhgrade reports were correlated for academic achievement school problems and academic aspirations socioeconomic status to assess parent educational attainment in singleparent families we used mothers selfreport of number of years of schooling completed in twoparent families we used both mother selfreport of years of schooling as well as mother report of number of years of schooling completed by the father to assess income in singlemother households we used mothers selfreport of income an average of mother and father selfreports of income were used in twoparent families income was reported in increments of 5000 results as a first step in the analyses we evaluated whether the differences in fluency between parents and children identified in prior work would be replicated in our sample consistent with prior findings children were more fluent in english than mothers t ϭ 2658 p ͻ 001 and fathers t ϭ 2267 p ͻ 001 furthermore children were less fluent in spanish than mothers t ϭ 3138 p ͻ 001 and fathers t ϭ 2409 p ͻ 001 these findings regarding language differences between parents and children indicate that these families are appropriate for evaluating the primary study hypotheses we evaluated our theoretical predictions by comparing nested structural equation models consistent with our hypotheses using full information maximum likelihood estimation fiml is considered an acceptable way to deal with missing data which was modest for this sample change in model fit was assessed using the chisquare difference test when evaluating the fit of structural models to the data we used the standard chisquare index of statistical fit the root mean square error of approximation the tuckerlewis index and the standardized root mean square residual rmsea values under 06 indicate a close fit to the data and tli values should be greater than 90 and srmr preferably less than 08 to consider the fit of a model to data to be acceptable these models were run separately for each of our three family process indices preliminary analyses showed no significant differences in findings by child gender or generational status with regard to the hypothesized model therefore we report analyses based on the entire sample model 1 in table 1 was the baseline model which allowed no correlations among the variables in the theoretical model as expected the fit of this model was poor for communication 2 ϭ 41832 rmsea ϭ 17 role reversal 2 ϭ 41222 rmsea ϭ 15 and conflict 2 ϭ 39559 rmsea ϭ 13 to evaluate the overall adequacy of our hypothesized structural model model 1a regressed each family process variable onto parent and child fluency in both english and spanish and two product terms consistent with the model in figure 1 the four different ratings of each family process variable were allowed to correlate academic outcomes during seventh grade in turn were regressed onto fluency variables family process variables and academic outcomes during fifth grade family process indices and academic outcomes were also regressed onto parent education and family income as expected allowing these structural paths resulted in significant improvement in model fit and model 1a was an acceptable representation of data for each of the three mediatorscommunication role reversal and conflict the next step in model fitting tested the direct paths from language fluency to child academic outcomes after controlling for all the other variables in our theoretical model as shown in figure 1 our theoretical model allowed no direct associations from parent or child fluency to academic outcomes to test for the hypothesized mediation model 1b removed the direct paths from the fluency variables to the three academic outcomes removal of these paths did not significantly change model fit suggesting that fluency variables do not predict change in academic outcomes controlling for the other variables in the model the direct paths from fluency to academic outcomes were therefore not retained in the following models the remaining models shown in table 1 reflect tests of difference in magnitude for particular paths and work toward an increasingly parsimonious model the first step in this process concerns possible differences between mothers and fathers model 1c provides a direct test for these differences by equating paths across parents model 1c did not significantly worsen fit for communication ⌬ 2 ϭ 808 p ϭ 78 role reversal ⌬ 2 ϭ 1488 p ϭ 25 or conflict ⌬ 2 ϭ 794 p ϭ 79 suggesting that the hypothesized pathways in the model operate similarly for both mothers and fathers the next consideration in model testing involved possible differences by language spanish or english model 1d provides a direct test for these differences by equating parallel paths across the two languages model 1d did not significantly worsen fit for communication suggesting that fluency in english and fluency in spanish operate similarly in terms of observed communication however model 1d significantly worsened fit for role reversal and conflict thus we did not carry forward the constraints for role reversal and conflict but retained the constraints for communication model 1e tested whether the pattern of associations from language fluency to family process variables differed between parent behavior and child behavior model 1e did not significantly worsen fit for role reversal but did significantly worsen fit for communication and conflict thus we did not carry forward the constraints for communication and conflict but did retain the constraints for role reversal the next question we addressed was whether the pattern of associations of the family process variables with academic outcomes varied across the four measures of that process model 1f constrained to equality the paths from the four measures of family process to each academic outcome this constraint did not significantly worsen fit for any of the models so these constraints were retained in our final models in the interest of parsimony model 1g set to zero all nonsignificant structural paths with the exception of paths predicting family processes and seventhgrade outcomes from family income and parent education and from lower order fluency variables in the presence of a significant moderation effect model 1g did not significantly worsen model fit for any of the three family process indices and was used as the final model results from model 1g for communication are presented in figure 2 observed parent communication with child was higher in families in which the parent reported higher fluency consistent with the constraints applied an identical pattern of results was found for both english and spanish fluency we found similar main effects for child fluency predicting communication to parents in addition observed child communication with parent was higher in families in which both parent and child simultaneously reported higher fluency in a common language examination of the standardized simple slope coefficients revealed that the association between child fluency and communication increased in magnitude as parent fluency in the same language increased turning to academic outcomes parentchild communication predicted significant rankorder increases in academic achievement and aspirations as well as rankorder decreases in school problems moreover the same magnitude of effect was found for all four measures of parentchild communication indirect paths from fluency to academic outcomes through communication were estimated using bootstrapped confidence intervals and were generally significant ranging in absolute value from b ϭ 002 to b ϭ 028 results from model 1g for role reversal are presented in figure 3 in terms of main effects parent passivity to child was lower among families in which parents reported higher fluency in english higher fluency in spanish and in which children reported higher fluency in spanish in addition joint fluency in spanish was negatively related to role reversal both for parents and children examination of the standardized simple slope coefficients revealed that the negative association between parent fluency in spanish and passivity increased in magnitude as child fluency in spanish increased child dominance to parent was lower among families in which both parent and child simultaneously reported higher fluency in spanish the negative association between child fluency in spanish and dominance increased in magnitude as parent fluency in spanish increased parentchild role reversal predicted significant rankorder increases in school problems but did not predict academic achievement or aspirations indirect effects through role reversal were not significant results from model 1g for hostility or conflict are presented in figure 4 parent hostility to child was lower among families in which parents reported higher fluency in spanish and in which both parent and child reported higher fluency in spanish the negative association between parent fluency in spanish and hostility increased in magnitude as child fluency in spanish increased parentchild conflict predicted significant rankorder increases in school problems indirect effects through conflict were not significant discussion the current study found support for several aspects of an extended version of the portes and rumbaut theory of dyadic cultural adaptation consistent with findings reported by portes and rumbaut most parents in our community sample were not fluent bilinguals due to low levels of english fluency similarly most children in this sample were not fluent bilinguals due to low levels of spanish fluency in observed parentchild interactions between these participants we observed only one family in which the child continued speaking english throughout the task even though the parent was speaking only in spanish tellingly that motherchild dyad was rated lower than average on communication and higher than average on hostility the theory of dyadic cultural adaptation of portes andrumbaut brings this language dynamic to the fore and hypothesizes specific family process mechanisms to explain how linguistic differences between parents and children may ultimately affect child experiences at school we consider our findings in relation to the various elements of the model portes and rumbaut considered the importance of language fluency in general by either the parent or child and also considered the issue of joint fluency by parent and child in the same language we first consider the issue of language fluency by either parent or child we replicated the finding by portes and rumbaut that child fluency predicted the parentchild relationship indices of communication role reversal and conflict we extended our test of that hypothesis by showing that parent fluency also predicts these same family process variables we also extended their theory by proposing that joint fluency in spanish would be related to parentchild communication role reversal and conflict although the theory of dyadic cultural adaptation highlights the benefits of parents and children sharing fluency in english in terms of these family processes a natural extension is that there may also be benefits of parents and children sharing fluency in spanish with regard to these same family processes furthermore because english and spanish are both options for parentchild interactions failure to include fluency in one language could lead to spurious effects for the other language the current study finds both english fluency and spanish fluency to be related to family processes fluency and family processes for example portes and rumbaut hypothesized that parent fluency in english would be particularly related to increased parentchild communication but in our data parent fluency in both english and spanish was related to higher levels of parenttochild communication a similar pattern holds for childtoparent communication that is child communication with parents is higher when children report higher fluency in either english or spanish parent fluency in english was negatively related to parent passivity consistent with the hypothesis of portes and rumbaut however parent fluency in spanish showed a similar association suggesting that role reversal is not as uniquely linked to english fluency as it is to fluency in general when parents can express themselves fluently in either language they are rated as less passive interestingly child dominant behavior toward the parent was negatively related to the childs fluency in spanish but not child fluency in english this finding suggests that the idea that fluency in english is related to more dominant behavior among secondgeneration children is incorrect instead dominant behavior by the children in this sample appears to be negatively related to their fluency in spanish it may be that communication using the spanish linguistic channel somehow facilitates an environment that prevents the emergence of child dominance alternatively child fluency in spanish may be an indicator of some other unmeasured variablesuch as more traditional cultural valuesthat is negatively associated with child dominance the third family process we examined was parentchild conflict operationalized as observed hostility in the current study higher parent fluency in spanish predicted less parent hostility this suggests that the emphasis on english fluency or anglo orientation in prior work on parentchild acculturation differences may be misplaced clearly with regard to our measure of observed hostility english fluency plays no role at all for parents or children an additional extension of prior work in this area was the finding that cooccurrence of parent and child fluency in a common language was a consistent predictor of all three family processes apparently fluency by one member of a dyad is not sufficient both parent and child need to report fluency in a common language to maximize its association with communication role reversal and conflict the current findings support prior theoretical work suggesting that fluency in a common language affects the quality of the parentchild relationship although portes and rumbaut emphasized the role of joint fluency in english this association from parent and child cofluency to childtoparent communication was also found for spanish interestingly this finding appears only for child communication with parents suggesting that children at this age may be more sensitive to or reliant on the fluency of their parents in order to communicate successfully with them role reversal was operationalized in the current study as parent passivity toward child and child dominance toward parents joint fluency in spanish emerges as a significant predictor for both parenttochild passivity and childtoparent dominant behavior that is joint fluency predicted less parent passivity and less child dominance this finding is consistent with the emphasis given by portes and rumbaut to joint fluency across generations but interestingly the association appears with regard to spanish not english as stated previously portes and rumbaut focused on parentchild differences in english the consistent associations we found from parentchild joint fluency in spanish to the four indices of role reversal reinforces the importance of considering both languages when predicting family processes among mexican american families as well as the importance of considering the cooccurrence of parent and child fluency in a common language joint fluency in spanish was uniquely related to less parent hostility toward the child parents who seek to maintain a strong communicative tie with their child and perceive their efforts to be stymied by a language barrier may experience stress which may lead to hostility alternatively fluency in spanish may be an indicator of some other unmeasured variable that tends to reduce parent hostility clearly fluency in spanish is related to lower levels of role reversal and parenttochild conflict and future research should explore further the nature of these associations family processes and school outcomes of the three family process variables hypothesized by portes and rumbaut and tested in the current study only communication successfully predicted rankorder increases in academic achievement and aspirations that is whereas communication predicted change in all three school outcomes conflict and role reversal only predicted one these results provide an interesting contrast with much of the acculturation gap literature which has focused on parentchild conflict as a key consequence of intergenerational differences in language use however our results are consistent with other work that suggests that negative effects of intergenerational differences in acculturation are caused primarily by communication problems not conflict in fact portes and rumbaut suggested that one possible reason fluent bilingualism is associated with many positive outcomes may be that fluent bilingualism makes possible better intergenerational communication because children can talk to their parents regardless of the latters english ability thus even when parents english language learning lags behind communication breakdown and other negative consequences can be prevented by joint fluency in spanish the current findings suggest that observed communication between parents and children is more consistently related to changes in school outcomes during late childhood future research will be required to determine if the relative importance of parent child communication for academic outcomes is consistent across other periods of development mediation or indirect effects communication was the only family process variable that showed consistent support for the mediational hypothesis of the portes and rumbaut model across the three child outcomes that is the associations between language fluency and change in academic outcomes can be explained by differences in observed communication between parents and children in addition to the support this result gives to other empirical work that focuses on the importance of parentchild communication among immigrant families this finding is also consistent with prior work noting that positive parenting often relates to positive child outcomes whereas negative parenting often relates to child maladjustment thus we would expect positive child behaviors to be more consistently related to positive elements of the parentchild relationship than negative elements parent gender another important issue for the current study was the degree to which the findings would apply equally well to mothers and fathers as expected the model predictions operated similarly for both fathers and mothers as noted earlier portes and rumbaut could not test for differences between mothers and fathers and findings from the current study demonstrate these hypothesized relations operate similarly across parents as parke observed the established differences between mothers and fathers with regard to play style and household division of labor should not cause researchers to lose sight of the many ways in which mothers and fathers have similar effects on children additional studies that test for differences between mothers and fathers are required to assess whether our findings of similar motherfather effects generalize to other domains of child functioning or other ethnic groups limitations and study implications this study has several limitations that should be noted although ethnic homogeneity is a strength of this study giving greater power to examine intraethnic differences replication across other immigrant groups will increase our confidence in the generalizability of our findings another limitation of the current study is that although we evaluated the causal framework proposed by portes and rumbaut ours is a nonexperimental design that cannot address questions of causality as directly as with an experimental design a third limitation concerns reliability of measurement the magnitude of our results may have been attenuated due to the modest reliability of some measures finally language is a carrier of culture and we cannot fully disentangle the effects of language and culture cultural factors may influence the way participants read and interpret questions researchers pose and could even create response biases with regard to likert scales and observationbased assessments future work in this area should continue to control for cultural markers and consider the possible role of biculturalism beyond bilingualism despite these limitations the current findings provide intriguing results regarding possible language influences on the parentchild relationship and academic outcomes if our interpretations are correct maintaining a common language between parents and their children is of paramount importance family therapists could consider that families in which all members are moderately fluent in the same language may nonetheless struggle with communication children especially appear to communicate more when both they and their parent are fluent instead of subfluent in a common language in terms of policy applications we believe the current findings support the promotion of fluent bilingualism for both generations thus instead of a onesided emphasis on fluency only in english fluent bilingualism for both parents and children may be a surer avenue to positive family relationships and optimal child development although we have tested these hypotheses among a sample of mexican american families it is likely that the same processes unfold in immigrant families regardless of whether their native language is spanish cantonese or vietnamese taken as a whole these findings suggest that researchers and practitioners who seek to foster parentchild communication among immigrant families would do well to encourage fluent bilingualism in both parents and children rather than advocate for fluency in a particular language or conflate limited bilingualism with full bilingualism parentchild communication was the only family process variable that provided a significant indirect pathway between fluency variables and academic outcomes should this finding be replicated in other samples it suggests that efforts to improve schoolrelated outcomes among children in bilingual families may profit by improving parentchild communication

the current study tested elements of the theoretical model of portes and rumbaut 1996 which proposes that parentchild differences in english fluency in immigrant families affect various family processes that in turn relate to changes in academic success the current study of 674 mexicanorigin families provided support for the model in that parentchild fluency in a common language was associated with several dimensions of the parentchild relationship including communication role reversal and conflict in turn these family processes predicted child academic performance school problems and academic aspirations and expectations the current findings extend the portes and rumbaut 1996 model however inasmuch as joint fluency in either english or spanish was associated with better parentchild relationships the findings have implications for educational and human service issues involving mexican americans and other immigrant groups

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introduction despite the antecedent of the bubonic plague in the middle ages or the spanish influenza in the early years of the 20th century for the first time in history humankind was able to witness the worldwide spread of a new disease in realtime the coronavirus disease 2019 broke out in wuhan china in december 2019 the virus showed a high infection rate fast transmission and considerable mortality as no vaccine or pharmacological treatment was available authorities throughout the world considered it a serious threat to the population after the disease reached asia it spread to europe and the americas governments declared a sanitary emergency in almost all countries with a restriction on mobility and social isolation as common strategies to avoid or delay the spread of the disease in mexico the conditions needed to declare the sanitary emergency were reached in the last week of march 2020 by this time most of the population was familiar with the high levels of people infected or deceased in other countries so the sanitary indications were neatly followed mobility decreased significantly while the social isolation conditions 2 of 11 reflected an extreme concern of the population regarding health and safety thus within a short time a large number of families began to experience stressful conditions in their daily lives the lack of social interactions restrictions on human mobility imposed fulltime interactions with family members and the new conditions of working from home or homeschooling may have influenced the modification of circadian rhythms in addition the alarming daily news and the uncertainty of the new economic conditions induced fear and agitation in big sectors of the population brought together all of these conditions could have induced sleep disturbances and the onset of mental health impairments such as anxiety or depression previous reports indicated that the 2003 pandemic of severe acute respiratory syndrome induced severe mental health disturbances mainly among asian populations 1 as most of the current health efforts have been oriented towards medical attention for those infected and health workers the psychosocial effects on the general population have been overlooked 2 in a recent review of the psychological impacts of quarantine some authors reported negative psychological effects 3 in addition recent reports from china indicated the presence of sleep disturbances generalized anxiety disorders and symptoms of depression in the population all associated with quarantine conditions 4 it is well known that isolation facilitates the onset of psychopathological manifestations including anxiety depression sleep disturbances hallucinations and suicidal behavior 5 recently the trigger of psychopathological manifestations was identified and includes boredom stress and sleep restriction 6 furthermore it is well known that sleep and mental health disturbances present reciprocal causation 7 sleep disturbances often generate a negative vicious circle worsening the quality of life of patients with mental health impairments in addition stressful situations such as social isolation often generate sleep disturbances that negatively influence mental health balance mainly worsening the state of anxiety or depression 8 9 10 in the last decades a great volume of scientific papers has reported the negative effects of sleep restriction these effects are observed both in the short and long term 1213 the shortterm effects of sleep restriction are characterized mainly by an impairment of executive functions including verbal and nonverbal working memory attention deficits and emotional and motivational regulation as well as difficulties in problemsolving among others the negative effects of sleep restrictions can be observed in a broad range of ages and are particularly critical in childrens daytime functioning 15 furthermore mood alterations due to sleep restriction also have been repeatedly reported 16 these mood changes are particularly in stressful working situations such as in hospitals the effects of sleep restriction on the increase of conflicts within groups have been repeatedly reported 17 medical residents display increasing impairments in their ability to show empathy towards patients and towards other members of the group 18 thus stressful conditions within the family group due to the sudden lockdown have an impact on the circadian rhythms and as consequence on sleep resulting in a significant level of sleep restriction as shown in preceding paragraphs quarantine and isolation conditions to safeguard human beings from covid19 could produce stressful circumstances that cause negative mental health effects such as depression anxiety and sleep disturbances 3 4 5 an additional factor that could be presented during quarantine is the increase of exposure to light stimulation at night by using bright screens such as cell phones tvs or tablets which may suppress the release of melatonin resulting in major disturbances of circadian rhythms and sleep disorders 19 knowing the effects of quarantine on sleep and mental health of the worlds population it is essential to design psychological and social interventions during and after the current pandemic in the case of mexico results that could guide such interventions and contribute to national and international scientific knowledge have not yet been reported thus the purpose of the present study was to explore the presence of sleep andor mental health disturbances as well as the use of bright screens at night in the mexican population while living in quarantine conditions to prevent covid19 infections we hypothesized that adult mexican people living in quarantine to prevent covid19 infection manifest sleep disturbances and symptoms of mental disorders such as anxiety and depression materials and methods participant recruitment an open invitation was sent via internet to participate in the present survey google forms focused on questionnaires about sleep habits sleep quality and mood were sent we used our social networks and those of the researchers and specialists affiliated with our group to invite people who voluntarily wanted to fill out the forms subjects included in the study and those who filled out the questionnaires were older than 18 years incomplete or incoherent responses were discarded in return participants received the results of their questionnaires accompanied by particular recommendations for improving their sleep quality as well as suggestions for sleep hygiene and relaxing antistress indications to improve their mood and decrease their anxiety levels the protocol followed the principles outlined in the declaration of helsinki and it was reviewed and approved by the institutional review board all the participants provided their written informed consent to participate in this study and their data were protected and kept in strict privacy electronic instruments questionnaires were electronically available from 28 march to 26 may 2020 although social isolation officially started on 24 march several families particularly in the big cities of mexico decided to decrease their mobility two or three weeks before thus the period we defined allowed us to obtain data regarding the initial week of isolation participants filled out demographic information a sleep diary for the final week the pittsburgh sleep quality index the generalized anxiety disorder 7item scale and the patient health questionnaire filling out these questionnaires took about 10 min the psqi includes 19 items that assess sleep schedules sleep latency frequency and the duration of awakening from sleep and nocturnal signs that suggest sleep disorders the version we used was the one validated and already used among mexican samples which considers a set point 5 to indicate low sleep quality 20 the gad scale explores the presence of symptoms representing the generalized anxiety diagnosis according to the diagnostic and statistical manual of mental disorders 4th ed it includes 7 items concerning anxiety data in the two weeks before when the participant answers we used the spanish version 21 previously validated among mexican samples 22 to identify the presence of mild moderate or severe anxiety the phq9 questionnaire assesses the presence of depressive symptoms during the 2 weeks before the test according to the dsmiv criteria with 9 specific items the mexican validated version 23 indicates no signs depression that could require treatment and depression that needs pharmacological or psychological therapy as bright light exposure can alter circadian rhythms and induce sleep restriction the daily hours of exposure to electronic screens or devices were analyzed to this aim a special questionnaire was designed to explore how many hours the subjects were exposed daily to a bright screen as well as the moment in which this exposure took place additionally in the same questionnaire we explored the activities the subjects performed before going to bed data analyses databases were generated and statistical analyses were performed using the statistical package for social sciences 21st version the chisquare test was used to analyze proportions and oneway anova with the duncan test binomial exact test and ttest for independents variables were used for group comparisons a pvalue of 005 was established as a maximum to consider significant differences results a total of 1230 questionnaires were received from people living in 31 of the 32 federal regions in mexico most of them came from the central region most of the participants were women and most of them were around 40 years old or younger concerning sleep quality to explore sleep disturbances figure 1 summarizes the results about the psqi items a high percentage of the sample reported a sleep latency of more than 15 min sleep duration for most of the participants was less than 7 h subjective sleep quality reported by the participants showed no major differences between goodvery good compared with badvery bad sleep efficiency was mainly reported as less than 85 a high percentage of presence of any signs of sleep disorders and a very low percentage of the absence of sleep disorders was observed and more than 80 of the participants reported daytime dysfunctions data analyses databases were generated and statistical analyses were performed using the statistical package for social sciences 21st version the chisquare test was used to analyze proportions and oneway anova with the duncan test binomial exact test and ttest for independents variables were used for group comparisons a pvalue of 005 was established as a maximum to consider significant differences results a total of 1230 questionnaires were received from people living in 31 of the 32 federal regions in mexico most of them came from the central region most of the participants were women and most of them were around 40 years old or younger concerning sleep quality to explore sleep disturbances figure 1 summarizes the results about the psqi items a high percentage of the sample reported a sleep latency of more than 15 min sleep duration for most of the participants was less than 7 h subjective sleep quality reported by the participants showed no major differences between goodvery good compared with badvery bad sleep efficiency was mainly reported as less than 85 a high percentage of presence of any signs of sleep disorders and a very low percentage of the absence of sleep disorders was observed and more than 80 of the participants reported daytime dysfunctions table 1 summarizes the statistical analysis by using the chisquare test for the items included in the psqi sleep latency was different between sexes with women showing longer sleep latencies than men sleep duration also differed between sexes a higher percentage of women slept less than 5 h regarding sleep quality a higher proportion of women reported bad and very bad sleep quality whereas men under the same parameter showed a lower proportion sleep efficiency showed a similar trend and differences were represented in extreme values the percentage of women with a sleep efficiency of 85 or more was lower compared to men on the contrary the percentage of table 1 summarizes the statistical analysis by using the chisquare test for the items included in the psqi sleep latency was different between sexes with women showing longer sleep latencies than men sleep duration also differed between sexes a higher percentage of women slept less than 5 h regarding sleep quality a higher proportion of women reported bad and very bad sleep quality whereas men under the same parameter showed a lower proportion sleep efficiency showed a similar trend and differences were represented in extreme values the percentage of women with a sleep efficiency of 85 or more was lower compared to men on the contrary the percentage of women with sleep efficiency below a value of 65 was higher than the percentage of men the presence of sleep disorders was also different between sexes since a high proportion of women experienced these problems once or twice a week concerning the use of sleep medication no significant differences were observed between sexes differences between sexes were observed regarding daytime dysfunctions with a higher percentage of women affected table 2 shows the results for the chisquare test when participants were grouped by age young 1840 years and old ≥ 40 years old the younger group showed longer sleep latencies a higher proportion of young participants reported a sleep duration of fewer than 5 h more than a half of the younger participants reported bad or very bad sleep quality a higher proportion of young participants reported low sleep efficiency 65 younger participants reported a higher frequency of sleep disorders once or twice a week the older group reported a high percentage of participants using drugs several times and daytime dysfunctions showed a proportion of more than half of younger participants reporting this issue as moderate or severe figure 2 summarizes the overall results concerning the psqi evaluation of sleep quality grouped by ages the ≤40yearold women seem to be the most affected group and showed differences from the other age groups similarly ≤40yearold men reported more sleep disturbances than the 40yearold participants no significant differences were observed between men and women who were older than 40 figure 2 summarizes the overall results concerning the psqi evaluation of sleep quality grouped by ages the ≤40yearold women seem to be the most affected group and showed differences from the other age groups similarly ≤40yearold men reported more sleep disturbances than the 40yearold participants no significant differences were observed between men and women who were older than 40 regarding anxiety 348 of women reported mild symptoms 183 moderate and 18 severe in the case of men 381 reported mild symptoms 169 moderate and 19 severe no differences between genders or ages concerning anxiety were identified regarding depression results for the phq9 indicated no differences between genders or age with p 0664however 245 of women and 186 of men reported moderately severe and severe depression symptoms in addition the results show that younger females reported a higher percentage of depression symptoms than older males furthermore when the use of electronic devices was analyzed the results indicate that more than half of the sample was exposed to bright lights for at least 5 h daily women reported a higher percentage of screen use at around 10 h daily and reported a longer used of screens compared to men p ≤ 001 when activities related to preparing for bed were explored a high percentage of the participants reported the use of some kind of electronic device as part of their activities prior to sleep no differences were observed regarding age discussion the purpose of this study was to explore the presence of sleep andor mental health disturbances in the mexican population while living under quarantine conditions to prevent covid19 infections our results included the evaluation of the first eight weeks of social isolation in mexico and focused mostly on big cities similar to an italian report a high percentage of females responded to the survey 2425 which suggests that women manifest a greater concern for their own and their familys issues regarding anxiety 348 of women reported mild symptoms 183 moderate and 18 severe in the case of men 381 reported mild symptoms 169 moderate and 19 severe no differences between genders or ages concerning anxiety were identified regarding depression results for the phq9 indicated no differences between genders or age with p 0664 however 245 of women and 186 of men reported moderately severe and severe depression symptoms in addition the results show that younger females reported a higher percentage of depression symptoms than older males furthermore when the use of electronic devices was analyzed the results indicate that more than half of the sample was exposed to bright lights for at least 5 h daily women reported a higher percentage of screen use at around 10 h daily and reported a longer used of screens compared to men p ≤ 001 when activities related to preparing for bed were explored a high percentage of the participants reported the use of some kind of electronic device as part of their activities prior to sleep no differences were observed regarding age discussion the purpose of this study was to explore the presence of sleep andor mental health disturbances in the mexican population while living under quarantine conditions to prevent covid19 infections our results included the evaluation of the first eight weeks of social isolation in mexico and focused mostly on big cities similar to an italian report a high percentage of females responded to the survey 2425 which suggests that women manifest a greater concern for their own and their familys issues according to our results a high percentage of the participants sleep was severely affected with reports of poor quality of sleep furthermore the percentage of women affected was higher than men additionally younger people seemed to be more sensitive to conditions of isolation and their sleep was more affected than that of older people women under 40 proved to be the most sensitive population to sleep disturbances these results are similar to those reported in early studies on italian 25 and chinese samples these results can be explained by the role that young women usually play within the family home in addition the increase in domestic violence mainly affecting young women has been recently reported 26 these results may reflect important sleep restriction conditions presented among the mexican population while facing quarantine conditions thus the present data should be taken as an extreme concern since current knowledge about sleep restriction suggests deficits in behavioral performance and mood swings 2728 and research conducted on medical students with sleep restriction reported an impairment of empathy and an increase of ingroup conflicts 29 in addition similar to what was reported in other countries during quarantine the calls to 911 reporting domestic violence and violence against health workers in mexico have considerably increased 3031 moreover and as reflected in our results disturbances of the circadian rhythm play a role in the onset of sleep disturbances in this sense the purpose of the study included the exploration of the use of bright screens at night participants declared a frequent use of these instruments with a clear trend of using them at night as has been reported the excess of blue light stimulation provided by electronic devices interferes with the onset of sleep 32 particularly in school children and adolescents the excessive use of electronic devices induces a delayed bedtime shortened sleep duration and longer sleep latency 3334 thus it seems that quarantine conditions facilitate the use of tv and electronic devices among the entire family which may affect circadian rhythms resulting in a cascade of adverse events that includes sleep restriction and reduced sleep quality 19 moreover the association between the use of electronic devices sleep disturbances and depression has been confirmed for adolescents thus the presence of depressive symptoms observed in our sample can be due at least partially to sleep disturbances induced by the excessive use of electronic devices 35 since there is a clear relationship between young women using electronic devices for 10 h daily and sleep disturbances concerning ages yu et al reported in 2018 36 that social isolation was the main factor for sleep disturbances in older people when comparing their results obtained from 639 participants in taiwan the authors indicated that social isolation and not loneliness was the main factor for sleep disturbances controversially our results do not confirm this report rather we observed that younger people manifested sleep disturbances included in the psqi whereas older people showed only slight changes in sleep furthermore young women appeared to be more vulnerable to lockdown conditions showing an increased frequency of sleep and mental health disturbances it is possible that the role and responsibilities that young women have within mexican families impose additional pressure on their mental stability it remains to be elucidated why young women seems to be more vulnerable to sleep loss in lockdown conditions some studies reported sleep disturbances in pregnancy and during premenstrual syndrome however to date endocrine factors cannot fully explain the increased frequency of sleep and mental disturbances in young women furthermore social isolation induces a decrease in solar light stimulation that negatively affects both circadian rhythm synchronization and mood 37 mexico city is the most crowded region of the country with nearly 20 million people and its authorities decided to implement measures of social isolation to avoid spreading the virus health authorities reported that more than 70 of the people decided to stay at home with minimal social interactions the present results are in accordance with other recent publications reporting mental health disturbances due to lockdown conditions all over the world 38 concerning generalized sleep restriction public health strategies should be discussed to avoid future adverse health outcomes since 2015 the american academy of sleep medicine and the sleep research society addressed the relationships between sleep duration and the risk of suffering from a wide variety of diseases including diabetes stroke endocrine dysfunction mental illness and cancer a panel of experts in sleep medicine reviewed the available scientific evidence in more than 5300 scientific articles after more than 12 months of review and discussion a final statement was disclosed the consensus statement indicated than sleeping less than 7 h regularly increases the risk of death this death risk was associated with the presence of obesity diabetes heart diseases and depression in addition there is also a greater risk of accidents 39 thus there is an increased probability that this prolonged period of sleep restriction leads to an increase in the frequency of dangerous diseases among the general population our exploratory study involved samples reflecting the first weeks of quarantine the most significant results indicate that a high percentage of the participants reported poor sleep quality and that women and young people were more sensitive to such effects in addition quarantine conditions seemed to facilitate the use of electronic devices at night which can affect the quality of sleep and favor the presence of depression particularly in young people these results are important for designing mental health intervention strategies during quarantine that include sleep hygiene habits and practices to maintain or improve the quality of sleep in the population and to prevent the presence of symptoms of depression with emphasis on women and youth the present results should be taken with caution because the population evaluated came only from the countrys large cities and not from other regions in which quarantine conditions and related information may vary furthermore our sample was limited to participants who could access digital devices to answer the questionnaires leaving out a large part of the population that does not have access to such resources importantly we do not have previous measures on sleep quality depression anxiety or the use of electronic devices in equivalent samples before quarantine conditions so although our results coincide with previous reports in italy and china they cannot be strictly associated with only quarantine conditions future studies can be conducted at different times in the pandemic as a comparative measure the pandemic and lockdown conditions have lasted more than expected so new surveys should be done to explore the effects of several months of social isolation on sleep anxiety and depression to understand in more detailed the effects of quarantine conditions on mental health

the coronavirus disease covid19 that broke out in china in december 2019 rapidly became a worldwide pandemic in mexico the conditions requiring the declaration of a sanitary emergency were reached by the last week of march 2020 and health authorities limited mobility and imposed social isolation were the main strategies to keep the virus from spreading thus daily living conditions changed drastically in a few days generating a stressful situation characterized by an almost complete lack of mobility social isolation and forced fulltime interactions with family members soon complaints of sleep disturbances anxiety and symptoms of depression were reported the present study reports the results of an online survey performed during the first two months of isolation questionnaires exploring sleep disturbances anxiety and depression were sent to people who responded to an open invitation a total of 1230 participants filled out the sleep questionnaire 812 responded to the anxiety questionnaire and 814 responded to the depression questionnaire both men and women reported poor sleep quality but women showed a higher proportion 79 than men 60 young women were more likely to be affected by social isolation concerning anxiety and depression both sexes reported high similar symptoms these data suggest that stressful conditions related to social isolation and the economic uncertainty caused by the pandemic may induce mental health disturbances which may become worse with sleep restriction

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introduction in the last 50 years evidencebased tobacco control policies have contributed to the worldwide decrease in the prevalence of cigarette smoking among adults 1 trends in many countries over the past 25 years have shown that smoking rates for men have dropped significantly more than those for women 2 the largest imbalance has been found in the southeast asia and western pacific regions 3 japan which is located in the aforementioned regions has ratified the who framework convention on tobacco control in 2008 who introduced the mpower measures to assist in the countrylevel implementation of effective interventions to reduce the demand for tobacco contained in the who fctc monitor tobacco use and prevention policies protect people from exposure to secondhand tobacco smoke offer help to quit tobacco use warn about the dangers of tobacco enforce bans on tobacco advertising promotion and sponsorship raise taxes on tobacco in an attempt to further lower smoking rates smoking cessation medication began being covered by health insurance policies in 2006 and tobacco tax increases and restrictions on smoking areas started being promoted however mpower measures have been found to be insufficient 4 both the smoking rate 5 and the decline in smoking rate show significant gender differences in order to reduce the smoking rate smoking cessation policies and the prevention of smoking initiation are both important factors regarding gender differences in smoking cessation women are more likely to have difficulty maintaining longterm abstinence from smoking than men including those with even moderate addiction 6 those between the ages of 30 and 55 6 those with some smoking cessation therapy 78 and those who consume alcohol 9 some arguments have been put forward stating that the gender differences observed in clinical trials 10 cannot be translated into realworld settings 11 but a recent study on the utilization of national tobacco cessation services among female smokers also suggested that further research considering genderspecific tobacco cessation support was needed 12 a who survey from 2015 on smoking initiation among women and girls noted that a better understanding of the key factors affecting this situation was needed in order to address the growing global pandemic of female smokers and the looming impact on womens health 13 the moststudied environmental influences thus far include parental sibling and peer relationships parental smoking has been shown to strongly and significantly affect smoking initiation among offspring 14 compared to offspring of nonsmokers those of persistent smokers had twofold smoking rates maternal smoking was more strongly associated with youths regular smoking than parental smoking 15 the effect of parental smoking appears to vary on the basis of the parents sexgender which is likely to be related to the traditional roles of mothers and fathers 15 regarding the influence of smoking grandparents results indicate direct linkages between both grandparent and parent smoking and parent and offspring smoking however the direct link between grandparents and grandchildren was not significant 16 according to a study in finland both girls and boys had higher odds for daily smoking if any of the four grandparents were current smokers results indicated the significant odds between paternal grandfather and girls paternal grandmother and girls paternal grandmother and boys maternal grandfather and boys maternal grandmother and girls and maternal grandmother and boys however when parents and grandparents smoking status was included in the same model grandparent smoking generally lost statistical significance 17 despite the potential effects of smoking grandparents the results were inconsistent furthermore this has not been studied in the asia pacific region which has a particularly large gender difference with respect to smoking rate we hypothesized that the integrated analysis of smoking behavior over three generations would reveal how it may consistently affect the next generation which is an extension of previously reported parentchild studies that only investigated parental influences to compare smoking behavior with that of parents and grandparents to investigate whether there are any gender differences between smoking initiation and cessation new evidencebased genderspecific tobacco policies can be implemented with the aim of reducing the smoking rate among women therefore it is necessary to clarify the gender differences in smoking behavior across generations the primary aim of this work was to perform a crosssectional study to investigate how gender differences affect smoking initiation and cessation in a japanese genome cohort focusing on intergenerational transmission over three generations from grandparents to their children and subsequently from their children to their grandchildren materials and methods study design and participants the present study was a crosssectional study using the nagahama prospective cohort for comprehensive human bioscience the cohort was recruited from the general population of nagahama city japan which has a population of 125000 a total of 9804 participants were recruited via mass communication by the local government and citizen organizations from 2008 to 2010 of these participants we excluded 26 nonjapanese participants using pca 18 and 14 participants withdrew their consent which left a total of 9764 participants for the analysis a structured questionnaire on smoking was implemented from 2009 to 2010 for baseline investigation and 8652 subjects were registered from 2009 to 2010 for our analyses figure 1 shows the study flowchart a copy of the questionnaire used to capture the data is provided in the supplementary materials the researchers and city employees held an information session for the residents regarding the present study japan has universal health coverage and this study included the specific health examination mandated by japanese national laws for medical insurers to prevent against noncommunicable diseases 19 the cohort was primarily aimed at healthy subjects and participants had to meet the following criteria be aged between 30 and 74 years old be able to participate in health examinations independently have no difficulty in communication have little serious diseasessymptoms or health issues and have voluntarily decided to participate in the study the municipal government staff made appointments for health examinations by telephone and the participants were registered at the site of the health examination written informed consent was obtained from all of the participants prior to their health examination the response rate was 100 and the interviews were carried out at the location of the medical checkup all protocols and informed consent procedures were approved by the kyoto university graduate school and faculty of medicine ethics committee the ad hoc review board of the nagahama cohort project and the nagahama municipal review board of personal information protection this study was carried out in accordance with approved guidelines smoking status intergenerational variables demographic and environmental variables and variables of noncommunicable diseases were collected using an anonymous selfadministered postal questionnaire outcome variables assessment of smoking status smoking status was categorized into three clinical groups current smokers eversmokers and neversmokers these groups were respectively defined as those who smoke every day or some days those who have quit smoking and those who have no experience of smoking to assess the factors of smoking initiation smoking starters were compared with neversmokers to assess the factors of successful cessation css were compared with ess correlated variables intergenerational variables the main correlated variable was the intergenerational transmission of smoking across three generations the intergenerational variables consisted of dichotomous indicator variables ie whether or not the mother father grandmother grandfather or siblings smoke all answers were chosen as either yes or no when the mother was recorded as a smoker we also determined her smoking status during pregnancy years of smoking and smoking initiation the number of years that css and ess had been smoking for was determined both their age and the number of cigarettes smoked per day at the time of smoking initiation were also provided as the smoking initiation status age was categorized as either 20 or ≥20 years and cpd was categorized as 110 1120 or ≥21 variables of alcohol consumption as alcohol consumption could have been a confounder the variable of alcohol consumption consisted of four indicator variables according to the answer to the following question how much do you drink a day in terms of glasses of refined japanese sake a glass of refined sake is equivalent to a medium bottle of beer 110 ml of shochu a glass of whisky and two glasses of wine demographic and environmental variables age and spousal smoking status were evaluated as moderators of the association between gender and smoking behavior smoking initiation and smoking cessation spousal smoking was indicated as either yes or no body mass index was evaluated as a moderator of the association with smoking cessation participants were grouped into the following categories according to bmi 250 and ≥250 variables of noncommunicable disease it is known that smoking facilitates the development of diabetes mellitus by affecting the function of insulin in lowering blood sugar levels triggering dyslipidemia by hindering lipid metabolism and increasing blood pressure due to the action of constricting blood vessels in the specific health examination and specific health guidance smoking habits are counted as an additional risk when combined with high blood pressure dyslipidemia or high blood sugar in addition to abdominal obesity there are three types of blood tests used in the specific health examination lipid liver function and blood sugar we also assessed renal function glutamic oxaloacetic transaminase glutamic pyruvic transaminase gammaglutamyl transferase total cholesterol blood sugar hemoglobin a1c systolic blood pressure and serum creatinine were evaluated as variables of noncommunicable disease statistical analysis using data from all of the participants we examined gender differences in smoking initiation and cessation the participants were stratified by gender we compared each variable between the two groups using fishers exact test and ttest we also performed an analysis of variance among the three groups in order to identify the potential association between the independent variables and smoking behavior all variables were entered into univariate logistic regression models multiple logistic regression analysis was performed to identify the correlated factors of smoking behavior when a high degree of correlation existed between variables they were not entered together in the same multivariable model multicollinearity was assessed using correlation coefficients and the variance inflation factor given the known relationship between smoking cessation and menstruation status 20 age could have affected gender differences in the success rate of smoking cessation age was thus categorized into groups multivariate logistic regression models were prepared to estimate the factors correlated with smoking initiation and cessation those variables included in the adjusted models were based on the existing knowledge of risk factors for smoking behavior continuous variables were categorized for regression analyses multivariate logistic regressions were subsequently used to extend the analysis and to assess the role of correlated variables when entered into the equation simultaneously the covariates for the adjusted models were age group spousal smoking status and family smoking history we evaluated the interaction between age and years of smoking in the final models using maineffect terms sensitivity analyses were performed to test the influence of the number of years of smoking to assess the influence of smoking during pregnancy we calculated the odds ratio using fishers exact test all statistical analyses were performed using software r version 412 a pvalue 005 was considered statistically significant results among the 8652 respondents who met the inclusion criteria 2833 were men and 5819 were women overall 141 were css 204 were ess and 655 were nss the rate of smoking among men was higher than that among women more women were nss with a rate of 855 compared with a rate of 244 among men table 1 shows a comparison of the demographic background and indices of noncommunicable diseases among the three groups data are presented as the median bmi body mass index got glutamic oxaloacetic transaminase gpt glutamic pyruvic transaminase γgtp gammaglutamyl transpeptidase tch total cholesterol bs blood sugar hba1c hemoglobin a1c bp systolic blood pressure serum cr serum creatinine gender differences in smoking initiation the results of the logistic regression analysis are shown in table 2 gender differences were observed to significantly correlate with smoking initiation in the final model women with smoking mothers 24 95 confidence interval 1832 and grandmothers had a higher likelihood of being a cs or an es men were not affected by their smoking mothers or grandparents while women were more likely to be affected by their smoking mothers and grandmothers age showed opposite trends with respect to gender women aged ≤55 years had significantly more smoking experience than those aged ≥56 years on the contrary men aged ≤55 years had less smoking experience than those aged ≥56 years both men and women were affected by their fathers and siblings gender differences in smoking cessation the variables used for the additional adjustment for smoking cessation were bmi cpd age at the time of smoking initiation spousal smoking status and alcohol consumption as shown in table 3 gender differences were observed to be significantly correlated with smoking cessation in the final model women who continued smoking were affected by their smoking mothers which is consistent with the findings of smoking initiation conversely men with smoking fathers grandfathers spouses and siblings continued smoking men aged ≤55 years of age continued smoking compared with those aged ≥56 years whereas no significant differences were found in women in men obesity was defined as having a bmi of more than 250 obesity in css was observed significantly less than in ess the results of the sensitivity analyses revealed that when years of smoking were entered in the model the age of women showed a reverse effect while the age of men did not have any influence age was thus retained in the model or odds ratio ci confidence interval association between maternal smoking during pregnancy and smoking initiation given the correlation coefficient of 060 between smoking mothers and antenatal maternal smoking maternal smoking during pregnancy was excluded to avoid multicollinearity in the multivariate analysis fishers exact test showed gender differences in maternal smoking during pregnancy the odds ratios were 028 for css and ess and 004 for nss among men and 025 for css and ess and 036 for nss among women antenatal maternal smoking affected smoking initiation among men but not significantly on the contrary it did not affect women discussion this crosssectional study in a japanese genome cohort based on data from the general population of nagahama city in japan demonstrated that gender differences were associated with the intergenerational transmission of smoking behavior across three generations there were three key findings in this study the first with respect to smoking initiation was that women were affected by their mothers and grandmothers the second with respect to smoking cessation was that smoking in all family members except the mother and the grandmother affected men whereas women were only affected by their smoking mothers the third with respect to age was that in the case of men the smoking initiation rate was significantly lower in the younger age group and the smoking rate was significantly lower in the older age group however in women the smoking initiation rate was significantly higher in the younger age group and the smoking rate was not different between younger and older age groups under the same tobacco control for both men and women there was no significant impact on curbing smoking rates because female smokers were in the minority given the fact that the smoking rate in younger women has not declined as shown in this study the who report in 2019 showed that the smoking rate among women in highincome countries was still the highest among all countries more than four times the average rate seen in lowand middleincome countries in contrast the highest rate among men was seen in middleincome countries where it was almost double the average rate found in lowincome countries among women in highincome countries it is globally rising 21 thus the use of the same tobacco control methods for men and women may not sufficiently restrain the smoking behavior of women in their social advancement the effects of parental smoking differed by gender for both smoking behavior and nicotine dependence 22 in the present study the smoking status of mothers significantly increased the likelihood of smoking initiation among women but not among men which is consistent with a previous report 1523 moreover we found that grandmothers had a stronger influence on smoking initiation among women compared with fathers and grandfathers in contrast to our results a previous study indicated that the direct linkages between grandparents and grandchildren were not significant 1617 however these studies also suggested that their offspring represented the combined influence of the family social environment as well as shared genetic factors affecting smoking initiation and nicotine addiction gender differences may reflect the distinctive sexual dimorphism of the brain including hormonal and structural factors that emerge during fetal development 24 similarities in smoking behavior could be due to shared genes particularly those involved in nicotine metabolism or those related to the availability of brain neurotransmitters such as dopamine and serotonin 25 pharmacogenetic studies have suggested associations between treatment outcomes and genes coding for drugmetabolizing enzymes 26 27 28 cyp2a6 metabolizes nicotine the rate of inactivation and the clearance of nicotine can ultimately influence smoking behavior as well as the ability of smokers to quit smoking in a recent study women were associated with higher cyp2a6 mrna expression relative to men in univariate analyses with similar trends for protein levels and enzyme activity but not significantly 29 if a genderspecific genetic etiology of smoking cessation is found not only is effective smoking cessation treatment possible but tobacco control can also be implemented according to the evidence the who has stated that smoking cessation interventions should be effective for and available to vulnerable groups of people 30 this indicates the need to consider appropriate tobacco control measures for women according to a previous canadian study on tobacco control price and taxation were the only policies related to smoking behavior in both men and women whereas the association between health education and smoking behavior was genderspecific 31 per capita health education expenditures were positively associated with the odds of being a nonsmoker for men but not women 31 even at a younger age there was no evidence that schoolbased smoking prevention programs have a significant effect on preventing adolescent girls from smoking 32 a cochrane review for familybased programs for preventing smoking by children and adolescents regardless of gender showed moderatequality evidence of familybased interventions having a positive impact on preventing smoking when compared to a nointervention control 33 however mothers and grandmothers are often positive role models for girls and smoking behavior is inherited as shown in our research this relationship could hinder the success of familybased programs we also paid attention to the intergenerational transmission of implicit attitudes in adolescents smoking initiation mothers who had more positive implicit attitudes had children with more positive implicit attitudes these positive implicit attitudes of adolescents predicted their smoking initiation 18 months later 34 gender differences in smoking rates and the declining smoking rates in japan could be explained by the following as smoking rates among fathers and grandfathers have declined over the last 50 years smoking in their affected sons has also declined meanwhile smoking rates among women have been maintained across generations of mothers and grandmothers resulting in no decrease in smoking initiation among women indicating that mothers and grandmothers have a strong influence on female offspring in terms of both smoking initiation and cessation effective smoking prevention education tools and timing for girls should be the focus rather than smoking cessation after initiation in order for tobacco public policy to succeed completely it is necessary to clarify the cause of intergenerational transfer for smoking behavior and further research is required for related evidence age groups showed gender differences in smoking cessation in previous studies gender differences were observed in smoking cessation among respondents between 30 and 55 years of age with women having greater difficulty abstaining from smoking 6 one of the big gender differences is presumed to be menopause since dramatic changes in the hormonal environment are associated with various health problems investigating the different effects of female hormones is a worthwhile avenue for future research the present study had several limitations this was a crosssectional study thus predictors could not be determined the data were based on selfreports allowing recall bias of the participants especially with regard to smokers indicating their status as nonsmokers conversely css and ess reflect their perceptions of their parents and grandparents smoking which can be considered even more important than the actual grandparents smoking status our setting was nagahama city which is a relatively populous local area in japan the population ratio of males to females is 489 to 512 along with 136 for ages from 0 to 14 years old 582 for ages 15 to 64 and 282 for ages over 65 while we consider our study cohort representative of the japanese population the small population may prevent the generalization of this study the intensity of smoking was also selfreported and not determined regarding smoking cessation one of the reasons for failure to quit smoking is nicotine addiction we captured cpd data but we did not determine the degree of nicotine addiction and smoking cessation therapy we analyzed the secondary data from the nagahama study we surveyed around 3000 male cases in line with a previous study 17 with 3535 samples even though our questionnaire response rate was 100 secondary data processing led to a sample size of 2833 men and 5819 women given the small sample size the statistical power may have been low conclusions in conclusion we found that gender differences in smoking initiation and cessation might be attributed to differences in the influencers of smoking among family members compared with men women with smoking mothers and grandmothers were more likely to be smokers and women with smoking mothers were less likely to achieve smoking cessation our findings suggest that smoking mothers may continue to affect the smoking behavior of their daughters and even granddaughters future research should focus on whether the longterm smoking behavior of women is due to genetic factors in matrilineal families or provide evidence to help develop effective genderspecific intervention programs to curb the longterm smoking behavior of women the nagahama cohort project and the nagahama municipal review board of personal information protection informed consent statement written informed consent was obtained from all of the participants prior to their health examination data availability statement this study was conducted by analyzing a dataset of the nagahama prospective cohort for comprehensive human bioscience the data are available upon request because we did not obtain consent from each participant for publication of individual data in the public domain data from the nagahama study are available upon request to the nagahama office we plan to make our data available at the national bioscience database center after obtaining consent from the participants in this study

global tobacco policies lowered overall and male smoking rates but female smoking rates have remained unchanged parentchild studies revealed the effects of parental smoking but gender differences had mixed results we investigated the effects of longterm smoking behavior in families over three generations in order to clarify gender differences a crosssectional study in a communitybased genome cohort was conducted using a selfreported questionnaire a total of 8652 respondents were stratified by gender regarding smoking initiation a logistic regression analysis was performed to analyze the family smoking history a total of 2987 current smokers and eversmokers were compared regarding smoking cessation with respect to smoking initiation women were affected by their smoking mothers odds ratio or 24 95 confidence interval ci 1832 and grandmothers or 17 ci 1124 women who continued smoking were affected only by their smoking mothers or 16 ci 105249 in conclusion gender differences in smoking initiation and cessation are possibly associated with family smoking history mothers and grandmothers were shown to have a strong influence on women with respect to both smoking initiation and cessation future research should focus on providing evidence for effective genderspecific intervention programs to curb longterm smoking in women

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introduction the launch of web 20 at the turn of the 21st century enabled a communication revolution this was followed by the rapid emergence of diverse social media platforms of which friendster was one of the first globally known ones in turn a growing scientific interest started to characterize the present era 12 this concentrated attention brought up a heterogeneous set of terminological approaches for the novel phenomenon termed social media 3 scientific publications in this domain commonly highlight the interactive function of the platforms in question furthermore their services that offer instant communication extended with possibilities offered as usergenerated content such as liking sharing and commenting based on such reasons one of the most widely used definitions in this area of research is offered by kaplan and haenlein according to whom social media platforms are internetbased applications that build on the ideological and technological foundations of web 20 and that allow the creation and exchange of user generated content 4 vanmeter et al stated that such platform is an interactive one which allows social actors to create and share in multiway immediate and contingent communications 3 the core nature of social media platforms is the purpose of enhancement and maintenance of individual user relationships therefore sm use can be considered as an investment in social relationships 5 the exponential user base growth on a plethora of social media platforms has a multitude of individual underlying reasons from which this paper will tap into the human drive for social interactions and engagement and evolutionary phenomena facilitated by cooperation and trust leading to the perception of an individuals reputation the human need to belong is a widely discussed psychological phenomenon 6 there are empirical suggestions for the influence of this drive on college students social media use manifesting in interaction and social engagement 7 the need for belongingness appeared in maslows 8 theory of human motivation which is manifesting itself on todays social media platforms drawing back to the thoughts of baumeister and leary this motivation leads individuals to enhanced efforts to broaden and strengthen their social connections as discussed in the previous social media literature belongingness and selfrepresentation 9 are considered among the primary reasons for social media use 10 taking into of lins definition social capital is the investment in social relations with expected returns in the marketplace 11 under these circumstances individual social media presence is indeed influenced by the drive for belongingness paired with expected returns which under these circumstances indicates enhanced social ties and the possibility of leveraging social support 12 considering the exponential growth of the global user base and the diversity of social media platforms which have become part of humanitys everyday lives the measurement of individual social capital on social media has become a crucial area of investigation the expected and perceived returns which characterize this phenomenon make it essential for scientists to empirically examine and quantify their potential impacts on the lives of individuals at a global scale therefore emerging scientific attention has turned to operationalize and validate social capital scales the evaluation of which can possibly describe this phenomenon in detail there are indications however that there are possible inconsistencies present regarding the measurement techniques of perceived individual social capital williams pointed out based on the theories of putnam that the bridging and bonding dimensions of the cultural view of social capital are not orthogonal which can lead to possible measurement discrepancies further concerns suggested that the distinction between bridging and bonding social capital is rather ad hoc 13 therefore their treatment in such manner can possibly lead to harmful consequences 14 additional critics 14 highlighted the issue that granovetters seminal works about the implications of weak and strong social ties 1516 which indicated that weak ones are possibly more important than strong ones are dominating this research field 17 in this manner this investigation aims to scope the presently existing measurement techniques and trends in this research area no hypotheses were set in this study reflecting on its exploratory nature the rest of this article is structured as follows in the next section we present a terminological outline of the existing social capital theories this leads to differentiation regarding online and offline social capital the birth and theoretical development of this phenomenon is then presented this includes a discussion of the cultural and multidimensional views of social capital as subjects of the vast majority of publications operationalizing social capital the items of measurement are detailed this is followed by a presentation of the research methodology aiming to explore past scientific research measuring social capital paying attention to possible inconsistencies regarding operationalization techniques the results are presented next followed by the conclusions limitations of the present paper and future research suggestions literature review social capital terminology has undergone a substantial transformation since its birth as a possible reason for such diversity fine 18 highlighted that previous research practices applied an appropriate definition matching the particular application in question 19 20 21 22 according to bourdieu social capital is the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition 23 emphasizing that it is a form of capital measurable on an individual or group level characterizing embedded relationships between individuals furthermore coleman defines social capital as an accumulation of resources stemming from various individual relationships 24 portes highlighted the importance of the structure of such relationships wherein the actors of this phenomenon are located 22 while fukuyama underlined the importance of cooperation among individuals which promotes social capital 25 according to putnam social capital is social networks associated with the norms of reciprocity indicating that the phenomenon itself jointly describes these networks and their effects on participating individuals 26 however to offer a brief outlook regarding the up to date inconsistencies regarding social capital discussed in detail by fine 18 the argument of social capital being the cause the effect or the process itself is a matter of present scientific debates as well 27 the emergence of web 20 brought further developments regarding the theory and parallel development of the applied measurement techniques of social capital distinguishing between online and offline contexts with research indicating that the use of the internet is associated with trust and community involvement enhancement 28 the impact of the internet as a surrogate and a supplement of human communication has been discussed widely in scientific research the focus of which has been email usage 29 or the functions of chat rooms in idea sharing and political participation 30 in the early stages of internet studies in social capital research with the emergence of computermediated social networks the discussion of the associations between social capital and individual tie strength research investigating both strong and weak ties in an online context based on granovetters social tie theories 1516 opened a new research field the aim for the development of online social capital became one of the core aspects of empirical research a milestone of which was the development and validation of the first comprehensive online social capital scale by williams 27 to better understand the importance and details of this contribution it is essential to discuss the most widely discussed existing views of social capital theory this is crucial to grasp the context of this scale which still has one of the most noted impacts in the present empirical social capital research measured on social media the birth of social capital as a scientific phenomenon is unclear 18 according to hofer and aubert lyda hanifans article from 1916 31 can be seen as a possible theoretical root 32 hanifans rediscovery during the beginning of the 21st century can be potentially attributed to an article by putnam and goss in which the authors stated that her definition encompassed all of the crucial elements identified ones in contemporary science 33 the beginning of the 1980s marked its first concentrated attention through the works of french radical sociologist pierre bourdieu joined by american rational choice sociologist james coleman who started elaborating on this topic in the late 1980s and early 1990s 34 robert putnams investigations during the turn of the century 26 took an important scientific step towards through the definition and conceptualization of bridging and bonding social capital this based on granovetters works on social tie strength 1516 wherein he proposed that strong social ties are not valuable for an individual in the process of a new job acquisition however weak social ties are beneficial for the individual in question 15 based on granovetters seminal works putnam proposed that a persons bridging social capital is valuable for the acquisition of previously unknown new information while the function of bonding social capital refer to an individuals strongest ties is the provision of social and emotional support in parallel to the previously described cultural view of social capital 23 2426 and theorists of the structural view 3818 the turn of the century marked nahapiet and goshals seminal work this work elaborated on the multidimensional view of social capital segmenting it into structural relational and cognitive dimensions 36 social capital has been put into relationship analyses with enormously diverse phenomena fine offered several curious examples 18 the most promising research platforms in social capital studies are social media platforms building upon belongingness as a human drive and social engagement the shared question of such studies is whether or not the use of social media affects the individuals perception of the social capital of the self and the perceived social support as a result the number of papers is growing rapidly in which the perceived individual social capital is analyzed on social media platforms 41 the different aspects viewpoints and theoretical considerations in terms of social capital raise the question of how these are operationalized for further empirical investigation and evidence the development of measurement techniques was already urged by quanhaase and wellmann in 2004 who argued for its necessity based on the accelerated emergence of the internet in parallel to the development of social capital 42 following this call williams created the internet social capital scale consisting of two scales proposed to measure bridging and bonding social capital respectively including 1010 measurement items based on putnams conceptualization 27 these scales were extended and modified 1 wherein the bridging and bonding social capital of michigan state university students was measured the aim was the analysis of student social capital the intensity of facebook use and further control variables in this article the authors introduced the definition and measurement of maintained social capital as well which refers to such prior high school social connections of students that were later maintained during their time spent in higher education the following table aims to introduce the measurement items of the iscs 27 in comparison to those items that were included in the seminal work of ellison et al table 1 illustrates that ellison et al adapted five statements from the iscs slightly adjusting the statements to the msu context while they operationalized and validated a scale for maintained social capital as well therefore table 1 presents the five distinct measurement items of this social capital construct as well the dichotomous handling of bridging and bonding social capital has raised concerns as williams pointed out these constructs are not mutually exclusive they are oblique rather than orthogonal to one another 27 their treatment as distinctive constructs can result in harmful consequences therefore they should be handled as oblique ones 14 further critics noted that the distinction between bridging and bonding social capital measurement instruments is rather ad hoc 13 additionally based on the wide recognition of granovetter which highlighted the importance of weak social ties academic research tended to highlight the existence of this phenomenon and sought evidence for its underpinning 17 this has also generated concerns in recent studies 14 the development of the measurement constructs in the multidimensional view of social capital followed a different path in operationalization from the end of the 1990s until 2006 this marked the year of the publication of the article by chiu et al which created and validated a comprehensive set of items for all three studied social capital dimensions 43 the history of measurement development in the multidimensional view of social capital reached a milestone with the seminal work of chiu et al which built upon the work of tsai and goshal the definition of the structural dimension as social interaction ties the relational one as trustworthiness and trust and the cognitive one as shared vision was defined by these authors they created a standardized betweenness index for the evaluation of social interaction ties while standardized indegree centrality was calculated for the measurement of trust and trustworthiness the cognitive dimension was measured through two likertscale items 44 it would be easy to find people to invite to my high school reunion interacting with people onlineoffline makes me feel connected to the bigger picture the people i interact with onlineoffline would put their reputation on the line for me interacting with people at msu makes me feel like a part of a larger community interacting with people onlineoffline reminds me that everyone in the world is connected the people i interact with onlineoffline would be good job references for me i am willing to spend time to support general msu activities i am willing to spend time to support general onlineoffline community activities the people i interact with onlineoffline would share their last dollar with me at msu i come into contact with new people all the time interacting with people onlineoffline gives me new people to talk to i do not know people onlineoffline well enough to get them to do anything important interacting with people at msu reminds me that everyone in the world is connected onlineoffline i come in contact with new people all the time the people i interact with onlineoffline would help me fight an injustice i maintain close social relationships with some members in the blueshop virtual community 2 i spend a lot of time interacting with some members in the blueshop virtual community 3 i know some members in the blueshop virtual community on a personal level 4 i have frequent communication with some members in the blueshop virtual community relational dimension trust 1 members in the blueshop virtual community will not take advantage of others even when the opportunity arises 2 members in the blueshop virtual community will always keep the promises they make to one another 3 members in the blueshop virtual community would not knowingly do anything to disrupt the conversation 4 members in the blueshop virtual community behave in a consistent manner members in the blueshop virtual community share the vision of helping others solve their professional problems 2 members in the blueshop virtual community share the same goal of learning from each other 3 members in the blueshop virtual community share the same value that helping others is pleasant in the next stage of measurement development ylirenko et al selected items for the structural and relational dimensions from the existing one by tsai and goshal while developing new items for the cognitive one in their paper the structural dimension was termed as social interaction while the relational one as relationship quality furthermore the cognitive dimension was defined as customer network ties 45 wasko and faraj proposed a selfrating scale for the cognitive dimension and applied the technique of tsai and ghoshal for the operationalization of the structural dimension they also defined two subscales for the relational one adapting previously operationalized scales from past literature 46 47 48 these approaches were synthesized and validated in the aforementioned study by chiu et al which set a virtual professional itrelated community in taiwan as the subject of the analysis 43 although previous research indicates that the two previously discussed viewpoints constitute the majority of the empirical measurement approaches in terms of the perceived individual social capital on social media the paper at hand intends to explore unique emerging measurement techniques as well to offer a broad and detailed scope for future studies the present article aims to scope out the practical characteristics of the empirical studies evaluating social capital constructs on social media therefore measuring individual social capital based on the previous studies social capital measurement techniques will be evaluated through a scoping review of 80 published studies to determine the measurement approaches used in past research papers employing bridging bonding andor maintained social capital will be explored followed by those of the multidimensional view along with a discussion of unique social capital measurement approaches the goal of the present paper is to span a broad and detailed scope evaluate these techniques and identify possible similarities or differences to provide a more transparent view about the state of this research area and its possible empirical performance and explanatory power search and filtering method the scoping review methodology 4950 was applied to map the current state of the scientific knowledge and identify possibly existing research gaps a scoping review is appropriate here as it provides an opportunity for a broader research question and the avoidance of biasassessment a multikeyword search was employed in proquest and google scholar the collection of scientific literature followed a funnel approach 51 only peerreviewed articles peerreviewed conference proceedings and peerreviewed book chapters were included into the search criteria the search process identified 2478 records four manually performed filtering steps were performed on the 2478 records abstracts and reference lists were checked quantitative studies were kept studies that did not measure social capital were eliminated and the citations of the remaining 53 papers were reviewed backwards and forwards after the four steps were complete the final set of n 80 records remained additional inclusion criteria for the final set of publications were as follows the manuscript has to appear in a peerreviewed article or conference proceedings or book chapter be written in the english language set individual perceived social capital as the focus investigate this phenomenon on one or more social media platforms and empirically measure the perceived social capital in a quantitative manner the categorization for comparison and coding were performed using tables in excel involving the application of the cultural view the multidimensional one or a unique approach the elements of the operationalized constructs were collected for evaluation based on consistency joined with the collection of authors whom the analyzed publications refer to in this regard furthermore the dimension names were collected with attention to papers empirically investigating the multidimensional view of social capital or using unique measurement approaches this process involved the authors and two additional independent reviewers stemming from the respective scientific areas of research results the analysis is based on the observations and trends extracted from the systematically collected literature as previously indicated two distinct operationalization techniques emerged from the analyzed n 80 records the majority of the analyzed publications investigated bridging bonding andor maintained social capital constructs these studies followed the theoretical considerations of putnam the multidimensional view was explored by onefifth of the papers these two viewpoints represent a contrast in terms of polarity as they did not intersect regarding their direction of operationalization however none of the analyzed articles empirically compared these two concepts bridging social capital was present in all empirical studies that operationalized the social capital constructs according to the cultural view with the exception of one manuscript bonding capital appeared in almost all studies apart from six thereby indicating its importance merely six studies quantified maintained social capital the description of individual measurement items was explored based on its cruciality for future replication possibilities the review concluded that replication was not possible in 18 of the studies interpreting bridging bonding andor maintained social capital measurement on social media as a lack of a measurement item description through the analysis of individual measurement items it became evident that there is a considerable diversity in terms of how many and what kind of items the studies employed among the underlying reasons for difference is that the performed principal component analyses and confirmatory factor analyses delivered different results in individual studies resulting in the exclusion of at least one or more measurement item the measurement consistency in the cultural view of social capital was clearly visible in other terms in the cases of all three measurement constructs however considerable heterogeneity was found in the operationalization techniques of the multidimensional view table 3 offers a summary of the measurement constructs of each social capital dimension according to the multidimensional view in the 15 analyzed papers with the exception of chiu and colleagues as table 3 illustrates there are distinct differences in terms of sources for measurement operationalization and the construct names for all three dimensions more specifically chiu and colleagues analyzed the structural dimension by employing one construct however table 3 shows a variety of construct names in this regard combined with the diverse operationalization techniques this trend is visible in terms of the relational and cognitive dimensions as well it is however necessary to note that all studies analyzed in this view offered clear sources in applied measurement combined with the availability of the measurement items which can greatly enhance the possibility of replication and the ability of results generalization in a cumulative manner the majority of the sampled records employed either the cultural or the multidimensional view of social capital along with their matching measurement techniques unique approaches are summarized in table 4 table 4 reveals a high degree of consistency in the wording for social capital however quite distinct differences regarding operationalization techniques are observable as well while all studies mentioned in table 4 aimed to analyze the same theoretical concept with a clear majority evaluating bridging bonding and maintained constructs the previously mentioned heterogeneity in operationalization discussed in the multidimensional view extended with these unique approaches further indicates that there is no particular measurement in this social capital view which can be considered as common starting point quite the contrary these results address the uncertainty regarding the construct measurement of social capital albeit the hypotheses aiming to find relationships with various constructs and social capital itself were verified in the individual papers they depicted these results through plentiful operationalization techniques meas items present in the article 52 structural capital 5354 relational capital 45 cognitive capital 5354 yes 55 relational capital 4553 yes 56 social networking 57 trust 58 shared language 36 yes 59 trust 58 yes 60 network ties 36 trust 58 shared vision 43 yes 61 social interaction 4345 trust identification reciprocity 434862 shared language 43 trust 43 shared vision 43 yes 70 social interaction ties 43 social trust 57 shared values 71 yes 72 structural capital 4357 relational capital 4357 cognitive capital 4357 yes table 4 list and basis of comparison in the cases of 12 publications employing unique measurement approaches study name of social capital measurement of social capital 73 social capital affinity 5 items partially adapted from the bridging measurement scales of 127 74 social capital affinity 5 items partially adapted from the bridging measurement scales of 127 75 social capital users view count on their individual videos and users subscriber count on their channel 76 karma measured as the karma rankings of slashdot users 77 individual social capital measured as the number of readers 79 individual social capital 6item index developed for social life features that represent effective collective action and pursuing shared objectives in the participants communities 80 social capital measured as physical distance and strength of friendship 81 reciprocal tagging activity as the formation of bridging and bonding social capital reciprocal actions in the form of likingcommenting a tagging activity or sharing the specific post the users were tagged in 85 social trust adapted and modified version of 86 civic and political participation a reduced form of the index of civic and political engagement developed by circle 87 88 social capital political participation 6 items adapted from the national election studies civic participation 5 items developed confidence in government 3 items developed discussion and conclusions the present paper aimed to discover and evaluate prior empirical social capital research conducted in the realm of social media the primary objective of the study was to tap into measurement operationalization techniques used for evaluating social capital concentrating on cultural and multidimensional view approaches and offering an extension into unique measurement approaches our analysis involved several tasks to provide a more transparent view about the state of the preceived individual social capital measurement on social media and its possible empirical performance and explanatory power span a broad and detailed scope evaluate the techniques and identify possible similarities or differences the paper intended to contribute to approaches such as the metaanalytical approach in liu et al who observed the relationship of bridging and bonding social capital with global social media use and site activity such contributions can offer an opportunity of comparison and jointly reveal effect sizes of multiple records to answer the core question whether the interpreted effects are existing statistically significant or the results of selective reporting 77 78 79 80 from the viewpoint of interdisciplinary research it seems necessary to discuss operationalization technique consistency and offer a synthesis to highlight that the possibility of future metaanalyses is strongly dependent on the comparability and coherence of measurement techniques to maintain validity in effect size measurement and the avoidance of systeminherent bias by means of a scoping review the present study assessed 80 articles to evaluate the standing of social capital research on social media concentrating on their operationalization techniques while there is a general observable trend regarding the interpretation of individual measurement items and constructs studies in the multidimensional view depicted great heterogeneity in terms of operationalization and proposed measurement techniques which indicates challenging conditions for future metaanalytical approaches in this domain on the other hand studies employing the cultural view of social capital along with the validated measurement techniques proposed by williams or ellison et al show a high degree of consistency it should be noted however that there is heterogeneity in the individual studies in terms of employed items from these scales based on the results of the performed pca and cfa analyses resulting in possible item drops furthermore unique social capital measurement techniques on social media are also present in this research domain enhancing the complexity of a possible empirical synthesis social media platforms offer to fulfill the human drive to belong and have an exponentially growing userbase the underlying motivations for the usage of such platforms along with the expected and perceived benefits as a result of being present and active on them are especially crucial to better understanding human behavior the present article aimed to provide a detailed view into the individual perceived social capital research on social media and limited itself for the discussion to articles exploring this phenomenon on at least one sm platform however as empirical social capital measurement is present in a plethora of further research fields in both an online and offline context while investigated not merely in a perceived notion nor solely on an individual level social capital which seems to be attached to a diverse set of behavioral phenomena 18 can be considered as one of such phenomena therefore its analysis and possible synthesis is an ever pressing issue since the concept of social capital is indeed a buzzword in science 89 the wide array of measurement approaches discussed in this article however raise questions about the measurement do they measure the same concept or as the opposite extreme maybe none of them do the importance of social capital research on social media has possible individual benefits in terms of student learning outcomes based on the discussed benefits of weak ties as an example further benefits include a diverse set of research areas including the challenge of the cultural barriers for womens economic independence and autonomy 90 highlighting the importance of these investigations aiming to reduce inequalities this cruciality also manifests itself in labor market studies wherein individual social capital can be considered as an enabler for successful labor market integration 91 it also manifests itself in healthcare research since online conversations can possibly strengthen patientcaregiver connections leading to successful online health communities and ultimately effective policy interventions 92 albeit these examples are far from reaching comprehensivity they do indicate the relevance of both the existence of social media for the benefits of humanity and the diversity of areas on which social media can possibly provide benefits for individuals through enabling social capital machinelearning based methods can further enhance the results of such empirical investigations which could be employed as an extension to reveal the underlying sentiment in student communication present on forums and class discussion boards the usage of big data in data sciences especially in the research area of digital marketing indicate the crucial importance of such investigations involving numerous industrial areas detailed recently by saura while companies aim to leverage from such methods from which the author distinguished nine individual core topics 98 highlighting social media listening as well the empirical research of individual perceived social capital might offer crucial insights for corporations aiming to achieve effective digital marketing strategies this implication is also supported by the relevant publications on the importance of social media marketing wherein electronic word of mouth is facilitated by usergenerated content which empowers customers with the ability of sharing their experiences about brands products or firms in which trust plays a key role 99 trust is an essential part of the perceived individual social capital according to the presently discussed views of individual social capital it is recommended that future research determines in detail how and in what manner levels of individual online social capital on social media can possibly enable corporational profit enhancements through the mediating role of electronic word of mouth possibly leading to more refined customer relationship management accompanied with a positive brand perception author contributions conceptualization fp and cs data curation fp investigation fp methodology fp resources fp software fp supervision cs writingoriginal draft fp writingreview editing cs all authors have read and agreed to the published version of the manuscript funding open access funding by the university of vienna

the introduction of the web 20 era and the associated emergence of social media platforms opened an interdisciplinary research domain wherein a growing number of studies are focusing on the interrelationship of social media usage and perceived individual social capital the primary aim of the present study is to introduce the existing measurement techniques of social capital in this domain explore trends and offer promising directions and implications for future research applying the method of a scoping review a set of 80 systematically identified scientific publications were analyzed categorized grouped and discussed focus was placed on the employed viewpoints and measurement techniques necessary to tap into the possible consistencies andor heterogeneity in this domain in terms of operationalization the results reveal that multiple views and measurement techniques are present in this research area which might raise a challenge in future synthesis approaches especially in the case of future metaanalytical contributions

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introduction in a world of constant transformation and change a world in which everything seeks to be measurable from economic and social action to environmental impacts international community and national policy measures all require rigour and constant transparent and factual evaluation thus if it is necessary to evaluate and measure to analyse the results of policies and their impacts and if local development is established as an objective in so many community and national policy measures it is easy to question why local development is absent from the spaces of evaluation in this way it runs the risk of becoming a phenomenon diluted in the discourse and in politics with no room for affirmation the problem faced by the researchers was the lack of debate and proposals to analyse and evaluate local development referenced in the field of community and national policies this need demanded a theoretical and sociological deepening in the field of development as well as the elaboration of a proposal of an evaluation matrix for exploration experimentation and analysis based on the research assumptions based on the premise that it is through research that the problems born in practice are reflected upon and problematized that the debate is raised and innovative ideas are built for this doctoral thesis a methodological design was constructed framed by the need to respond to the starting question is the exercise of evaluation of © 2023 the authors journal compilation © 2023 european center of sustainable development local development according to the perspective that the animar association has been consolidating possible to implement by listening to social economy entities if the social economy entities have a set of principles enshrined in article 5 of the basic law of social economy of 2013 of may 8th which frame their line of action and in which they contribute to the local development of the territories the answer to this question allowed an analysis of whether the perception of social economy entities can evaluate local development based on the matrix that is presented as a proposal the first assumption had as a point of analysis to understand local development as a critical and alternative proposal to the capitalist and neoliberal based development model from its political value inscribed in various documents of national and community relevance the second assumption understood local development and the civil society entities that implement it within the framework of the social economy in portugal as they are covered by article 4 of the basic law of social economy previously referred to and are thus attributed a set of principles that place them within the mission to contribute to the general interest through pursuing the interests of their members users and beneficiaries when socially relevant the third assumption suggests that as animar associação portuguesa para o desenvolvimento local is the representative entity of local development within the social economy in portugal it would make perfect sense for the social economy entities framed by this association to naturally become the object of analysis of the research literature revision development is a phenomenon strongly studied in the field of social sciences with a dominant discourse associated with economic growth and of capitalist nature and of wealth generation defended by smith marx and ricardo having prevailed however it should be noted that other authors defend perspectives linked to organisations the market and the economic sociology proposed by swedberg as well as in the relationship with public institutions up to the perspective of sen by defending development associated with the dimension of freedom many authors have explored this concept and their concern with community changes as they are affected by development such as nunes by suggesting the existence of behavioural changes a position which currently takes on greater clarity with the speed with which changes occur and behaviours change the idea of development associated with anthropocentrism humanity as the dominant being of the planets natural resources through a selfish rationality defended by amaro and previously pointed out by neoclassical authors as characteristics in the face of a homo economicus resource explorer gave rise to a wider debate of development and around the unsustainability of the dominant development model on the other hand the idea of sustainability associated with degrowth recovers the importance of the experience and ancestry of peoples and their cultures in their relationship with the planet from latouche it is this idea of conflict or opposition to the dominant development model that between the defence of sustainable development and the actions of community development in the search to respond to local problems in other words in the search for an alternative development that directs the theoretical deepening of research to the field of common interest or common home proposed by francisco based through local communities which are interdependent on the development of humanity understood in its entirety this idea of multidimensional interdependent and singular sustainability in the face of the territory of development assigns to the local the need to envision development as a mission that must be integrated in planning systemic in action and holistic in vision a proposal resumed and defended in the continuity of the study local is a symbolic community space debatable and with a multiplicity of variables that poses serious obstacles to its clear and evident definition when associated with development in this study the option for associating it with the political and administrative dimension of action and implementation of the universe of policies recognises on the other hand the necessary sense of belonging and identity the sharing of cultural references of an identity through the valorisation of endogenous resources and the capacity of the parties involved to negotiate and enhance them in favour of local development requires a territorial and symbolic proximity between the parties involved and the governance structures this position guided the study in the sense of opting for low density municipalities as territories which due to their geographic and demographic characteristics are favourable to the dynamics of proximity between the parties involved and the structures of governance it is in the understanding of ruivo and also of the animar association that this option is reinforced as it is considered that it is in the governance of the local area as a territory of political management of the local authorities that the rules and mechanisms are established where the conditions for local development to take place are built it is in this broader community sphere among different parties involved whether at a political social and business level that based on their dialogue and interests the local development process can be strengthened thus in the relationship between the structure of governance rules mechanisms policies and the subjective dimension of the territories associated with the participation and citizenship of the people and the inseparable relationship between development and democracy which are privileged informants in the exploratory phase of the study in the search for a greater understanding of the relationship between these and local development one of the concerns that reinforces this position is the imbalance of these relations by emptying the role of participatory democracy and social economy entities as they are appropriated by the state and merely seen as service providers or extensions of public administration local development cannot be understood as a policy but rather as a process of interdependent relations between influencing factors and multidimensional that seeks integrated approaches from this perspective there are dimensions that are assumed to be relevant for the evaluation of development and for the exploratory phase of the study when proposing the evaluation of local development the economic social and environmental dimensions appear naturally related to the concept as well as the cultural dimension due to the community identity it assumes in the place where it is materialised these are dimensions which related to the necessary participation of the people in their communities require a governance component which should be framed as an evaluation © 2023 the authors journal compilation © 2023 european center of sustainable development dimension and key for the analysis of local development it is in this perspective that the exercise of participation and democracy is particularly relevant to favour the process as development another dimension that was considered pivotal for exploration in the evaluation matrix refers us to the educational dimension that which allows emancipation and the development of a critical posture of the community regarding its position in the location and its role as promoter of change local development emerges in the weaknesses and fears felt by the advance of the global development movement which has given rise to serious economic social environmental and cultural problems of great significance for territories that do not fit into the characteristics and determinants that the neoliberal model has capitalised on for the logics of development associated with economic growth it is in the alternative dimension of this model that the animar association proposes to defend local development as an alternative to the capitalisation of the economy as a priority dimension of development on the other hand it is also the dimension of governance or in other words the role of the local parties involved in their community and the cooperation between the structures of power and the exercise of citizenship which reinforces participative democracy and the search for participative governing agendas for development by insisting on citizenship and participation the organisation of civil society and the formal structures representing its interests emerge it is in this context that the universe of the social economy and its organisations emerge as potential listening entities for assessing local development these due to their characteristics and principles prioritise people and the common interests of the communities where they operate to the detriment of the legitimate economic interests of business entities it is these entities that the animar association represents defending new models of relationship participation and collective decision based on partnership and collaboration dynamics opposing the dominant and hierarchical posture of governance of the territories proposing a community and local based development as a facilitating process of change and of social transformation for the integral development of the territories epistemological framework the methodology proposed follows the line of alain touraines theory of action which suggests that collective action is the object of study of the sociologist in this study we sought to understand the collective perception of the social economy organisations and we also proposed to deepen the perception of the social movements considering that the researcher is not a distant observer but rather a mediator between the social movement and the militant group understood by ideological action according to fortin et al the path of constructing the sustaining empirical design of an investigation is not complete without presenting the hypotheses sustaining the investigative procedures the hypotheses are the indispensable means for understanding the phenomenon under analysis to the extent that they are assumed as potential suggestions for explaining the facts under study resulting from propositions as also advocated by pocinho published by ecsdev via dei fiori 34 00172 rome italy in an attempt to clarify the concept hypothesis fortin et al refer that it is a formal statement about the anticipated relationships between variables through this definition it is understood that the construction of research hypotheses presupposes the existence of a relationship between the independent variables and the dependent variables they are also and to the same extent a proposed relationship between concepts or phenomena which in the case at hand taking the hypotheticodeductive body that underpins the present research results in two fundamental assertions from which the following hypothesis proposals were built for verification hypothesis h1 the evaluation of local development in a territory is influenced by the type of legal nature of the social economy entity hypothesis h2 evaluation of local development in a territory is influenced by certain organizational characteristics of social economy entities after these phases a modelmatrix was constructed to serve as an instrument for evaluating local development in a territory requiring a geographical delimitation for subsequent experimental testing the researchers through theoretical assumptions and by listening to the privileged informants through interviews opted for techniques which were capable of guaranteeing an analytical qualitative and quantitative approach in the exploratory phase of the study followed by the use of the questionnaire as a quantitative approach which allowed the study hypotheses to be evaluated and on the other hand verified after the structuring phase of the methodological design and after the construction of the theoretical and conceptual body of the study it was understood that the interviews would be the methodological option that best met the need to listen to the experts with a view to producing knowledge thus providing the first part of the investigative methodology with a qualitative and quantitative nature insofar as it favours the emphasis on the representations and perceptions of the interviewees thus a theoreticalempirical framework of analysis was built which would enable the construction of a first proposal of an evaluation matrix and its assessment by privileged informants using interviews their results and respective interpretation are reflected in a second evaluation matrix that advanced to exploratory testing in three territories through questionnaire surveys the exploratory approach started with listening the specialists already referred to designated as privileged informants in order to deepen their beliefs opinions attitudes representations and values regarding the phenomenon under study together with them we sought to analyse the perception of a proposal for the evaluation of local development which would simultaneously enable the redefinition of hypotheses in the construction of the interview the choice was made to present five semidirective questions and oriented in their sequence and in the search for content allowing the informant to respond based on their value systems their normative references their interpretations of conflicting or nonconflicting situations their readings of their own experiences among others the interviews were conducted by sending the interview script to each of the respondents and their answers were requested between february and march 2020 via email in word format or editable pdf the interviews were directed to 30 informants based on 5 defined profiles seeking a balance of response by informant gender the approach together with the informants was duly reasoned through previous contacts trying to increase the good will of the interviewee and therefore to create a more cooperative attitude by highlighting the importance of their expertise for the researcher in a universe of 30 informants who were asked to respond as shown in figure 8 a sample of 20 responses was obtained within the defined deadline which represents a percentage of 666 of responses and the same number of responses according to gender thus creating the conditions for the research to move forward the type of sampling defined was chosen by convenience identifying the privileged informant according to five defined profiles where differentiated readings were sought with a strategic base political technical and academic once the problem objectives and hypotheses were defined and from a methodological point of view the objective was to give this study a quantitative nature which was considered preponderant for the analysis of the facts the research design included the questionnaire survey data collection instrument which is defined as a technique composed of a more or less large number of questions presented to participants in writing with the purpose of knowing opinions beliefs feelings interests expectations situations experienced among others data collection to organise the universe of social economy entities by municipality involved consulting the social charter database the municipalitys online portal and requesting data from local development associations in the respective municipality to collect email contacts results the analysis of the interviews allowed for the drawing of conclusions and guidelines considered fundamental for the reformulation of the evaluation matrix initially proposed starting from the simplification of the proposed concept resulting from the analysis of the interviews to the first two questions local development is understood as a process of construction from the active and participative citizenship of a community and its resources in the search for the resolution of problems or the leveraging of opportunities contributing to changes that favour a greater integral development of its communities built from the influence of structural factors and subjective dynamics associated to citizenship movements and community participation interdependent among themselves the analysis of the proposed evaluation matrix resulted essentially in the collection of a set of indicators and reflections that enabled the review of the initial proposal in its dimensions and indicators allowing the presentation of the final proposal of the evaluation matrix since the need for the matrix to be flexible and adaptable to the evaluation territories was a concern and a proposal that emerged from the interviews it was considered essential to include a question in the questionnaire that would allow the degree of importance of the dimensions to the development needs of the territory to be assessed in the evaluation territory the last question allowed validating the initial proposal of testing the matrix to be implemented by municipalities as local development evaluation territories this position is also reinforced by the relationship of influence between structural factors associated with the conditions that local power generates and on the other hand the action of the dynamics of participation and citizenship in that same territory although the definition of the territory resulted in various proposals of which the parishes stand out due to their proximity to the communities that is with the dynamics of participation and citizenship this possibility was discarded due to the difficulty of autonomy and governance that is the structural factors considered determinant for local development to take place in this sense it was considered to maintain the initial proposal the municipality as fundamental although the dimension of proximity with the communities was valued or to propose low density municipalities as those that best meet the conditions for local development evaluation the application of the questionnaire survey aimed to respond to the second general research objective to test the proposed local development evaluation matrix with social economy entities in three low density municipalities and as a specific objective to verify the study hypotheses thus the survey was structured in 50 questions subdivided into three parts characterisation of the institution evaluation of local development and observations and contacts in the analysis of internal consistency and after the results verified through the cronbachs alpha value there was evidence that the dimensions presented a good consistency leading published by ecsdev via dei fiori 34 00172 rome italy the researcher to conclude that the evaluation matrix presents good conditions to evaluate local development having analysed the values obtained and through the application of descriptive statistics and kruskallwallis tests it can be seen that hypothesis h1 evaluation of local development in a territory is influenced by the type of legal nature of the social economy entity is not verified that is it can be seen that the type of nature has no influence on the results of the evaluation of local development having analysed the values obtained it can be seen that hypothesis h1 is not verified it can be seen that the type of nature does not influence the results of the evaluation of local development and the hypothesis h2 it is found that they are not influenced by their organizational characteristics and that hypothesis h2 is not verified in any category we conclude that the matrix proposed within the scope of this study does not present any parameter of influence in relation to its legal nature or organisational characteristic which allows us to infer that the proposed matrix of evaluation of local development enables the evaluation of local development in low density territories through social economy entities conclusions the first utility of the study carried out refers to the concept of local development understood by animar association based on the exploratory research carried out we can consider local development as the starting point for a process of territorial development with the involvement of the state the market and civil society at different levels in the answer to the starting question is the evaluation of local development feasible through the perspective of social economy entities it is affirmative in the absence of influence factors we can state that social economy entities based on their mission to seek the wellbeing of communities allow without significant influence of their characteristics the evaluation of the different dimensions of analysis of local development ensuring a useful diagnostic evaluation for the development and planning and implementation of territorial public policies according to the analysis carried out to the data obtained the dimensions are all above average reflecting the need for the methodological proposal to integrate all the proposed dimensions without exclusion since it is verified that they are relevant in the evaluation although naturally with differentiated positions per municipality according to the results it was shown that the dimensions present internal consistency for six dimensions and only the environmental dimension has a correlation close to acceptable it is considered that the methodological proposal fulfils the appropriate conditions for its applicability and that it allows the evaluation of local development per territory and according to the perspective of social economy entities the main result of this work is the contribution to the evaluation of local development by municipality and through the research carried out it becomes possible to measure analyse compare and identify dimensions combining the participatory dimension with the representative one in the pursuit of the public interest it is an instrument that can be used as a mechanism for listening to the community creating conditions for public policies to respond to the needs and priorities of the population and their community in short local development is an integrated concept systemic and multidimensional and is built on the dichotomy between structural conditions and citizenship and in their interdependent relationship the methodological proposal of evaluation of local development presents appropriate conditions for its applicability and allows the evaluation of local development from the perspective of social economy organisations through the research carried out it becomes possible to measure analyse compare and identify dimensions as recommendations the research of new indicators is suggested to respond to local characteristics so the model should be flexible and adaptable to the territory where it is located the evaluation methodology may have an algorithm that allows measuring and assigning greater weight to the dimensions considered priority and most relevant according to the data obtained it is essential to develop evaluation mechanisms with public and free access allowing the promotion and strengthening of social participation a key principle in local development

the absence of the evaluation of local development in academic literature reflects the lack of debate at present but also the need for analysis of evaluation proposals and models this article aims to present the results of recent research work in this field seeking to contribute to the debate around the evaluation of local development through exploratory interviews with 20 key informants with links to animar portuguese association for local development as the representative entity of social economy in portugal its analysis resulted in a politicaladministrative space of evaluation and the local development evaluation a methodological proposal of an evaluation proposal with 7 dimensions of analysis and 37 indicators it is concluded that the evaluation of local development based on the proposed model generates a set of possibilities by contributing to a local diagnosis through the auscultation of the entities of the social economy sector

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introduction as technology empowers humans to achieve many unthinkable things it is also seen as the cause of several problems in society popular media often covers news stories discussing the narcissism associated with heavy use of social networks and describe an addiction that young people live with today some professional help resources are accepting patients for selfdiagnosed addictions to technology such as google glass researchers recognize the negative perceptions of technology and have conducted some qualitative documentation of the negative impact of smartphones on relationships within families despite the controversial nature of technology use many young information systems clients are not familiar with a different way of life and thus do not see the problem with heavy technology use the assumption that constant technology use is a negative is an assumption that might not be consistent with outcomes in 1996 the american psychological association first considered adding internet addiction as a psychiatric disorder but opted against it largely because there is no substance involved according to the apa an addiction is a condition in which the body must have a drug to avoid physical and psychological withdrawal symptoms interdisciplinary researchers have failed to come to consensus on the authenticity of internet addiction a major reason for this is the split in semantics over internet addiction and problematic internet use however most agree there is a negative aspect associated with smartphone and more specifically sns use while acknowledging the negative connotation of addiction this paper will continue to use the term addiction as that is the most understood current term used for the phenomena across disciplines despite no formal clinical or psychiatric diagnosis despite the associated negative sentiment of people aged 1829 years old 89 are sns members and 67 of those access snss via a mobile phone this group is composed of people raised completely engrossed in the use of technology referred to as digital natives beyond just digital natives 74 of all internet users claim to use a sns the ubiquitous use of technology is clear however research on technology addiction assumes that constant use is a problem the assumption that technology use is a negative is the focus of this research the use of a delivery system to effectively connect people and share information is the crux of the informing science framework arguably facebook is damaging social relationships but those that use it claim more close personal relationships with others than those that do not use the sites knowing where to draw the line between addiction and dependence or even frequent use has not been thoroughly investigated in the sns context a key feature of addiction is the impact the abuse has on the life of the addicted one way of gauging the impact is by assessing quality of life there has been a call for is research to study the relationship between is usage and quality of life this research takes the perspective of the is client if is clients do not see frequent use of facebook as a problem it is arguably not something that can or possibly should be changed it is well known that the first step of dealing with an addiction is determining there is a problem this research seeks to understand the relationship between the is clients understanding of technology addiction and how that impacts the is clients overall life satisfaction more specifically this research contributes to grow the interdisciplinary knowledge base by addressing the relationship between technology addiction and a broader impact on the individuals life as the debate about technology use continues this research offers another perspective on technology use outcomes this also fills a gap by further addressing antecedents that lead to addictive behavior on snss to make progress in reducing the dependence on snss the first step is identifying if the is client sees it as a problem instead it might be a major paradigm shift in how people communicate and society is resisting the change by negatively defining it the remainder of this paper is arranged as follows first a review of literature outlines the addiction construct and appropriate antecedents as well as satisfaction with life scales and the informing science framework in prior research next a model is developed based on five hypotheses concerning sns addiction the methodology explains the administration of a survey and statistical results are presented discussion of practical implications for research and practitioners follows finally limitations and future research directions are outlined before concluding remarks literature review addiction technology use is often the ultimate goal of systems as can be seen through two of the most successful models of the is discipline the technology acceptance model and the is success model the function of an information technology developer is to encourage use one way to encourage continued use of is is to get the user to form habits which can moderate the relationship between intention to use an is and actual usage while habit encourages use of technology it can also create problems and lead to addiction habit is often preceded by use and satisfaction with satisfaction as the most influential predictor the negative side of technology has not been considered by many researchers throughout most of the history of technology however it is becoming more relevant as the ubiquity of computers is realized five negative it related issues were recently identified technostress information overload multitasking addictions and technology misuse these factors relate to how a delivery systems impact on is clients who are trying to receive information they all suggest technology is having a negative impact on the information client also these factors often overlap however this research focuses on the independent concept of addiction within the realm of negative is the term addiction has not been clearly defined across disciplines in psychology addiction usually refers to ingestion of and dependence on a substance and is preceded by dependence the only addiction that does not involve a substance that is recognized by the diagnostic and statistical manual of mental disorders fifth edition is pathological gambling technology is not an ingestible substance and therefore some are unwilling to claim the addiction state instead terming it simply as the overuse of it the terminology debate divides researchers some argue for addiction while others argue that it is just problematic use currently the apa considers internet gaming disorder the only online related disorder considered as a condition for further study and encourages research and debate about this phenomenon in the meantime the idea of sns addiction has not been researched enough to warrant further classification in the dsmv addiction can be broken into a mental and physical aspect the mental aspect might include individual characteristics of the is clients such as internal differences of each person the physical aspect might be features of the substance itself or external features of a persons social network the most common mental dimensions of addiction are harm and inability to selfregulate harm might include conflicts at home poor work or academic performance or even depression inability to selfregulate means once a person begins using a system the person is unable to stop even if the person wants to stop an implied third element is frequent use of the technology like practice this phenomenon is also termed many different things in research some authors define addiction as dependency but also go further and add the debilitating feature of addiction others include dependency but also add excessive use some include excessive use in the definition of dependency and others use addiction and dependency interchangeably one researcher uses the term unregulated media usage because the term addiction implies the need for a cure still others refer to the whole phenomenon as problematic internet use instead of either addiction or dependency the distinction between terms might be most noticeable in connotation beyond formal apa definitions addiction has a very negative cultural connotation often associated with substanceabuse and often encourages thoughts of harm to society or loved ones dependency is a term that encourages thoughts of weakness for the user almost equally blaming the substance or behavior and the actor problematic use is a much softer term that gives the impression the behavior can easily be reversed or righted a related research area is to addiction is habit which is often a predictor of addiction habit is repeated activity resulting from an is client learning to do something over time the habit becomes uncontrollable by the user and becomes problematic or possibly an addiction one research team found that enjoyment of using a social network can lead to both a good and bad habit a bad habit could be termed an addiction according to the authors prior research on addiction and technology considers sns use as an antecedent to smartphone addiction further research shows that sns use is a stronger predictor of smartphone addiction than even gaming therefore sns use is related to multiple technologies and addiction suggesting it is common to many types of is clients in summary the term addiction is loosely defined in research thus this research draws on literature using all similar terms generally addiction has a very negative connotation it includes an impact on personal life as well as an inability to change behaviors satisfaction or enjoyment with the technology often correlates with a reason people become addicted in the first place while researchers debate semantics very few directly ask actual is clients about their own perceptions of technology addiction or habit satisfaction with life addictions have a negative impact on those that are addicted this can include an impact on social relationships work or school performance or bodily harm due to texting and driving the impact of technology on use outcomes has been measured however little research has focused on overall satisfaction with life and technology this is an important area of research because technology is now ubiquitous in the broad sense technology is often assumed to improve the quality of life technology helps solve simple problems such as getting from one place to another it also solves more complex problems such as difficult mathematical equations or intercontinental communication the advancement of technology is usually regarded as progress and as a result is clients adopt the newest technological innovation as an improvement sometimes technology adoption creates more problems such as the prevalence of automobiles has negative impacts on the environment and on peoples health however many people would say that automobiles improve overall quality of life per psychology literature quality of life can be evaluated overall or in specific domains which unite to make an individual life some domains include family work friends leisure finance and oneself some argue that these individual domains combine to impact overall life satisfaction termed a vertical or bottomup spillover similarly these domains might not be mutually exclusive causing horizontal spillovers for example family life might influence a persons leisure life either negatively or positively causing the quality of life in one domain to impact the other domain a relatively small amount of research has focused on either the domain specific approach or the overall approach to satisfaction with life in is the relationship between certain individual domains and overall satisfaction with mobile data services can have a positive impact particularly if the is client is satisfied moreover mobile data services can impact many different domains of life simultaneously considering overall quality of life the impact of technology can best be assessed in communities that are new to technology advancements for instance in thailand a study evaluating the impact of computers on socioeconomically disadvantaged people found that overall quality of life is improved with computers recent research indicates that using a sns more regularly can positively increase satisfaction with life at a university contrastingly the impact of internet communication on wellbeing of an individual can be negative for adolescents interestingly the same study indicates a tendency to talk to strangers can make the relationship positive this finding suggests that communication with new people might have an impact on the value of internet communications in the eyes of adolescents some research addresses the relationship between smartphone addiction and satisfaction with life finding support for the relationship when mediated by stress findings indicate no direct relationship between smartphone addiction and satisfaction with life other research indicates when people first adopt the internet life satisfaction increases for technology the overall satisfaction with life is important because happiness refers to total satisfaction importantly technology is a part of every aspect of life and not easily split into unique domains for instance snss are usually comprised of work and social contacts historical and present contacts and intimate and superficial contacts most technological systems are no longer used for only one task in coordination with the ubiquity of technology younger generations ie digital natives have never lived without technology those that learn technology as adults instead of being born into it are called digital immigrants despite the fact that they may be very skilled with technology as the number of digital natives begins to outpace the number of digital immigrants technology will have a greater impact on overall satisfaction with life the informing science framework and social network sites the informing science framework revolves around understanding communication of information the discipline focuses on information senders receivers and the tools that help pass this information in this research the relevant delivery system is the sns which is trying to enable is clients to connect with each other and share personal and public information snss include websites that are communities meant to allow is clients to interact in a social way mimicking realworld social networks the most prevalent sns in the united states is facebook research on facebook in all social sciences falls into five main categories descriptive analyses of is clients motivations for use identity presentation the role of facebook in social interactions and privacy and information disclosure most research focuses on the role of facebook in social interactions and descriptive analyses the wilson et al comprehensive literature review does not specifically discuss the relationship of habit problematic use or addiction proving the newness of the area of study limited current research argues one of three things a person can be addicted to an sns use of an sns can lead to other addictions or sns use can have an impact on overall life the relationship between addiction dependency or habit with snss has not been studied significantly even though some argue that social network addictions is one of the most relevant addictions the research that exists often finds addiction effects for instance social network dependency is positively related to habit formation on snss turel found a relationship between habit and addiction for facebook users and ultimately these led to discontinuance intentions mediated by guilt feelings and selfefficacy to discontinue facebook has also been associated with both good and bad habits in is clients these studies taken together indicate that snss can lead to a frequent use that may or may not be desirable for the is client and that desirability might change over time as the user becomes more engrossed in the sns the direct role of sns in forming other addictions has also been studied the use of social networks can lead to general internet addiction similarly one study found that mobile phone addiction was positively related with increased sns use these studies explain a broader addiction than sns use by using sns frequency of use as indicators whether or not sns use is an addiction the impact of sns on life outcomes is certainly important however minimally researched some sns clients feel that the social network is a burden because they are required to give social support to others on snss this is a negative impact on life satisfaction as a result of sns use facebook can also make is clients feel more or less related to other individuals on the positive side some use a sns to stay in touch with old friends many people use snss to help form positive impressions of themselves to their peers like most technology snss were developed to help solve a problem such as communicating with others which has turned into a negative for some is clients hypothesis development overall life satisfaction as impacted by sns addiction has not been extensively explored in the is literature the role of snss in the ability to communicate information effectively between the information environment and the is client is under studied this research focuses on how the relationship between the is client and the delivery system to understand life impacts based on the many definitions previously offered for technology addiction for this research addiction to sns refers to extensive use of an sns that the user is unable to stop using and is beginning to have negative impacts for the is client the term addiction is used because it is the most prevalent term across all research however this research recognizes that it is a particularly negative connotation that might be interchangeable with dependence problematic use or bad habit to understand the relationship between how is clients perceive sns addiction and overall life satisfaction the research model in figure 1 is proposed and elaborated on below figure 1 proposed research model diminished impulse control refers to an inability to suppress feelings to stop using a sns if the user wishes diminished impulse control was developed as part of the online cognition scale it is similar to the discontinuance selfefficacy construct developed elsewhere one of the fundamental ideas of addiction is that the person is unable to change behaviors even though they want to change these two constructs have been proven to correlate with problematic internet use and addiction if a person is addicted to something in this case an sns then the person will feel compelled to continue using it even if it is causing problems this leads to hypothesis 1 h1 diminished impulse control will positively relate to sns addiction distraction is the inability to focus on the things a person intends distraction is negative or harmful because it sidetracks is clients from productivity or efficiency when trying to accomplish a task distraction has been shown to positively correlate with problematic internet use and addiction distraction hinders progress and as a result most people try to avoid distraction if a person is addicted to a site it is reasonable that this person is distracted by the sns which is causing negative impact hypothesis 2 reflects this relationship h2 higher distraction will positively relate to sns addiction the extent that a person believes important contacts want them to use a sns is referred to as social influence other research has used the idea of social comfort to incorporate how the is client feels around others on a sns while similar the former is more relevant because the person is likely to use a sns only if there are others on the site with whom the person already associates if people feel pressured to join a sns to appease others they are likely to continue to using the site frequently developing into addiction the relationship between social influence and sns addiction is addressed in hypothesis 3 h3 greater social influence will positively relate so sns addiction the final characteristic of addiction in the proposed model is satisfaction with the sns satisfaction with a site stems from continuance research and is an evaluation a person makes about the attitude of using the sns satisfaction was the most influential indicator of habit in a study of worldwide web usage and is also positively associated with habit in the context of facebook in general higher usage rates of sns relates to higher satisfaction if a person is going to form an addiction to a site there must be frequent usage if there is going to be frequent usage the person must first have a reason to use the site this reason is broadly termed satisfaction this relationship is formally stated in hypothesis 4 h4 increased satisfaction with the sns will positively relate to sns addiction finally satisfaction with life is an important construct to understand how technology is impacting the is client the distinction made between the offline and online life is becoming harder for young people to make some people feel that the use of technology in general is enhancing the way we communicate and relate to people while others see it as deteriorating human relationships research on this topic is split some finding a correlation with satisfaction and others not one study indicates that greater satisfaction with life relates to less problematic facebook use for the is client contrastingly college students that observe others actions on facebook are less likely to be depressed further one study found correlation between overall satisfaction and dissatisfaction when using a sns given that research on this topic is split this research takes the psychological perspective that addiction has a negative impact on life satisfaction as reflected in the definition of addiction for this research traditional substance addictions have a negative impact on overall quality of life conversely if a person meets the requirements for current definitions of addiction but there is no relationship with satisfaction with life then the addiction construct is either poorly labeled or not as negative as often discussed working from the assumptions of society this research argues that there is a negative relationship between sns addiction and satisfaction with life hypothesis 5 expresses this h5 sns addiction will negatively relate to satisfaction with life research methodology to test the model presented a survey of undergraduate students at a large university in the southwestern united states was conducted undergraduate students represent a good sample for this survey because they are highly active on facebook an sns those between the ages of 16 and 24 now spend more than a day online per week the general age of an undergraduate student is also within the range of digital natives who are the upcoming generation to form opinions on technology operationalization of the constructs of the model were contextualized from previous measures respondents were provided a 7point likert scale ranging from strongly disagree to strongly agree the online cognition scale was developed to evaluate is client opinions of problematic internet use diminished impulse control and distraction were adopted from the online cognition scale and modified to reflect the context of this study social influence was adopted from the welltested unified theory of acceptance and use technology measures satisfaction was modified from the is continuance model the addiction measure was also adopted from a previous study of technology dependence this scale was used similarly as an antecedent to an outcome variable that focuses on human attitudes thoughts behavior and psychology therefore this particular measure of addiction is tested in a similar context the satisfaction with life scale was developed to measure overall satisfaction with life internally by the respondent there are two important distinctions from other measures of life satisfaction it is not a judgment imposed by external parties on anothers life and it is an overall measure of satisfaction not just satisfaction with one element or aspect of life it is a timeless parsimonious scale for determining general satisfaction with life this survey was administered online via qualtrics survey software six classes offered the survey for course credit which encouraged ample attention to the survey there were 854 potential respondents in the sampling frame 589 responded resulting in a 6897 response rate of the responses only participants that reported facebook as the primary social media tool were kept for analysis to ensure consistency ten surveys were omitted due to lack of variance across the entire survey this resulted in 413 usable responses for analysis almost 90 of respondents are digital natives complete demographics of the sample are listed in table 1 results the first step of the analysis was exploratory factor analysis to determine if factors of a construct are loading together on one construct this was performed with a varimax rotation upon closer review limited items were removed due to poor adaptation to the context all factors load higher on their expected construct than on any other indicating convergent validity further all latent variable average variances explained should exceed 05 as indicated in table 2 the reliability of constructs shows how consistent the measurement of the construct is and should have a cronbachs alpha greater than 07 and composite reliability greater than 08 reliability calculations are shown in table 2 given the reliability and validity of the constructs next the risk of common method bias needs to be eliminated common method bias is the concern that something external to the variables is responsible for the results harmans single factor test is often used to indicate common method bias specifically all items were evaluated with unrotated factor analysis with the specification of one factor the single factor explained only 3600 of the variance which is well below half of the variance suggesting there is little concern of common method bias next smart pls 20 allows analysis of the structural model structural equation modeling is ideal because it accounts for measurement error of the entire model concurrently the variance explained by the model should be greater than 03 to indicate explanatory power the regression weights and r 2 values are shown in figure 2 hypotheses 1 2 3 and 4 are all significant at the 0001 level hypothesis 5 is not significant meaning there is no significant relationship between addiction to a sns and satisfaction with life overall the antecedents of addiction represent 556 of the variance in the construct only 1 of the variance in satisfaction with life can be explained by addiction to the sns discussion hypotheses 1 through 4 are all significant this simply indicates that the prior research on addiction and technology use has clearly identified antecedents to addiction specifically diminished impulse control is related to addiction signaling an is clients inability to stop using the site secondly the sns is distracting and consequently related to addiction presuming people prefer not to be distracted when trying to accomplish a task the relationship between social influence and addiction implies people are more likely to heavily use a sns if others think it is important finally satisfaction with the sns relates to addiction to the sns the addiction construct for this research was borrowed from previous research the connotation of the prior research implies that addiction is a problem however hypothesis 5 shows that what is called addiction is not significantly related to satisfaction with life the nonsignificant relationship and virtually nonexistent r 2 indicates that the negative relationship is not actually manifested as a negative to the digital native is clients of the technology instead the respondents meet the criteria for what research terms addiction but do not correlate this with a negative impact on satisfaction with life as outsiders researchers term the phenomenon of heavy use or dependence on technology as a negative when digital natives are actually not seeing the same impact this research does not find a significant relationship between sns addiction and satisfaction with life which contributes to the growing dialogue of negative technology use this is a key revelation for both researchers and practitioners in understanding the is client of the future future research should consider technology integration in the social life as a new norm instead of a problem specifically these finding are informative within the informing science framework the ability to help communication among is clients through the delivery system notably the delivery system is effectively connecting the informing environment and the is client suggesting it is working considering these ideas from a transdisciplinary perspective can guide future research for organizations understanding how is clients view their own technology uses is important in understanding how to relate to the customer further focus on the value that sns technology brings to is clients instead of the change it causes might relate better to digital native customers while digital immigrants might see significant problems with heavy technology use digital natives grew up constantly interacting with technology instead of a problem this is just a way of life for digital natives internet addiction when first being discussed was absolutely labeled as a concern however the pervasiveness of online access might be shifting this negativity one researcher suggests that the combination of the digital native generation and ubiquity of technology is signaling a paradigm shift for computer use technology use is undergoing a paradigm shift from use when needed to constant use this research is not without limitations however they can easily be improved in future research the first limitation of this study is the use of one specific sns facebook continues to have significant membership however it is becoming less important to younger audiences while sns addiction has been related to other technology addictions this might indicate that it would be good to perform a similar analysis using a different sns or broaden the scope to a more general technology secondly the sampling frame for this analysis used a convenience sample broadening the variation of respondents beyond mostly business undergraduate students might make the results more generalizable similarly satisfaction with life might be difficult for an undergraduate to accurately determine at a young age it is argued that younger is clients do not yet realize the implications of their online profiles because the future is seemingly far away despite this it is important that the scale used is purposefully judged by the individual and not outside actors this research could also benefit from a comparison of digital natives and digital immigrants who as reflected in society may view addiction to sns as having different impacts on life satisfaction finally the satisfaction with life construct is intended to be broad due to the ubiquity of technology however further analysis into other dimensions and the potential of vertical and horizontal spillovers might be warranted in future research it could also be beneficial to consider other outcome variables beyond satisfaction with life to properly measure impacts heavy sns use is having on actual life outcomes conclusion socalled technology addiction is a growing phenomenon people become more dependent on the technology around them every day research shows that addiction is existent among young people on snss however the impacts of this addiction are not truly understood addictions by definition cause harm to the user however in this research it is clear that frequent use of an sns to the point of being labeled an addiction does not significantly correlate with satisfaction with life instead of a true problem digital natives see no impact of frequent sns use on overall life satisfaction this suggests that people are using the technology to receive and send information without seeing the use as negative or at least as negative as media suggests this research establishes that people meet certain prior accepted conditions for addiction and also statistically shows common measures of addiction are related the fact that these antecedents do not relate to satisfaction with life is a clear indicator that the terminology associated with frequent sns use is overly negative prior literature has assumed that addiction is a negative instead of an addiction this signals a paradigm shift concerning how people interact with the world and those around them

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sampling technique and participants the 2018 ndhs adopted a twostage stratified sampling technique using the sampling frame of the nigeria population and housing census conducted in 2006 by the national population commission the 36 states and fct were subdivided into local government areas where urban and rural localities were selected at the first stage sampling the administrative units were further subdivided into enumeration areas that resulted to the selected 1400 clusters called the primary sampling unit in the second stage thirty households were then selected per cluster to make a total of 42000 households selected and postpartum women of age were interviewed regarding anc sba and pnc that makes up maternity continuum of care information on respondents demographic economic and health indicators were also collected comprehensive information on the 2018 ndhs sampling methodology where 41821 women participants were recruited has been documented 16 operational definition completion of maternity continuum of care is the outcome variable and is simply an act of a woman finalizing the main maternal health services provided during pregnancy institutional delivery assisted by skilled births attendants and postnatal care immediately after childbirth till the sixth week of delivery 2239 measure of outcome coc is define in this study as a dichotomous response to whether a postpartum woman received anc in a healthcare facility at least 4 times during pregnancy childbirths aided by sba and pnc check for the mothers took place after childbirth thus anc sba and pnc are the three key component measures of the outcome variable the outcome was measured according to the who recommendations of at least 4 anc visits and the use of sba at birth 1011 the recently recommended 8 anc contacts by who was not applied to avoid bias from setting coc completion 1 complete ie recieved anc sba and pnc 0 incomplete ie dropout of the coc at least once stringent rule since the dhs operationalization was based on birth in the last 5 years using the minimum of 4 anc contacts which is yet to even achieve required coverage and also the updated who guidelines for 8 anc contacts were recently implemented after the births of most women respondents in the dhs in nigeria 1640 the measure of pnc for mothers after birth was however due to the fact that most of maternal morbidity and mortality occur in this period and therefore make it a crucial indicator in measuring maternity completion of care and even towards assessing the possible attainment of the sdg3 841 explanatory variables explanatory variables in the study were classified based on individual demographic and autonomy community socioeconomic childbirth and mother interaction with healthcare system similar to classification from previous studies and as a model framework for maternity continuum of care predictors 24 35 36 37 41 the independent variable categories are also consistent with the variable classification on the dhs and previous literatures on maternity care service 42 43 44 45 46 also the behavioral ecological framework was adopted to classify the independent factor as follows 1447 individual and householdlevel characteristics maternal age level of education marital status partners level of education religion ethnicity getting medical help permission women healthcare decision wanted pregnancy birth order provider of anc tetanus toxoid vaccine taken institutional delivery delivery by cs child sex at birth child size at birth wealth status mass media exposure covered by health insurance medical helpmoney communitylevel factors place of residence region medical helpdistance community unemployment community socioeconomic community rural proportion statistical analysis basic descriptive analysis was performed and reported in frequency for all categorical responses the frequency and proportion reported was based on women characteristics by the coc completion status and thus the supporting bivariate chisquare statistics was reported the pearson chisquare was reported throughout as none of the expected cell count was 5 also the phi and crammers v statistics that assessed the relationship between the women coc completion and the binarymultinomial independent factors were reported respectively further bivariate associations were evaluated using the forward stepwise regression approach such that the empty model was first fitted and the individual and community factors are then added in turn thus the factors that significantly increase the 2logl at p 010 were retained and added to the model and otherwise excluded this validated the associated factors in the bivariate chisquare analysis as the factors measuring both childsex and community illiteracy insignificantly add to the 2logl also identified the variables for inclusion in the multivariable analysis hence the regression coefficients and wald statistics were reported the multilevel binary logistic regression assessed the fixed individuallevel effect and the random communitylevel effect the respective adjusted effect was reported for each individual and community factor estimate of the intraclass correlation was determined from the null model and compared to the fitted full model to obtain the proportion of explained variation in the model which is referred to as the proportional change in variance the median odds ratio was assessed to evaluate the clusterlevel risk of completing the coc the likelihood deviance akaike and bayesian statistics compared the null random fixed and full multilevel model fitness data management and analysis were conducted using stata version 170 and all statistical tests and analysis were carried out at a 5 level of significance maps reported in this study were generated from microsoft 360 sampling weights indices included in the ndhs data were applied and the svyset command was used to adjust for disproportionate sample due to the complexity of the survey design multicollinearity was investigated through variance inflation factor and controlled by excluding and substituting type of union with marital status in the multivariable analysis the multilevel analysis multilevel model was fitted at each model stage to evaluate enumeration area cluster dependencies in prediction of maternity continuum of care modeli is the empty model ie intercept only terms modelii is the individual only term modeliii comprises of the community term while modeliv combined all the terms as a full model 4849 the individuals within households are nested in communities enumeration area cluster therefore resulted in a twolevel mixedeffect logistic regression with fixed effect at the respondents household level and random effect at the community level the twolevel mixed effect model can be expressed as in general the full multilevel model is produced when eq is substituted into therefore lead to eq below where ln p ij 1p ij is the odds of postpartum women completing the maternity continuum of care α 00 is the fixed intercept τ 0j is the community j random intercept term β are the regression coefficients of the independent variables or covariates x ij are the set of individual i and community j predictors e ij is the noise or error term e ij and τ 0j are normally identically and independently distributed with mean 0 and constant variance σ 2 thus the icc measured the degree of clustering based on heterogeneity between clusters ie the proportion of total variation in maternity coc attributable to the community level randomeffect component which can be expressed as where σ 2 u is the between cluster variance and π 2 3 3291 is the within community cluster variance from assumed normally distributed population 4950 the explained variance is computed from the proportional change in variance which estimates the difference in variance between the null and the model with at least a factor term as a ratio of the null model variance where σ 0 is the variance of the null model σ i is the variance of observed factor for i is the number of factor or covariates terms in the models ie model ii iii and iv 214950 the median odds ratio measures the odds of coc completion at highrisk cluster relative to the lowrisk cluster if two reproductive age women are randomly selected from the two clusters the fit statistics was assessed based on the likelihood deviance akaike and bayes information criterion were computed from the respective model log likelihood the model with the least deviance was however adjudged to best predict the coc completion 49 50 51 ethical approval and consent to participate the study was a secondary analysis and thus relies on the ethical clearance of the dhs which was obtained from the institutional review board of inner city fund international macro at fairfax virginia united states and the country irb in nigeria the author was granted access to the dhs data written informed consent was obtained from all survey participants prior to data collection this study adheres to appropriate reporting guidelines and did not involve any conduct of experiment or clinical trial results women characteristics and association with maternity coc completion table 1 presented the women sample distribution and the bivariate association with maternity coc completion most women are 2534 years married and without formal education about 45 are poor while 351 are rich over 51 have had four births while only 155 had one birth only 395 are exposed to mass media only 51 and 61 of women that receive tt and iron drug completed the coc about 97 had vaginal birth health insurance only covered 23 of the women and only 398 had health facility delivery with distance being a problem in 283 about 615 reside in rural areas with high rural proportion and poverty rate of 753 and 429 respectively all the women factors were associated with coc completion at p 010 except child sex and community illiteracy ln p ij 1 p ij β 0j n p1 β x ij e ij β 0j α 00 τ 0j ln p ij 1 p ij α 00 τ 0j n p1 β ij x ij e ij icc community σ 2 u σ 2 u π 2 3 σ 2 u σ 2 u 3142 2 3 pcv σ 0 σ i σ 0 mor exp √ 2×σ 2 v × 06745 exp 0 coverage of maternity continuum of care completion the coverage of maternity coc completion is shown in fig 2 overall 65 of the women completed the maternity coc while as high as 935 did not complete the maternity gamut of care community prevalence of maternity continuum of care figure 3 shows prevalence of maternity coc by urban and rural communities prevalence of optimal anc is different by 14 between urban and rural less than half of the women who had optimal anc in the rural continue to sba the proportion of continuation to pnc reduces by about 6 folds from 234 to 43 in urban and from 136 to 22 in rural coc completion rate in urban is almost twice the rural stepwise forward regression analysis of coc completion predictors the stepwise logit model predictors of coc completion are shown in 2 overall 18 identified women factors that significantly increase in the log likelihood when added in turn at p 010 were retained in the model multilevel predictors of maternity coc completion among women the predictors of maternity coc completion are shown in 3 the community level cluster variances and the icc is large for the null model i and decreases as the factors are added in model iiiv thus 285 of the coc completion effect is attributable to the community predictors with 632 of the variation explained in the full coc model compared to the null model the median odds ratio shows that coc completion is twice as likely in highrisk community compared to the lowrisk community assessment of the maternity coc model adequacy the fit statistics of the maternity coc model is presented in table 3 the deviance statistics computed for each of the specified model iiv are 848038 747896 812804 and 741690 respectively the full modeliv has the least deviance similarly the values of the akaike and bayes information criteria for the full modeliv is the least of all the models and therefore perform best subnational distribution of maternity continuum of care completion figure 4 shows the distribution of maternity continuum of care completion by states completion rate is higher in southern region enugu oyo imo ekiti than in northern region kebbi zamfara among others states where there are more dropouts also very high proportion of women dropout from the coc completion in sokoto yobe taraba katsina jigawa coc completion was highest in oyo followed by kaduna rivers imo lagos and enugu while 0 maternity coc completion was seen in bayelsa coc completion was near 0 in kebbi sokoto and zamfara compared to women in kano enugu women are about 135 times more likely to complete the maternity coc women in ekiti imo and oyo are more than 10 times more likely to complete the maternity coc than those in kano whereas the odds of completing maternity coc reduces by 80 69 and 67 in kebbi zamfara and sokoto respectively odds of maternity coc completion was also high by more than 5 folds in ondo rivers and kwara states when compared to kano subnational analysis of maternity continuum of care completion discussion this study applied the multilevel analysis techniques to investigates the individual and community prevalence and predictors as well as the subnational distribution of the maternity coc completion from pregnancy to childbirth and postdelivery ie anc sba and pnc based on the who recommendations for optimal health and survival of mother and newborn this is to achieve an evidencebased policy strategy specific to supporting and improving mnch programming at the community and subnational level and towards achieving the 2030 sdg3 goal it was observed that more than twothird of the pregnant women in nigeria attended anc but less than threefifths completed the minimum recommended four visits this is similar to national survey report and studies on anc compliance with who recommendation in nigeria 1216 prevalence of sba continuation after optimal anc uptake is 37 and completion rate of the three essential maternity coc is only 65 however nearly twothird of the prevalence of maternity coc completion in nigeria was observed in the urban compared to the onethird in the rural which can be ascribed to the easier access to maternal healthcare in urban compared to rural and hence the higher likelihood of maternity coc completion in urban than the rural as reported in the recent multicountry study in ssa 52 overall prevalence of continuation of care diminishes as women progress from pregnancy to delivery and postdelivery with significant dropout observed at the pnc stage this is because those that utilized sba tends to be absent from pnc as they are less likely to have postdelivery complications compared to those that do not utilize sba at delivery and thus high dropout rate was observed at pnc as found in study investigating dropout pattern in nigeria and other ssa countries 202253 also completion rate is cumulatively higher in southern states than northern states owing to contribution of oyo with highest prevalence of maternity coc completion education residence wealth decider of healthcare tetanus toxoid taken in pregnancy place of residence distance to medical facility geopolitical zone among other individual and communitylevel factors were significantly related to maternity continuum of care child sex and community illiteracy level were however not associated with women completion of coc comparable factors were reported in studies in ssa to be associated with maternity coc completion 2422375254 it was discovered that odds of gamut of maternity care uptake continuation and completion increase with progression in education and wealth maternal education effect is understandably due to exposure and ability to listen read and write as women with higher education are more likely to be able to comprehend and follow medical instructions and prescriptions than those with secondary education 39 and those with secondary education perform better in maternal service utilization than those with primary education only and so on agreeing with recent findings from studies on the effect of female education and moderating role of partner education on maternal healthcare in ssa 5556 the effect of wealth is attributed to being able to bear expenses of maternity range of cares as commitment can be motivated by financial strength and it is not surprising that women who had the big problem of getting money for medical help are less likely to complete the maternity gamut of care this is in congruent with study outcome on positive effect of wealth and health insurance coverage on maternal healthcare in ssa 5758 women exposure to media and healthcare decision making positively influence maternity coc completion by 22 and 37 respectively this explains the role of media as well as the women autonomous health decision making on their own health compared to partner decision as only pregnant women knows her health better similar findings were reported from studies on factors associated with maternity healthcare service utilization and coc completion in african settings 18343637395254 furthermore the chance of completing maternity coc is higher in women who had a minimum of two required number of tetanus injection than those that had none since the who recommended 2 or more tt immunization required for women to develop antibodies to protect their newborn against tetanus and will encourage more anc visits to facilitate optimal reception of anc and subsequently drives sba and pnc as previously enunciated to have a big impact on infant 59 also iron drug taken in pregnancy almost twice increase the likelihood of a woman completing the coc compared to those that do not take iron supplement in pregnancy this was corroborated by the findings from previous study on maternity predictors of coc coverage 22 however having nurses tba and chewchw as anc provider big problem of getting money for medical help and health facility delivery are the individuallevel predictors with negative influence on the maternity coc completion hence women whose anc was provided by chew and tba are about 7 and 20 times less likely to complete the maternity coc respectively having hospital birth almost twice reduces the likelihood of coc completion as those who had hospital births after anc are more likely to have vaginal birth and dropout of pnc this is in consonance with findings on dropouts of coc predictors of maternity coc in nigeria and the determinants of maternity coc in cambodia 20224660 also caesarian section delivery positively drive coc completion after anc utilization as a result of the necessity to seek for medical help after delivery as women who had cs birth are more likely to attend pnc for followup care on surgical site due to poor postnatal quality of life which adversely impacted the optimality of newborn breastfeeding compared to women who had vaginal birth 6162 it was observed that place of residence geopolitical zone and community rural percentage are the communitylevel factors associated with maternity coc completion in nigeria thus women who resides in the rural and within community of high rural population proportion have 23 and 28 excess risk of not completing the maternity coc which can be ascribed to the prevailing problem of limited access to health facility majorly worsened by distance health finances and sociocultural factors in the rural communities as substantiated by recent studies in ssa 224652 nevertheless women in the southern region are more likely to complete the maternity coc than their counterpart in the north the significance of communitylevel variance indicated the suitability of the multilevel analysis to evaluate dependency in maternity coc completion the icc implies that 285 of the variation in maternity coc completion are attributable to the community heterogeneity thus 632 of the variation in maternity coc completion were explained by the communitylevel effect relative to the null model corresponding findings were observed in studies applying multilevel method to evaluate predictors of maternity coc dropout and completion 204863 the model assessment based on deviance statistics further stressed the robustness of the multilevel method and identified the full model with random and fixed effect component as the optimal model across the four specified model model iiv studies on multilevel analysis also reported findings analogous to comparison among null random fixed and the mixed effect models 5051 when the subnational impact on maternity coc completion was compared with the state with largest women population women in enugu state reported highest effect and are about 13 times more likely to complete the maternity coc also ekiti imo and oyo women are more than 10 times as likely to achieve maternity coc completion the chance of maternity coc completion is about 7 times more in ondo and rivers than kano also the subnational effect was positive in kwara fct osun abia lagos edo akwaibom kaduna bauchi delta ogun benue and anambra however the effect was negative in kebbi zamfara sokoto yobe and katsina as pregnant women in these states are 25 times less likely to complete the maternity range of cares strengths and limitations the study was not free from recall bias majorly associated with crosssectional studies as it relies on respondents events in the last 5 years preceding the survey inference from the study should be interpreted based on association not causal factor as it does not control for temporality and other condition to ascertain causality analysis was also subjected to the operationalized variables measured in the dhs based on the survey questionnaire as information such as type of healthcare facility were not collected however the use of nationally representative large dataset improves the target population generalizability also the application of sampling weight further enhanced the accuracy and reliability of the study findings therein the multilevel analysis technique that accounted for clustering effect by assessing variations between clusters was suitable for the cluster survey design and can also be regarded as strength conclusions in conclusion only one in fifteen pregnant women completed the maternity continuum of care completion rate is however significantly different between communities with the twothirds of the prevalence in urban and only onethird in the rural women coc completion is twice more likely in the urban clusters than the rural and thus highlight place of residence community rural proportion and geopolitical zone as the community drivers of the maternity gamut of care completion chance of coc completion increase by education and wealth but decrease by cadre of anc provider women autonomy to her own healthcare decision media exposure tetanus toxoid and iron drug taken in pregnancy positively influence coc completion while health facility delivery and medical finances negatively influence coc completion about onethird of the variation in maternity coc completion is attributable to the significant communitylevel factors hence the mixedeffect model was optimal women coc completion rate is higher in southern than northern subnationals with enugu ekiti imo and oyo the four topmost states with highest likelihood of maternity coc completion recommendations the generally low coverage of maternity coc completion is an indication for the need to strengthen maternity healthcare practice through sensitization programs capacity buildings and increase access to quality maternal healthcare service particularly in the rural anc packages should be reviewed to encourage optimal visits and discourage dropouts northern subnationals should emulate what works and learn from what doesnt work in the southern region contextual research on dropout of maternity coc completion is required particularly in the rural to understand the militating sociocultural factors towards devising interventional programming strategy data availability the deidentified data is available in the public domain analyzed dataset used in this current study are available on reasonable request from the corresponding author and can be access at the open repository of the dhs program dhspr ogram com competing interests the author declares no competing interests additional information correspondence and requests for materials should be addressed to oko reprints and permissions information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

understanding population discrepancy in maternity continuum of care coc completion particularly in subsaharan africa is significant for interventional plan to achieve optimal pregnancy outcome and child survival this study thus investigated the magnitudes distribution and drivers of maternity coc completion in nigeria a secondary analysis of 19474 reproductive age 1549 years women with at least a birth level 1 in 1400 communities level 2 across 37 states covered in the 2018 crosssectional survey stepwise regression initially identified important variables at 10 cutoff point multilevel analysis was performed to determine the likelihood and significance of individual and community factors intracluster correlation assessed the degree of clustering and deviance statistics identified the optimal model only 65 of the women completed the coc completion rate is significantly different between communities 43 in urban and 22 in rural χ 2 39242 p 0001 and was higher in southern subnational than the north education aor 161 95 ci 120216 wealth aor 173 95 ci 135246 media exposure aor 122 95 ci 106140 women deciding own health aor 137 95 ci 113166 taking iron drug aor 184 95 ci 143235 and at least 2 dose of tetanustoxoid vaccine during pregnancy aor 135 95 ci 102178 are associated individual factors rural residency aor 184 95 ci 143235 region aor 184 95 ci 143235 and rural population proportion aor 184 95 ci 143235 are community predictors of the coc completion about 632 of the total variation in coc completion was explained by the community predictors magnitude of maternity coc completion is generally low and below the recommended level in nigeria completion rate in urban is twice rural and more likely in the southern than northern subnational women residence and region are harmful and beneficial community drivers respectively strengthening women health autonomy sensitization and education programs particularly in the rural north are essential to curtail the community disparity and optimize maternity coc practiceanc antenatal care ci confidence interval coc continuum of care icc intracluster correlation imr infant mortality rate lmic lowermiddleincome country mmr maternal mortality ratio mnch maternal newborn and child health ndhs nigerian demographic and health survey nmr neonatal mortality rate pnc postnatal care prmr pregnancy related mortality ratio sba skilled birth attendants

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jamie oliver the british celebrity chef quoted above has been featured in a number of tv series attempting to reform the nations eating habits in 2005 a fourepisode documentary series was broadcast by the television channel channel 4 in the united kingdom titled jamies school dinners here the celebrity chef successfully made the case for improving the quality of school dinners with media coverage highlighting the potential for his scheme to be undermined by mothers at a school in rotherham yorkshire england passing fast food to their children through the school gates while the public consensus seems to be that at least hes doing something such initiatives can be seen as a problematic in a number of ways from our perspective one of the key problems was that parents perspectives were given very little genuine coverage or exploration these voices have been generally absent from a media debate about school food mostly dominated by male politicians and celebrity chefs yet feeding children is an everyday activity suffused with moral discourses of good and bad parenting with such judgements falling more heavily on mothers in this paper we examine how moral accountability and notions of good mothering are visible through the mundane and everyday object of childrens packed lunches to wider concerns about childrens rising level of obesity and the national health service expenditures for treating obesity related diseases these moral discourses have also been reflected in tabloid reports that children were arriving at school hungry and unable to concentrate research studies looking at childrens lunchboxes highlight how they are a container for various aspects of the private and the public the focus of such articles includes the politicized school initiatives of enforcing government healthy eating the pervasiveness of brands in teens lunchboxes and the practices of eating lunch box food at school although these studies provide useful insights into the complexity of discourses and practices surrounding the preparation and consumption of lunchboxes we are left with little understanding of mothers everyday experiences of preparing lunchboxes for their children exceptions are the works of allison morrison and donner analysing mothers experiences of making lunchboxes for their children allisons study on lunchboxes in japan shows how preparing a lunch considered nutritious and appealing by the school teachers was a way of displaying good mothering to the school similarly morrison shows how mothers in the uk negotiate their norms of good mothering through school regulations and sanctions concerning what constitutes a proper packed lunch donners study of middle class mothers in calcutta shows how preparing lunchboxes is one of the major preoccupations of mothers who sometimes challenge school regulations concerning proper lunches by applying domestic norms of a meal to the school setting despite being conducted in different countries and at different times these studies highlight how lunchboxes are connected to cultural order and ideological meanings such as good mothering indeed women are judged as good mothers in terms of their culinary skills health knowledge and ability to make a nutritional and aesthetically appealing lunchbox for their child family display and moral accountability the recent literature on mothering highlights how presenting oneself as a good mother is not simply a matter of being but rather of doing this involves enacting contextualised norms of motherhood through practices including all practices surrounding the work of feeding the family furthermore sociologists have highlighted how doing motherhood is also a matter of display family display is understood as the process by which individuals and groups of individuals convey to each other and to relevant audiences that certain of their actions do constitute doing family things and thereby confirm that these relationships are family relationships further conceptualisations of display highlight how the concept hides a strong normative aspect of family life and mothering since through objects social interactions and narratives people communicate to each other and to external audiences that their family relationships adhere to prevailing social norms however being on display also risks being judged as troublesome or as an illegitimate form of family in the case of differing from prevailing social norms replicating the ideological dominance of white middle class heterosexual nuclear family settings empirical work has focused on diverse family types including lesbian couples whose work of displaying motherhood is intensified at certain points in time such as during pregnancy such display work can be seen as a strategy orientated towards gaining recognition of being a family and overcoming the uncertainties for families whose contours are not easily recognised in contrast it has been argued that women in more conventional family settings such as the heterosexual nuclear family already have official recognition of being a family and therefore have less need to display other writers have highlighted the importance of understanding the role of the context wherein display takes place for example kehily and thomson show how first time mothers narratives of motherhood are delineated by wellestablished social norms of proper middle class mothering in the uk in line with the trend in recent studies of looking at motherhood as connected with display we explore participants own accounts of motherhood as they emerged from their tales of making of childrens lunchboxes discourses and practices of everyday mothering are delineated by strong social norms which goffman defines as guide for action supported by social rewards in case of compliance or sanctions in case of infraction as the existing literature shows mothers accounts are indeed moral ones this implies that mothers accounts are likely to draw on existing expectations that the role of motherhood carries in specific contexts and in relation to a specific audience the idea of moral accountability draws on the work of goffman to argue that research participants are telling moral tales that is establishing and defending themselves as having morally acceptable identities in their interview accounts norms of good motherhood include mothers selfsacrifice and a nonnegotiable obligation to put childrens needs first interestingly this obligation to put children first appears to fall more heavily on mothers than fathers despite many changes in family life and womens roles such as more women being in paid employment in looking at how participants represent themselves in relation to the current norms of mothering in the uk context we take into consideration the dominant discourses of proper motherhood in our context of study in particular the current concerns about eating habits are strongly linked to notions of social class and in particular to the type of subjects seen as socially valuable studies looking at social class and food consumption show how middle class taste is associated with the display of wider gastronomic knowledge consumption of exotic food and prioritising selfdiscipline it has been suggested that middle class parents tend to promote health and nutrition related to futureorientated concerns whereas working class parents have a more functional relationship with food also middle class taste is associated with disregarding and avoiding food associated with lower social class our paper focuses on the different discourses at play within the discussion of lunchboxes including being a good mother negotiating home food in school and responding to childrens requests research methods this study draws on photoelicitation interviews with eleven mothers recruited from a primary school in surrey england mothers with children aged between nine and eleven years old were targeted since children at this stage have well established food preferences and can negotiate their choices with adults fieldwork was conducted between january and march 2013 mothers were recruited via an email sent out to all parents with children aged nine to eleven at one school the research participants were all white british aged between 39 and 50 and all were in paid employment either on a full or part time basis in terms of family form ten mothers were married and one mother was a lone parent the sample was relatively affluent generally with a household income greater than £50000 and the majority were owneroccupiers all participants selfidentified as middle class mainly in terms of their cultural and economic capitals described in the forms of holidays hobbies family activities salaries and house ownership the middle class nature of the sample was not an intentional feature of the study design our initial aim was to recruit parents from a diverse socioeconomic backgrounds the class bias is likely to be related in part to the geographical area where the study was conducted as well as selfselecting characteristics concerning parents who are happy to volunteer for such studies i given the small numbers of participants and the homogeneity of our sample our analysis does not have any ambitions to claim generalisable findings but it has the more modest aim of providing a more in depth analysis of the life stories expressed by a relatively small number of participants the methodological design involved two interviews and a focus group discussion the first interview provided an introduction to the family how food was managed within the household responsibility for preparing lunchboxes how their content was decided and guidance given from the school and other sources mothers were then given a disposable camera and asked to take photographs of lunchboxes prepared during one week the second interview asked mothers to discuss the photographs taken and provided an opportunity for the researchers to follow up questions emerging from the first interview finally a focus group enabled parents to discuss lunchboxes in a group setting this was considered valuable because we wanted to provide an opportunity for interaction between parents with potentially different viewpoints although very similar perspectives were noted when the focus group took place seven participants attended the focus group discussion although the focus group data helped to inform our analysis quotations used in this paper have been drawn from the first and second interviews as they provide more indepth insight into individual perspectives interview and focus group data were transcribed verbatim data analysis using thematic coding began after the first interview and was ongoing throughout the study the analysis focused on mothers perspectives and following gabbs suggestion we used the concept of family display as a sensitising concept in our analysis first we elaborate on the rationale parents gave for providing children with a packed lunch as opposed to school dinners mum knows best the decision to provide a packed lunch opting for a lunch box rather than a school meal was framed as a matter of parental care which takes the form of providing food that satisfies childrens taste and preferences as well as parents own understandings of what constitutes a proper lunch this contrasts with the portrayal of mothers in jamies return to school dinners where packed lunches were equated with lack of caring some mothers in the present study highlighted how they viewed meals provided by the school as unable to accommodate childrens desires and satisfy their hunger for example denise explains that for a growing boy who plays rugby and does swimming it is not enough food we prefer school dinners were so small and especially jack was coming out saying i am hungry or whatever else or alice will come out and say i did not like that so she wouldnt eat enough so we thought right okay but we know how much they will eat although results from the school food plan highlight how the perceived high cost of school meals is a key factor for opting for a packed lunch our participants did not generally seem to be concerned about the price of the lunch but rather focused on their quality considering the middle class nature of our sample providing a lunchbox was framed as a way of feeding the children with home food which is considered better than school food better was not simply a question of the nutritional or material quality of the food but rather a way of providing the child with hisher own food made especially for hisher own desires requests but also dietary restrictions and allergies in this respect lunchboxes are a continuation home food away from home or as others have pointed out lunchboxes can be seen as a bridge between home and school the photographs generated by mothers as part of the research showed lunchboxes prepared on kitchen counters among the ingredients of daily living bottles of calpol cookbooks spices recipe cards from supermarkets chopping boards blenders bottle of wine and other cooking equipment not necessarily being used for lunchbox preparation mothers talked about lunchboxes as one task among many to be accomplished on a conveyer belt of activity for example paula said of preparing lunchboxes its just there its just got to be done it would be much easier for me if i didnt have to do it because it would be one less thing to have to do but it has to be done so you just get on with it despite mothers highlighting how their lunchboxes were individually crafted for accommodating childrens requests andor controlling their diets their understandings of a proper lunchbox were remarkably similar indeed the structure of the analysed lunchboxes echoes the standard structure of adults packed lunch and consists of a drink usually a fruit juice a savoury element often a sandwich wrap bagel or pasta a piece of fruit andor some raw vegetables and a packet of crisps andor a sweet such as a biscuit often described as a treat if such content has been highly criticised for its poor nutritional quality sociologists have pointed out how the structure of the packed lunch is part of the cosmology of the meal system in britain and as such it is balanced culturally rather than nutritionally as will be shown in the following sections our findings confirm how lunchboxes are cultural artefacts influenced by classed notions of good mothering which reflect a tension between convenient and handmade food such discourses are entangled at the micro level in the everyday mundane and routinized practices of selecting a specific brand opting for new products and avoiding some food items these discourses often perpetuated through national campaigns advertising culinary tv programs with celebrity chefs as well as local and school initiatives are so imbedded in participants everyday life that they become part of their own vocabulary for example in describing the content of her daughters lunchbox heidi referred to the 5 a day health campaign ii which she employed as a reference for explaining the number of fruit and vegetables she gives to her daughter during a day so i just want to encourage her to eat five portions of fruit and vegetables a day i think they add a bit of colour as well … so i think if i can encourage her to eat a good lunch then if she snacks through the evening then shes had a good proportion shes very good shell come home if she hasnt had a banana shell have a banana she knows now i think its got through that she needs to make sure she has these five portions a day as well as all the other stuff echoing the findings from previous studies the mothers in this research generally appeared to embrace the healthy eating guidelines and were keen to demonstrate their own healthy eating and cooking knowledge being a good mother being a good mother invokes discourses of care for others without begrudging the effort and work incurred this work of crafting lunchboxes was particularly evident in household where siblings are provided of different lunchboxes reflecting their different tastes and desires illustrating this hannah explained today theyve had chicken wraps with one doesnt like salad so she didnt have any salad in hers but lucy did katie will probably have a sandwich tomorrow … katie likes sausage rolls and she likes scotch eggs and those sorts of savoury things as well lucy possibly would have a sausage roll i dont know shed have to be really in the mood … katie will but lucy wont eat things like yoghurt or anything like that either linked to the idea of care through food a number of mothers articulated a desire to avoid processed and prepackaged foods for example mary said this concern to provide and encourage children to eat healthy food was shown to be related to a classed notion of good mothering this is not to imply that working class mothers do not seek to provide healthy food for their children rather we argue that the way that mothers in our predominantly middle class sample discussed lunchboxes class became an important social division that was alluded to within their narratives for example in her interview olivia spoke about recent media reports about children going to school with cold fish fingers in their lunchboxes she explained i i think what theyre highlighting when theyre saying that is that people its the socioeconomic…people cant afford to make the packed lunches to buy the stuff for the packed lunches but if theyre in that much of a dire strait then theyre entitled to free school dinners in describing the content of her own childrens lunchboxes olivia referred to some convenient items that she will not include since they symbolise bad mothering arguably all food purchased in supermarket and in shops is mass produced and manufactured but olivia seemed to imply that convenient fo od items that do not require any work for their consumption are a sign of an uncaring mother a lot of it is laziness i can remember the lady that was my nanny saying to me one day she had a child come into nursery when she worked at a nursery with a packet of cheese slices in her lunch box well what do you do with that and another child that used to come in every day with two packets ofwhat are the little cheese biscuits called the little round orange things do you know what i mean theres got to be a huge element of i cant be bothered okay maybe the child is fussy but youre not going to make the child eat and help the child to eat by just giving it cheese biscuits … they dont understand the nutrition so youve got a packet of crisps full of enumbers a chocolate biscuit and it actually probably costs more than my jar of leek and potato soup although the they referred to in this narrative is not fully unpacked it seems to focus on mothers who are from a lower social class than olivia and who do not share her education about food mothers who give their children junk food became a powerful image that mothers worked to distance themselves from by embracing the school and government guidelines and displaying a concern for healthy eating fresh produce and home cooking rather than relying on prepackaged convenience products olivia continued there was that awful thing in rotherham with jamie oliver with the woman who was shoving hamburgers and chips through the school railings why the thought of doing that wouldnt even enter my psyche in one of the pictures olivia took as part of the research image c jamie olivers book ministry of food book was positioned behind the lunchbox almost as if the celebrity chef himself is towering over its contents with the words fruit veg visible on the cutting board at the bottom on the right hand side we can see a glass jar of homemade sour dough which was not part of the lunchbox but appeared in the picture the inclusion of these items could have happened by chance or they could be read as an attempt to symbolically demonstrate to the interviewer that olivia should be seen differently to the problematic mothers featuring in her narratives although olivia was the respondent for whom class appeared to be the most salient within her narrative others also made a connection between lunchbox food and social class through the narratives developed in the interview setting mothers suggested themselves to be more relaxed regarding food for their children in private familial settings than that consumed in the public world of lunchboxes and childrens parties this suggests a fear of being labelled a bad mother on the grounds of not providing the healthy diet promoted by public health campaigns and celebrity chefs for example mary talked about her daughters interest in healthy eating and attributed this to peer group influence as well as changing and classrelated social attitudes to fast food she said i cant imagine the kind of response you would get if you were to have a mcdonalds party people would just be horrified that you would expose their child to that i guess its a bit of a snob thing the group theyve been brought up in they wouldnt do that im not saying we dont go to burger king or mcdonalds because we do but if you were looking after someone elses child for instance you would never send them home having eaten something like that crucially mary suggests a difference between the food consumed in public and that consumed in private although providing only for ones own children an important element highlighted here is the public nature of lunchbox consumption interestingly lunchboxes were not a regular source of conversation or explicit showing and discussing among mothers as contemporaries respondents said that lunchboxes were something that had been spoken about more frequently when children were younger but less now that children were in the final two years of primary school however this is not to say that mothers were not interested in what other mothers were giving their children they described finding out about them in a less direct manner by asking their children about their friends lunchboxes this was a low stakes and less exposing way to get information about what other parents are doing implicit in this activity is the possibility that their own practices may be reported back to other parents mothers narratives also alluded to the anxiety of keeping up with new trends for example jane explained the friend i was out with today she had lunch she was saying shed just bought a flask some sort of thermos flask but a food thermos flask to keep pasta warm in it i think ill probably investigate that actually to keep stuff warm 2 negotiating home food in school given that government health campaigns on healthy eating are partly administered through the school and its staff the school was an important potential audience within mothers narratives the school through which research participants were recruited had rules concerning what should not be included in lunchboxes including fizzy drinks solid chocolate sweets and nuts however a process of interpretation was also required for example is a homemade cupcake considered a sweet surveillance took place through lunchbox checks the results of which were reported back by children illustrating this heidi explained milly will come home and say oh they did a lunchbox check so and so had this great big chocolate and we are not allowed that she was worried her cake bar wouldnt be allowed but because it is not solid chocolatei mean they are only little as well i find it quite hard sometimes because i think if you make their lunchboxes then you are happy for them to eat it our respondents generally agreed with the restrictions placed by the school which fits with existing research findings concerning middle class families and compliance with dominant discourses of health and nutrition these guidelines were believed to be important for childrens future physical health and cultural capital potential judgement could result if parents provided food items that were not allowed mothers narratives alluded to a concern that packing a bad lunchbox could be seen to imply that one was a bad mother illustrating this mary explained i wouldnt want the school to think oh my god like davids mum has just spent two seconds packing this or it to look specifically like hes packed it himself in terms of the content … i think there is an element thereof i dont want to be judged on the basis that my kids got inappropriate food regularly on a regular basis because you want people to think youre at least a good parent or trying your best anyway supporting previous research findings this implies that some mothers such as mary were aware that the school requires a specific performance of motherhood however it is also important to note that there was some variation about mothers practices and there were some examples of mothers knowingly contravening the school guidance this is illustrated by kerry who works full time brands available in the market childrens requests can be linked to peer influence and advertising for example sophie explained how her daughters would make such requests sometimes theyll come home and say soandso has something in their lunch box can i have that or youll go out shopping and the little one will see something and say soandso has that or look specifically then theres all the new things like the fruit strings and the fruit winders and all that stuff that wasnt available two or three years ago… recognised as competent consumers able to advance requests for the content of their lunchboxes mothers responded to childrens requests evoking the principle of moderation or balance although participants had varied opinions as to what constitutes a moderate amount of treats all seemed to consider the treat in relation to the overall content of the lunchbox as well as the rest of food to be eaten during the other meals of the day everything in moderation i think so that is what im trying to give to her … i have said to her you know you need to eat as many vegetables as you can so once youve had that then yes then you can have your treats on top i think she understands treats have the function of rewarding children for being committed students engaged in school and sports activities as well as having eaten the healthy food items as such they can still fit within discourses of moral accountability and good mothering despite containing potentially unhealthy items this supports previous works highlighting how food choices are often made as a compromise between indulgence and health also this echoes previous works on mothering highlighting how the work of caring is a compromise between providing food considered healthy as well as food that children will enjoy this tension was well summarised by heidi affirming that well sometimes you cant keep them happy because youve got to keep them healthy in providing food that children will enjoy childrens needs and desires concerning how they want to spend their lunchtime were also relevant for example if they preferred to play outside with friends or take part in sport that would lead to less time to eat a packed lunch and mothers needed to pack the contents with this in mind illustrating this hannah said sometimes theyll say to me oh mummy just put three things in there because i havent got time thats another thing with school lunches that its a bit of a conveyor belt and theyre rushed so i know if theyve got a club or something at lunchtime maybe one or two things get left aware of the short amount of time for eating lunch hannah needed to select food that at the same time is filling appealing and can be eaten quickly her lunchbox therefore displays evidence of her maternal knowledge of her childrens preferences pressures and activities daniel and gustafsson evaluated the changes to school meals in three london primary schools and argue that healthy eating initiatives have neglected the social significance of lunchtimes as childrens spaces within the adult controlled school day schools have therefore been criticized for focusing on what children put in their mouths at the expense of creating a pleasurable social context where food is consumed relevant factors include where children eat the time they have to eat who they are eating with and the choice they have over this and how eating lunch is fitted in among other activities it can be argued that mothers narratives showed an awareness of the social context to childrens lunches and are displaying this to others and themselves reinforcing a sense of good mothering that goes beyond purely nutritional concerns discussion participants saw their everyday preparation of lunchbox as one of their mundane routinized and taken for granted practices surrounding mothers identity of providing not simply food but food that will satisfy them the family the care mothers took in customising lunchboxes in relation to the childs preferences moods and dietary restrictions as well as school activities and regulations shows how lunchboxes are understood not simply as a way of providing food for children but also as a way of providing home food fitting the school environment finch emphasised that the core message of display is these are my family relationships and they work our findings suggest that mothers were displaying to themselves as well as external audiences that they are competent caring mothers this takes place against an interesting backdrop miller notes that womens experiences of pregnancy childbirth and early mothering in the west is shaped by hierarchical forms of authoritative knowledge where professional expertise is most highly valued although the mothers in the present study have children aged 911 and could then be expected to be more confident in their role as experts in their childrens lives than those with younger children the research was conducted within a wider context where mothers authority and knowledge could be seen as under attack within media and policy discourses displayed and consumed in the school setting mothers are on display through their lunchboxes and accountable to others thus family display operates not only on extraordinary family occasions and celebrations but also on a daily basis in our routinized and ordinary practices such as making the shopping lists for the week looking at the new arrivals in supermarkets and indeed preparing a lunchbox the findings also illuminate the crucial role of the perceived audience in the process of display mothers navigate different requests vocalised by their children other mothers accounts of their domestic lives and also those visible in the supermarkets shelves tv programs and cookbooks and school regulations interestingly the role of fathers seem to be virtually absent in mothers narratives and this seemed to be linked to the way in which childrens lunchbox preparation was still seen as womens work this echoes previous research which has highlighted the gendered nature of parenting in the west the school seems to be regarded as one of the most powerful potential audiences to whom mothers felt morally accountable although there were some examples of resistance to the school regulations we found that overall mothers followed school guidance this could be explained by the fact that these mothers do not want to position themselves as problematic mothers who do not know how to feed their children properly relatedly millers study of early motherhood highlighted the way in which notions of motherhood are culturally shaped and morally grounded and that this may lead to selfsilencing because the repertoires of what it is possible to say about motherhood appears limited this is likely to have affected the way mothers in the current study presented their narratives as well as reflecting gendered assumptions the notion of feeding the child with proper food was also framed in relation to social class being a middle class mother able to make proper dietary choices for her children discourses and practices around the everyday work of feeding their children are embedded in wider discourses of producing and marking social class as well as marking mothering as skeggs has shown class is related to hierarchical attributions of value in food consumption as well as other areas middle class lifestyles are presented as the ideal to follow furthermore as previous research has found the making of ethical selves is a relational classed process certain gendered and classed bodies are considered as deviant and pathologised through moral discourses perpetuating class distinction indeed moralising discourses around healthy eating and the look and shape of the body are rooted in gendered and classed discourses wherein the most socially valuable subjects are positioned as white thin affluent and healthy ones in relation to school food working class women are constituted through media and governmental discourse as lacking in taste education and morality as reflected in some of the narratives presented in this paper this picture of deficit is constructed in opposition to the normative position of middle class motherhood whereas the existing literature highlights the particular importance of displaying family in less traditional contexts our data suggests that more attention could be paid to the everyday display work performed by mothers in relatively hegemonic positions although the size of the sample of this paper is limited and caution should be exercised in extrapolating from the findings one of the striking things about data presented here is that it suggests that middle class heterosexual women mainly in nuclear families still feel compelled to do a lot of everyday work to display good mothering even amongst relatively privileged mothers there was a certain uncertainty of being able to display good mothering this can be noticed in mothers fear of losing the plotas one of the participants saidand their activity of subtly monitoring and keeping uptodate with what other mothers do and make for their children these feelings of uncertainty highlight how the process of doing and displaying middle class motherhood is an ongoing process never completely accomplished by mothers who need to learn how the display of being middle class evolves in the marketplace our findings confirm skeggs argument that class is not a given but is in continual production indeed our findings show how a classed display of motherhood is a moving target never fully achieved by mothers since their work of display requires them to keep updated with changing and contrasting demands of mothering proposed by relevant audiences in this respect media and marketplace discourses epitomised by celebrity chef programmes and the constant introduction of new products and brands seem to exacerbate the process of good mothering as a moving and a never fully achieved target this paper has built upon finchs concept of family display by illuminating how through the preparation of lunchboxes middle class mothers engage in mundane and routine processes of display with reference to different audiences our findings point to some of the ways in which mothers try to maintain control and input into food provision outside of the home in looking at participants feelings surrounding their preparation of lunchboxes our paper reveals a certain anxiety in the subject on display who despite being part of a relatively hegemonic group of white middle class mothers feel under scrutiny and potentially under attack i although we were not able to address the class bias in the present study due to limited time and resources a subsequent study by the authors has successfully recruited parents from more diverse class and ethnic backgrounds via schools in london and surrey ii following world health organization guidelines the five a day campaign was introduced in the uk by the department of health in 200203 to encourage people to consume at least five portions of fruit and vegetables a day image b image c i have on occasion when i havent been shopping and i havent had anything in and i have had to give a bag of crisps in the lunch box just to make sure theyve had enough to eat kerrys son did come home and say im not supposed to have crisps yes hed been told from the school i knew he wasnt allowed to have them but it was weighing up the option of i dont have time now i need to get to work i dont have anything in…i dont want him to be hungry so a bag of crisps in in this example an ethic of care was presented as justification for less than complete adhesion to the school rules kerry described how she was able to psychologically distance herself from the criticism saying i kind of ignored it and said dont worry about it this suggests that even when transgressing the ideal of healthy food cooked from scratch kerry could still draw upon a form of moral accountability to argue that she was still putting her sons needs first as well as putting childrens needs first another salient aspect of good mothering invoked by the mothers was responding to childrens needs and desires 3 responding to childrens requests mothers described their children as an audience demanding the inclusion of specific food in the lunchbox it appears that children did not contest the overall structure or content of the lunchbox but sometimes advanced specific requests of new foods which parents described as treats mostly sweet food items that do not constitute the main element of the meal but have a similar function as a dessert if the main element of the lunchbox remains under mothers control the treat represents a space of negotiation between mothers and knowledgeable children usually up to date with the new products and

this paper explores middle class mothers narratives on their daily routines of preparing lunchboxes for their children in this study lunchboxes are understood as an artefact linking together discourses and practices of doing and displaying mothering media and government discourses of feeding children and broader issues of care and surveillance in private and public settings drawing on semistructured photo elicitation interviews and a focus group discussion this paper illuminates how mothers feel on display through the contents of their childrens lunchboxes

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covid19 skepticism can be conceptualized as the denial of the seriousness of the illness and the perception that the pandemic is overblown or a hoax this perspective is of great concern as people who do not perceive covid19 to be a threat to their health and the health of others may thwart efforts to reduce transmission individuals who discount the seriousness of covid19 may become critical disease vectors if they become infected and engage in high contact behaviors or travel to areas with low infection rates in the current study we were interested in examining the correlates of covid19 skepticism specifically we were interested in the association between frequency of engaging in covid19 prevention behaviors and covid19 skepticism the association between covid19 skepticism and political ideology social norms about distancing covid19 perceived risk and covid19 information seeking behaviors and associations between endorsement of covid19 conspiracy theories and covid19 skepticism prior research suggests that correlates of skepticism of science differ by issues research from other domains indicates that political ideology may be associated with skepticism for example political ideology is a strong predictor of climate change skepticism and associated with science skepticism but there are mixed findings on the relationship between political ideology and vaccine skepticism and little relationship with genetically modified food skepticism economic interests can also influence political ideologies and skepticism associations between political ideology and economic interests with climate change skepticism are well documented economic interests have motivated the promotion of climate change skepticism with a handful of scientists paid by the oil and gas industry to question firm scientific data a metaanalysis of 171 studies firmly establishes the link between political ideology and climate change skepticism this dynamic of economic interests political ideologies and climate change skepticism has led to climate change and environmental issues becoming politically polarized and has greatly impeded the government from addressing climate change in the us covid19related science may similarly run counter to political and economic values in the us and brazil conservative media and associated political groups tended to downplay the epidemic when it was in its early stages promotion of covid19 skepticism may also be motivated by political and economic interests as social distancing policies to reduce the spread of covid19 have adverse financial impacts such as reduced spending particularly in restaurants retail and air travel sectors perceptions of health and illness often have a strong social component with social norms influencing perceived risk and health behaviors specifically covid19 skepticism may be influenced by the covid19 attitudes and behaviors of others in ones social group social norms have also been linked to climate change skepticism in addition to social norms influencing behaviors people with the same behaviors and attitudes about covid19 may affiliate together especially those who do not social distance which can reinforce normative beliefs and behaviors according to health behavior theories such as precaution adoption theory perceptions of personal risk may also influence health behaviors such that those who perceive themselves to be at lower risk are more likely to be skeptical about the seriousness of covid19 a key tenant of the precaution adoption theory is that for individuals to engage in behavior change they need to perceive the risk and believe that they are personally at risk due to optimism bias people often perceive a risk but do not view themselves to be personally at risk this casual pathway between covid19 skepticism and perceived risk may be bidirectional those who are skeptical of the severity of covid19 are likely to downplay their personal risk of getting and suffering from the disease similarly if people do not feel that they are at risk of a disease they may not view it as a serious threat to their health or the health of others in the current analyses based on the precaution adoption theory we examined perceived risk to self perceived risk to important others and perceived risk to the population of covid19 scientific skepticism has been found to be associated with advocating or endorsing conspiracy theories furthermore beliefs in conspiracy theories related to health behaviors have been linked to engagement in social media sources that may promote inaccurate news a study by lewandowsky found that greater endorsement of conspiracy theories was associated with opposition to genetically modified foods vaccinations and climate science additionally in a large international study of antivaccination attitudes hornsey et al found associations between antivaccination attitudes and conspiratorial thinking as well as a low tolerance for infringements on their freedoms and individualistic and hierarchical worldviews covid19 skepticism may also be fueled by engagement with scientific information or exposure to and reliance on misinformation rumors false information and conspiracy theories have been well documented during the covid19 pandemic false information is known to circulate in environments of little information and low trust in governmental and other institutions shortly after its discovery in late december 2019 covid19 rapidly spread around the globe causing rising death tolls and widespread uncertainty about mitigation strategies and economic stability this environment of uncertainty provided fertile ground for misinformation as state actors as well as purveyors of conspiracy theories and propaganda sites used social media channels to diffuse information which rapidly outpaced the slower development and dissemination of scientific evidence in the current study we examined whether people who endorsed covid19 skepticism beliefs would engage in less frequent covid19 prevention behaviors in addition we explored the relationship between covid19 skepticism and political ideology social norms about distancing covid19 perceived risk and covid19 information seeking behaviors finally we examined whether covid19 skepticism may be linked to covid19 conspiracy theories methods study respondents participated in an online twowave longitudinal study the first survey was administered from march 24th 27th after many governors had declared states of emergency and had enacted social distancing policies the second survey was administered from may 5th14th at that time there were over 1 million cases and over 65000 deaths in the us and of the states that had instituted stay at home orders the majority still had them in effect study participants were recruited through amazons mechanical turk service study populations recruited through mturk are not nationally representative but they outperform other webbased opinion sampling on several dimensions previous research has supported the reliability of data from mturk participants study protocols were designed following mturks best practices participants eligibility included being age 18 or older living in the united states english speaking and reading having heard of the coronavirus or covid19 and provision of informed consent the enrollment criteria for the mturk platform included 97 or higher prior approval rate and greater than 100 hits completed following recommendations proposed by rouse and colleagues we embedded checks to mitigate inattentive and random responding we repeated questions to ensure consistency additionally we included survey questions that had exceedingly low probability such as the frequency of deepsea fishing in alaska and the number of appendages removed we also examined the amount of time for completing the survey and the completeness of the data participants were compensated 250 for the completion of the first survey the equivalent of an 1120 hourly wage for the second survey they received 300 the study protocols were approved by the johns hopkins bloomberg school of public health irb the baseline survey recruited 809 valid responses of which 794 provided contact information and 683 completed the followup assessment measures covid19 skepticism was assessed by the three survey items the health risks from coronavirus have been exaggerated the coronavirus is a hoax and the coronavirus isnt any worse than the flu the response categories were strongly agree agree neither agree nor disagree disagree and strongly disagree these three items were summed as a scale and had a cronbachs alpha of 85 we also examined covid19 skepticism as a dichotomous measure based on the distribution for a dichotomous measure of covid19 skepticism individuals who endorsed strongly agree or agree for any of the three items were considered to score high on covid19 skepticism whereas all others were considered low scores to assess covid19 prevention behaviors participants were asked are you spending more time in your house to prevent getting the coronavirus and do you wear a face mask when you are outside with the response categories never sometimes and always social norms were assessed with the question what percent of your friends do you think are socially distancing the response options were ten categories with 10 increments from 0 to 10 to 90100 this variable on friends social distancing was recoded into three groups based on the distribution less than 70 7080 and more than 80 perceived risk was assessed based on perceptions of covid19 risk to others and self two questions assessed the perceived risk to others one question asked what percent of people in the country do you think will get the coronavirus and was recoded to 20 or less 2040 and 40 or more based on the distribution a second question included people im close to may die from the coronavirus the response categories were strongly agree agree neither agree nor disagree disagree and strongly disagree the perceived personal risk of covid19 was assessed with the question how likely do you think it is that you will get the coronavirus with choices extremely unlikely unlikely neutral likely and extremely likely responses were recoded as likely versus unlikely we also assessed whether participants perceived that they were currently infected had been infected or had been tested for the coronavirus endorsement of conspiracy theory was assessed with the question china purposely spread the coronavirus the response categories were strongly agree agree neither agree nor disagree disagree and strongly disagree for the analyses the categories strongly agree and agree were compared to neither agree nor disagree disagree and strongly disagree perceived health status was assessed with the question in general would you say that your health is excellent good fair or poor for the analyses the categories of excellent and good were compared to fair and poor gender was used for all participants except one who did not report binary gender and biological sex at birth was used we also assessed covid19 testing and whether respondents believed that they had covid19 all analyzed questions were from the followup survey except for six items from the baseline which assessed the frequency of covid19 information seeking as well as demographic characteristics including political ideology income education gender and age frequency of covid19 information seeking was assessed with the question on average how often do you watch listen or read news about the coronavirus the response categories were multiple times an hour every 12 hours a couple of times a day once a day and less than once a day political ideology was assessed with the item where would you place yourself on a scale running from very liberal to very conservative the response categories were very liberal liberal slightly liberal moderate slightly conservative conservative and very conservative family income was dichotomized at less than 60000 versus 60000 or more education was classified as a bachelors degree and higher versus associate degree or less age was assessed as a continuous variable analyses the analyses were crosssectional with all key variables from wave two except for political conservatism and demographic variables which were collected at wave one we conducted the analyses with primarily crosssectional data at followup since this was well into the pandemic in the us whereas at baseline there had been a relatively small number of recorded cases and deaths we examined covid19 skepticism as both a dichotomous and continuous variable bivariate logistic regression models were used to examine the relationship between the independent variables and the level of covid19 skepticism for the multivariate analyses ordinary least squares regression and multivariate logistic regression models were used for the latter approach a stepwise model was employed with first entering demographic variables and then using forward stepwise to remove variables that were not statistically significant p 10 as the statistical significance was set at p 01 this approach was use both to obtain a parsimonious model and to remove variables that may be partially or fully redundant in accounting for the variance the statistical power for the osl regression was 097 which was calculated based on 11 predictors a significance level of 05 multiple partial correlation coefficient of 2 and a sample size of 683 two individuals had missing data given the small number we removed these two cases results there were 683 participants in the analyses most of the respondents were female 428 were married 29 single and 205 were in a committed relationship 262 were currently required to work outside the home 12 had a high school education or less 319 had completed some college technical school or an associate degree 403 had a bachelors and 158 a graduate school degree 773 were white 75 black 38 hispanic 83 asian and 31 other 587 were employed fulltime and 141 parttime the mean age was 391 most respondents rated their health as excellent or good with 184 rating their health as fair and only 18 as poor a minority of the sample endorsed one or more of the covid19 skepticism items with 167 agreeing or strongly agreeing that the covid19 health risk had been exaggerated 78 agreeing or strongly agreeing that the covid19 is not worse than the flu and 31 agreeing or strongly agreeing that covid19 is a hoax for the covid19 skepticism scale the mean was 53 regarding prevention behaviors 925 reported spending more time inside to prevent transmission and 82 wore a mask outside sometimes or always almost half of participants perceived that 80100 of their friends were socially distancing regarding the risk of covid19 infection 385 expected that 40100 of the us population would become infected with covid19 and 18 reported that it was very likely or likely that they would become infected no one in the sample reported testing positive for covid19 whereas 32 attempted to test for the virus and 69 reported that they might have had or currently have covid19 about half of the respondents agreed or strongly agreed that people that they are close to might die from covid19 the vast majority of study participants reported accessing covid19related news once a day or more some participants endorsed the conspiracy belief that china spread the virus purposefully in the bivariate logistic regression analysis covid19 skepticism was found to be associated with subjective health the proportion of friends social distancing people close to them dying from covid19 the proportion of people in the us anticipated acquiring covid19 perception of the number of friends social distancing prevention behaviors of staying in ones house and wearing a mask and frequency of acquiring news about covid19 although we did not find that the demographic variables of age gender education or income were associated with covid19 skepticism in the bivariate logistic regression models we retained them in the multivariate logistic regression models after adjusting for race gender education and income age was the only demographic variable associated with an increased likelihood to endorse skepticism those of younger age better health and who identified as more politically conservative were more likely to endorse covid19 skepticism statements people who reported higher skepticism were also less likely to believe people close to them would die from covid19 furthermore greater skepticism of covid19 was associated with reduced engagement in covid19 prevention behaviors including spending time inside to prevent coronavirus and frequency of reporting wearing a mask outside individuals who endorsed covid19 skepticism reported fewer friends social distancing those who were more skeptical about covid19 were also more likely to believe the conspiracy theory that china purposefully spread the virus assessing covid19 skepticism as a scale in the ols regression model provided similar results to the dichotomous assessment in the logistic regression model the ols model r 2 was 46 and the adjusted r 2 was 45 for the ols regression model there were 5 outliers with the standardized residuals ranging from 303 to 323 and two outliers at one end of the distribution and three at the other removing these cases did not change the results we tested the assumptions for ols regression by examining the residuals distribution the residuals were normally distributed with no evidence of homoscedasticity in both models the perceived risk of covid19 was significant in the multivariate model but not in the unadjusted logistic regression model discussion covid19 skepticism was strongly associated with reduced engagement in covid19 prevention behaviors including spending time in ones household as a social distancing measure and wearing a face mask these findings are of great concern given the extensive spread of sarcov2 if people are skeptical about the dangers of covid19 and do not engage in prevention behaviors they are more likely to become infected and transmit the virus this dynamic may also be exacerbated by the reports that those who had high levels of covid19 skepticism had a lower proportion of friends who were also social distancing there was also a strong negative association between covid19 skepticism and the perceived risk of others close to the respondent dying from the virus those who endorsed covid19 skepticism were also much more likely to believe that china purposely spread the virus it is interesting to consider why the discounting of the threat of covid19 might be linked to this conspiracy theory one potential explanation is that news sources for those who endorsed covid19 skepticism may be different from those consumed by people who did not endorse such skepticism for example these individuals may be exposed to different news sources such as fox that have promoted these beliefs or maybe consuming social media sources in which covid19 conspiracy theories have flourished another potential explanation is similar to what has been seen with antivaccine beliefs which are more prevalent among individuals who score high on measures of reactance and express intolerance when others including those in government or public health fields encourage them to think or act in a certain way individuals high in reactance may thus be prone to accept conspiracy theories because they may be viewed as outsidethemainstream or independent perspectives the finding that covid19 skepticism was associated with political conservativism may also be explained by sources of news that these participants consume and more negative attitudes toward government spending on public health among conservatives compared to liberals the association between subjective health status and skepticism revealed that those who reported better health were less likely to endorse covid19 skepticism one explanation for this association is that those who perceive that they are in better health also believe that covid19 will not impact them and hence discount covid19 as a factor that could threaten their health which has been documented with other health conditions there were few differences between the ols and logistic regression models in the ols model the survey item on the percent of the country anticipated to be infected with covid19 was associated with covid19 skepticism this variable was not significant in the logistic regression model which is likely due to its overlap with other independent variables and the use of a dichotomous variable in the logistic regression model it was noteworthy that the perceived likelihood of getting covid19 was significant in the logistic regression model but not in the ols model we did not find that demographic or socialeconomic status variables were associated these data suggest that a proportion of the population is skeptical about the severity of covid19 this group is also less likely to engage in behaviors to prevent the transmission of sarscov2 a distrust in mainstream media and propensity to believe conspiracy theories may also lead to downplaying the dangers of covid19 a common response to address unscientific attitudes is explication which refers to the process of explaining evidence in clear language this approach is based on the assumption that evidence and data drive attitudes however evidence suggests that people develop attitudes and then find evidence to support those attitudes interventions that attempt to refute antivaccination myths have not been successful and may lead to a boomerang effect if this group is similar to those who hold antivaccination beliefs it is not likely that additional information is likely to change their beliefs it may be a better use of resources to target health education interventions at individuals who have a greater latitude of acceptance for covid19 information as compared to those who have more extreme views unfortunately this finding suggests that mandatory prevention behaviors such as mask wearing may be needed since some people are downplaying the severity of the disease as we found that covid19 skepticism is associated with political conservativism it is critical is associated with political conservativism it is critical to have conservative leaders speak out about the dangers of covid19 and the role of government to protect its citizens an economic conservative may be concerned that prevention efforts have a profound negative impact on the economy it is also important to address the economic consequences of covid19 as they are disproportionately impacting disadvantaged populations and a salient concern of political conservatives many of the current public health recommendations for addressing the pandemic ignore the social and economic factors that also impact health for example there are few recommendations on how government funding related to the economic impact of covid19 can be used to reduce physical and mental health disparities caused and exacerbated by covid19 although political conservativism was found to be associated with covid19 skepticism we do not know if other political attitudes such as alienation and distrust of government are also associated with covid19 skepticism which should be assessed in future studies there are several study limitations that should be noted the study population was not a representative sample which limits external validity the sample did have demographic characteristics similar to other crowdsourcing studies prior studies have found that mturk samples tend to be younger more educated less religious and less likely to be a racial minority conservative or fully employed than those in a nationally representative study we followed guidelines of best practices for using crowdsourcing data collection to enhance the surveys validity and included validity checks in the survey moreover prior research has found that comparisons of mturk to other forms of nonrandom sampling suggests that mturk participants are no more or less likely to engage in dishonest or disingenuous behavior in this study we assessed the frequency of accessing covid19 information we therefore do not know whether participants were accessing information based on science or misinformation future research should assess the source and content of covid19 information and how these are associated with covid19 skepticism respondents who endorsed covid19 skepticism also reported that their friends were less likely to engage in social distancing we do not know if these individuals tend to affiliate with others similar to themselves or if they simply assume that their friends are engaging in behaviors that are similar to their own behaviors in addition the measure of covid19 skepticism was brief and may not have captured different dimensions of this construct moreover the survey did not assess vaccine attitudes and intentions these data do suggest that it is important to monitor and assess covid19 skepticism with a national random sample due to its link to covid19 transmission risk behaviors since individuals who endorse covid19 skepticism beliefs are less likely to follow covid19 prevention guidelines such as mask wearing and social distancing these findings bolster the arguments for making these public health recommendations mandatory moreover as certain beliefs such as antivaccine beliefs are exceedingly difficult to change it is critical to develop approaches that promote covid19 prevention behaviors that may be inconsistent with individuals beliefs however governmental and nongovernmental organizations should also ensure that everyone has adequate resources to prevent and treat covid19 as well as address the negative economic and mental health consequences of the pandemic data availability the datasets generated during andor analyzed during the current study are available from the corresponding author on reasonable request compliance with ethical standards conflict of interest no conflict exists financial disclosures none ethics approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards consent to participate informed consent was obtained from all individual participants included in the study publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

skepticism can be conceptualized as the denial of the seriousness of the illness and the perception that the pandemic is overblown or a hoax in the current study we examined the association between covid19 skepticism and frequency of engaging in covid19 prevention behaviors political ideology social norms about distancing covid19 informationseeking behaviors and covid19 conspiracy theories a survey was administered from may 5th14th at that time there were over 1 million covid19 cases in the us participants were recruited online through mturk the three outcome variables were handwashing mask wearing and social distancing injunctive and descriptive norms were assessed as well as measures of perceived risk to self and others there were 683 participants in the analyses in the multiple logistic regression model those who were of younger age aor 097 p 005 better health aor 056 p 001 and more politically conservative aor 132 p 001 were more likely to endorse covid19 skepticism statements people who reported higher skepticism were also less likely to that believe people close to them would die from covid19 aor 42 p 001 engage in covid19 prevention behaviors including spending time inside to prevent coronavirus aor 033 p 001 and frequently wear a mask outside aor 044 p 001 those who were more skeptical about covid19 were also more likely to believe the conspiracy theory that china purposefully spread the virus aor 638 p 001 covid19 skepticism was strongly associated with reduced engagement in covid19 prevention behaviors these findings bolster the arguments for making these public health recommendations mandatory

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introduction several studies have suggested that the aspects of mental health among university students are considerably poorer than that of their peers in the general population 1 2 3 4 5 depression is one of the most prevalent mental health problems among university students and the prevalence is rising 6 7 there are varied prevalence estimates of depressive symptoms among university students ranging from in the area of 10 8 9 10 11 to in the region of 20 12 and up to 40 and 80 13 14 15 however the mean prevalence of depression in university students stands at 306 6 university students are in a critical period of life since they transition from adolescence to adulthood which requires them to make many major decisions during this period they encounter tremendous pressures chiefly from economic stress academic demands interpersonal relationships and struggles with making crucial decisions 16 depression manifests in a wide range of symptoms encompassing sleep and eating disturbances lack of selfcare poor concentration anxiety and disinterest in everyday activities 17 for university students depression is correlated with poor academic strengths and limitations of this study ► this research is among a very few studies in developing countries in which standardised tools are used and rigorous analyses are performed ► it included a large sample of students randomly selected from all departments in two public universitiesone in the capital city and the other in a provincial townusing a multistage cluster sampling method ► limitations of the study however included the representativeness of the study sample the crosssectional nature of the data that limits causation inferences unknown validity of the scales used to measure important constructs in the cambodian contexts and potential bias of selfreported measures open access achievements 18 dropout 19 20 relationship instability 21 suicidal ideation and attempts 18 22 23 poor work performance 24 substance abuse 25 26 acute infectious illnesses 27 and poor physical and mental health in general 28 29 moreover depression in this early period can build up negative consequences in adult life through its impacts on career prospects and social relationships 30 31 thus tackling depression among university students is vital since most lifetime mental disorders commence during the university age 32 and their mental health has essential ramifications for campus health services in particular and mental health policymaking in general 33 34 put another way from a public health standpoint early detection and prevention of mental health problems among young adults in higher education is paramount comprehension of their salient psychological distress namely depression and its correlates would enable tailormade and early screening and intervention programmes to reduce mental health problems in this population this is integral for their educational performance and triumph in their prospective profession as well as for the national advancement since they are future leaders the prevalence of depression is induced by many factors including study populations sociodemographics 16 35 study sites 16 36 diagnostic tools and sampling methods 36 37 and sociocultural environments 16 contextualisation of facets linked with depression thus is significant for mitigation measures in cambodia little is known about social and behavioural determinants of depressive symptoms among student populations in 2012 a study on 1943 students at 11 junior high and high schools found that exposure to violence among community members peers or family was a predictor for depressive symptoms in the students 38 39 a 2013 qualitative study on a sample of 28 students at a cambodian university found that life events problems of everyday life and availability of social support were the main stress factors affecting university students life satisfaction 40 moreover exposure to daily hassles was a stress factor having a strong impact on students psychological and somatic responses nonetheless no research has been conducted to examine social and behavioural determinants of depression among cambodian university students this study therefore intends to identify factors associated with depressive symptoms among university students in cambodia methods study sites and population this crosssectional study was conducted with students at the university of battambang in battambang province and the royal university of phnom penh in the capital city of cambodia in june and july 2015 epi info was used to calculate the sample size from the university student population of approximately 168 000 41 the anticipated percentage frequency was not known so 50 was put for the calculation to prevent any underestimated prevalence based on a 95 ci and a 5 margin of error the minimum sample size required for this study was 767 students adjusted for 10 of incomplete responses missing data and rejection rate the final minimum required sample size was 850 students patient and public involvement the development of the research questions and outcome measures was informed by university students priorities experience and preferences gathered through consultative meetings with representatives of students faculty members and school administrators the workshops aimed to collect inputs from the representatives for designing the study and developing the study protocol and materials the representatives were also invited to participate in the study finding dissemination workshops in each participating university sampling and data collection procedure a multistage cluster sampling method was used to select the participants first the two universities were purposively selected considering administration and logistic limitations all departments of the selected universities were included in the study in each department a nonproportionate quota sampling method was used to select the sample from a name list provided by the department administrator to meet the required sample size on the designated date of data collection all selected students were approached by trained data collectors with support from a school administrator questionnaires and instructions were then distributed to them in a classroom for selfadministration which took approximately 30 min to complete questionnaire development and training we first developed a structured questionnaire in english and translated it into khmer the national language of cambodia then the khmer questionnaire was backtranslated into english by a local expert to check its accuracy the khmer questionnaire was pretested with a sample of 20 students at rupp to ensure that the wording and contents were culturally suitable and clearly understandable we also received comments on the questionnaire from experts working on health and education in cambodia the questionnaire was finalised based on their feedback and findings from the pretest the questionnaire is available on request from the corresponding author a 2day training on the study protocol and data collection methods was provided to the data enumerators and supervisors the training focused on building familiarity with the study protocol and questionnaire interview techniques privacy assurance and confidentiality it also addressed quality control strategies such as rechecking and reviewing the questionnaires after administration and resolving issues that might arise during the fieldwork the data collection supervisors were instructed to variables and measurements depressive symptoms depressive symptoms were assessed by using the center for epidemiologic studies depression scale 42 this scale consists of 20 questions addressing six symptoms of depression including depressed mood guilt or worthlessness helplessness or hopelessness psychomotor retardation loss of appetite and sleep disturbance experienced during the preceding week each question is scored on a scale of 03 according to the frequency of the symptoms and the total cesd score ranges from 0 to 60 to calculate the total score four items were reverse coded the criterion validity of the cesd scale has been well established in western 42 and asian 43 populations we defined depressive symptoms as present when a subject had a cesd score of ≥16 a cutoff value of ≥23 was also used to define severe depressive state 44 sociodemographic characteristics substance use and sexual behaviours we adapted standardised tools from the most recent cambodia demographic and health survey 45 as well as from our previous student and young people health surveys in cambodia 38 39 4648 to measure socioeconomic characteristics sexual behaviours with different partners and substance use sociodemographic characteristics of the respondents included study site gender age marital status academic year living situations perceived family economic status and perceived academic performance healthrelated behaviours we used the health behavior survey 49 which was designed as a broad survey of healthrelated behaviours and beliefs components of the national college health risk behavior survey 50 and the global schoolbased student health survey 51 each health behaviour area was addressed by only a limited number of items for example frequency of consumption of fast food in an average week was assessed by a question on average how many times do you eat fast food per week with response options of 0 time one to two times a week and three or more times a week similar questions and response options were used to assess consumption of several other kinds of healthy and unhealthy food such as highfat snack or fruitsvegetables selfratings were also used for some questions such as perceived body size and general health status adverse childhood experiences five questions were adapted from the brief screening version of the childhood trauma questionnaire to measure aces 52 the five yesno questions asked about the experiences of physical abuse emotional abuse sexual abuse physical neglect and emotional neglect during childhood selfrated health sf12 health survey was used to measure selfrated health 53 54 the sf12 is a multipurpose shortform generic measure of health status it is a subset of the larger sf36 and monitors health in general and in specific populations the sf12 measures eight health aspects namely physical functioning role limitations due to physical health problems bodily pain general health vitality social functioning role limitations due to emotional problems and mental health data analyses double data entry was performed using epidata version 3 χ 2 test or fishers exact test when a sample size was smaller than five in one cell was used for categorical variables and students ttest was used for continuous variables to compare sociodemographic characteristics health risk behaviours selfrated health and aces among students with depressive symptoms defined by a cesd score of ≥16 to those among students without depressive symptoms the same comparisons were also made among students with and without severe depressive symptoms defined by a cesd score of ≥23 in multivariate models we first included all variables significantly associated with depressive symptoms in the bivariate analyses at a level of p value 005 simultaneously in the models variables with a p value 005 were then removed and the models were refitted the steps were repeated until all p values of the remaining variables were 005 in the final models adjusted ors were obtained and presented with ci and p values spss v22 was used for all statistical analyses ethical considerations participation in this study was voluntary in the process of obtaining a written informed consent students were made clear that they could refuse or discontinue their participation at any time and for any reason the confidentiality and privacy of the respondents were protected by administering the questionnaires in a private premise and by excluding personal identifiers from the data and field notes after completing the survey each participant received a small gift for their time compensation results sociodemographic characteristics the study sample included 493 students from ub and 866 students from rupp about half open access of the respondents were male with a mean age of 213 years sd23 less than 20 of the students initially selected for the study declined the participation mostly due to their time constrains they were then replaced by the next gendermatched student in the student name list the majority of the respondents were unmarried and 434 were living with their parents regarding their family economic status 592 reported that their family was neither rich nor poor the proportion of students with depressive symptoms and severe depressive symptoms were 506 and 196 respectively table 1 shows that a significantly higher proportion of students with depressive symptoms were from ub and from a poorer family and reported poorer academic performance similarly a significantly higher proportion of students with severe depressive symptoms were female and from a poorer family selfrated health table 3 shows that significantly higher proportion of students with depressive symptoms perceived that their general health status was poor a significantly higher proportion of students with depressive symptoms reported higher levels of limitation in several daily activities such as limitation in moderate activities climbing several flights of stairs or other kinds of activities in the past 4 weeks as a result of their physical or emotional health problems furthermore they reported higher levels of problems in several other physical and emotional health aspects in the past 4 weeks such as a feeling that they had accomplished less than they would like pain interferes with their normal work having less energy downhearted and blue and that their physical health interferes with their social acts adverse childhood experiences as shown in table 4 a significantly higher proportion of students with depressive symptoms reported having been hit slapped or kicked by a parent or guardian that people in their family had said hurtful or insulting things to them and that someone had tried to touch them or make them touch him or her in a sexual way in contrast significantly lower proportion of students with depressive symptoms reported that there had been someone to take care of them and take them to medical care when they got sick and someone who helped them feel that they were loved and important the odds decreased significantly with the perception that their body size was slightly underweight compared with the perception that their body size was very overweight risk regarding selfrated health the odds of depressive symptoms increased significantly with the perception that their general health status was poor and the report of higher level of limitation in moderate activities higher level of pain interference with their normal work and higher level of feeling downhearted and blue for aces the odds of depressive symptoms increased significantly with the report of having been hit slapped or kicked by a parent or guardian and that people in their family had said hurtful or insulting things to them during their childhood in contrast the odds of depressive symptoms decreased significantly with the report that there had been someone to take care of them and take them to medical care when they got sick discussion this study explored the prevalence of depressive symptoms and unearthed a number of social and behavioural factors correlated with the symptoms among university students in cambodia the proportion of students with depressive symptoms and severe depressive symptoms was 506 and 196 respectively the salient factors comprised cultural and socioeconomic dimensions individual behaviours and attitudes and nurturerelated facets the bivariate outcomes display that students from the provincial university and a poorer family were more susceptible to depressive symptoms although not manifesting in the multivariate model these factors are corroborated by the existing scholarship various studies revealed that university students from rural areas and low socioeconomic backgrounds were predisposed to higher depression 1 16 28 55 56 this could be explained by an economic situation where students with a rural background tended to stipulate a poorer family status plus financial vulnerability could further exacerbate depression in students from lowincome families a metaanalysis of 60 studies unveiled that people in the lowest socioeconomic quintile had 181 the probability of depression compared with those in the highest socioeconomic quintile 57 a global study on 17 348 university students from 23 highincome middleincome and lowincome countries also uncovered that higher depressive symptoms were recorded among students in lowincome countries and economies with greater income inequality 16 the cambodian economy has been growing rapidly in terms of income per capita yet income gaps between the rich and the poor and between rural and urban areas remain large 58 the gaps in income and material growth which typify economic conditions may induce peoples mental health problems in another word poor economic status may bring about low selfesteem and selfconfidence which would lead to depression our multivariate results depict that students with depressive symptoms regardless of severity tended to report poor academic performance and higher consumption of unhealthy food these findings conform to a systematic review of 24 studies 6 and studies in asia such as china 7 which pinpoint low scholastic merit and suicidal ideation as consistent correlates of depression in university students probably as a culmination of poor concentration and solitude on the consumption of unhealthy food the transition from adolescence to adulthood and thus the changes in lifestyle such as living arrangements and independence might have rendered university students to indulge in unhealthy food as pinpointed by a metaanalysis of 39 studies in china 7 as aforementioned more than half of our sample were not living with their parents therefore it might have been hard for them to maintain healthy daily food conversely depression might have made students carefree about themselves and consequently eat unhealthily 17 this implies that nutrition education for both physical and mental health stressing healthy food for the body and mind is imperative for university students students with depressive symptoms regardless of magnitude also tended to have a negative perception about their body and their general health status these findings confirms the general perception among depressed people who are not gratified with their body and health 17 although these relationships require a cautious interpretation given that cesd also measures some aspects of negative selfperception furthermore depressed students were more likely to have limited physical activeness more pain interference with their normal work and more dismay or sorrow these findings are consistent with findings from previous studies in different populations and settings 59 60 however the interpretation of these complex relationships must be made with caution given that the nature of the data does not allow causal relationship to be established open access open access finally students with depressive symptoms disregard of severity were more likely to encounter physical violence by their parent or guardian psychological abuse by their family members and lack of general and medical care by their family when they were growing up as for the physical violence and psychological abuse this finding tends to acquiesce with a study in cambodia that postulates that exposure to violence within family is associated with depression in high school students 38 39 on the lack of general and medical care by family a chinese study on 5245 students at six universities found that students who had a poor parental relationship were more vulnerable to depression 11 also a global study on 17 348 university students from 23 highincome middleincome and lowincome countries iterated that university students with less individualistic cultures particularly in asia reported higher extents of depressive symptoms 16 students of these cultures longed for more familial and societal ties and assistance and thus felt depressed once this social capital was unavailable 16 this highlights a significant role of family bonds and scaffolding in association with depression among university students the lack of social support from the family presumably would only be a factor for students living independently however for those living with relatives friends or spouse they would still have such support a study on a sample of 2671 respondents in nine provinces and a capital city in 2012 revealed that cambodia greatly needs more and better counselling and mental health services 61 the study also pointed out the shortage of skilled professionals in the field of mental health particularly those open access 61 62 this number equates to approximately 02 psychiatrists per 100 000 population which is similar to the average in southeast asia 62 many health staff lack training supervision and experience in these areas only about 300 doctors completed basic mental healthcare training 63 at university level the 2012 study called for more awareness raising for selfcare and burnout prevention and mental health counselling services for staff and students 61 given the paucity of mental health services in general let alone at universities our findings fuel the needs for more and better mental healthcare in cambodia further to medical care universities should provide measures such as student loans and healthy canteens to mitigate some key predictors of depression among students such as financial hardship and poor diets this study contains certain limitations first it examined students at only two public universities one in the capital city and the other in a province hence its findings cannot be generalised at a national level second the crosssectional design did not enable an establishment of the causal linkages between depressive symptoms and the related factors given the temporal order and the crosssectional nature of the data causal relationships between the variables could not be derived potential bidirectionality of the associations could occur either way for instance physical inactivity could cause depression nonetheless the reverse could also be truethat depression could lead to inactivity and of course both could be true simultaneously where depressive symptoms worsen with physical inactivity making physical activity less likely third this study employed selfreported data which might have been subject to overreporting and underreporting caused by the negative cognitive biases associated with depression as well as possible recall bias future studies should attempt to use more objective data to increase validity of the information nonetheless the quality of the data was ensured by thorough training of the enumerators and field supervisors on the study protocols and data collection method finally the main outcome measure and some other measures such as aces and sf12 were modified from other research and have not been validated in the cambodian settings therefore the interpretation of the findings must be made with caution notwithstanding these malfeasances the findings of this study offer first and foremost implications for policy development and future research in the cambodian context conclusions this study identified social and behavioural factors associated with depressive symptoms among cambodian students at two universities while causation could not be drawn between these factors and depression we surmise that these factors were intertwined and thus need to be addressed in an integrated and holistic fashion these findings render three major implications first given the current educational reform and labour market that demand better quality and ergo more competition among university students the correlates of depressive symptoms could not be more critical for tackling for the time being failure to ameliorate these factors would jeopardise the qualification and career development of this populace open access and finally the human capital for nationbuilding second these findings warrant an acceleration of oncampus counselling services for university students throughout the course of studentship efforts should be invested in comprehensive screening and intervention programmes to diagnose those susceptible students early offer immediate treatment and cater appropriate support universities could play very important roles in taking this research forward by providing future research outputs to improve mental health of the students that would in turn improve their academic outcomes ultimately the jurisdiction of refining students mental state should go beyond universities to families and pertinent governmental bodies at large provided we are to assist the young to overcome their academic challenges and enjoy a prosperous postgraduation life further research could delve into changing lifestyles and their associations with depressive symptoms among a larger sample of university students furthermore validation studies are required to develop and validate reliable instruments for use in cambodian populations contributors sy kp and st conceived research questions designed the study and developed the research protocol and tools sy and cn analysed the data and interpreted the results and drafted the manuscript kp pc and ry supported the protocol and tools development and were responsible for training and data collection all authors contributed to the writing and approved the final manuscript funding data used for this analysis were collected as part of a larger study funded by the united states agency for international development disclaimer content of this paper is the responsibility of the authors and does not reflect the view of usaid or our respective institutions the funder had no role in study design data collection and analyses decision to publish or preparation of the manuscript competing interests none declared patient consent obtained

objective to explore social and behavioural factors associated with depressive symptoms among university students in cambodia design crosssectional study settings two public universitiesone in the capital city of phnom penh and another in battambang provincial town participants this study included 1359 students randomly selected from all departments in the two universities using a multistage cluster sampling method for a selfadministered questionnaire survey in 2015 primary outcome measure depressive symptoms measured by using the center for epidemiologic studies depression scale all measures in the study were selfreported results the proportion of students with depressive symptoms and severe depressive symptoms were 506 and 196 respectively after adjustment in multivariate logistic regression analysis depressive symptoms remained significantly associated with poor academic performance adjusted or aor 731 95 ci 224 to 2386 higher consumption of unhealthy food aor172 95 ci 108 to 276 a negative selfperception about body shape aor054 95 ci 029 to 099 and general health status aor299 95 ci 128 to 700 and limited physical activeness aor030 95 ci 016 to 058 depressive symptoms also remained significantly associated with adverse childhood experiences including physical violence aor139 95 ci 104 to 186 psychological abuse aor182 95 ci 137 to 242 and lack of general and medical care aor051 95 ci 030 to 086 by family during childhood conclusions the key factors associated with depressive symptoms were family related and individual behaviours and attitudes thus efforts should be invested in comprehensive screening and intervention programmes to diagnose those vulnerable students early offer immediate treatment and cater appropriate support

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introduction the coronavirus disease 2019 declared as a global pandemic by the world health organization on 11 march 2020 1 has introduced a huge strain on communities and health care systems worldwide with the second or third pandemic wave many countries are finding it difficult to respond to increasing health care needs of people infected with covid19 especially if they are also diagnosed with other chronic diseases cancer patients have a higher risk of covid19 infection 2 with an estimated 2fold increased risk of having a positive covid19 test in comparison with the general population 3 they are also more susceptible to severe covid19 infection followed by higher morbidity and mortality than people without cancer 2 4 5 6 the main underlying reason behind this is likely to be their immunosuppressive state as a result of underlying malignancy or anticancer treatments 7 therefore it is necessary to ensure early detection of coronavirus infection given that cancer patients have a high risk of unfavourable outcomes a study using the uk biobank data found that sociodemographic factors were relevant in determining a risk of covid19 infection in the general population including lower educational attainment and nonwhite ethnicity 8 however the influence of socioeconomic factors on covid19 transmission severity and outcomes among cancer patients are not yet known 9 we aimed to identify and explore the most important socioeconomic risk factors associated with testing positive for covid19 among incident cancer patients in the uk biobank cohort materials and methods study design and study participants we developed a casecohort study with a modified casebase sampling design consisting in using the complete cohort as the control population 10 the casebase design involves using an extracted sample from the source population as controls in order that every person has the same chance of being included as a control ie cases can be included as controls this type of sampling only works with a previously defined cohort and the inclusion of the complete cohort as control source prevents the use of weights to upweight sampled controls 10 the casebase sampling provides a valid estimate of the risk ratio without assuming that the disease is rare in the source population 10 study participants were identified using the uk biobanka populationbased prospective cohort which recruited 502655 volunteers aged 4069 years from 2006 to 2010 11 each participant provided longitudinal data on sociodemographic lifestyle and behavioural factors medical history and medications enabling research into genetic and lifestyle determinants of common diseases of middle and older age 11 from all the uk biobank participants we selected those who were diagnosed with incident cancer regardless of the tumour site defined as cancer cases diagnosed after enrolment to the uk biobank cohort in contrast to the prevalent cases diagnosed before the enrolment we excluded nonmelanoma skin cancers and other types of nonmalignant neoplasms patients who died before the first available covid19 test results were excluded to allow all participants to have the same probability to be exposed to severe acute respiratory syndrome coronavirus 2 dates of death were obtained from death certificates held by the nhs information centre and the nhs central register data on cancer diagnoses were obtained by uk biobank through nhs digital and public health england for participants in england and wales and nhs central register and information services division for participants in scotland 1213 previous evidence linking routine registration of colorectal lung and breast cancer with information from the hospital episode statistics showed that the completeness of case ascertainment in english cancer registries exceeds 98 14 from the selected subcohort of incident cancer we then identified our cases as all those who tested for sarscov2 with a positive result based on data from the phes second generation surveillance system it is a centralised microbiology database covering english clinical diagnostics laboratories that provides national surveillance of legally notifiable infections bacterial isolations and antimicrobial resistance 15 through the individuallevel linkage of these two systems phe provides a regular and exhaustive feed of new covid19 test results for the uk biobank participants 16 the majority of samples tested for covid19 among uk biobank participants were from combined nosethroat swabs while in intensive care units lower respiratory samples may have been taken 17 inpatient tests arise from specimens collected from an acute care provider an emergency department or an inpatient location 17 samples were analysed using a reverse transcriptase polymerase chain reaction test for sarscov2 17 casebase constitution and casecontrol definition the first covid19 test results were released from 16 march 2020 onwards until the 31 august 2020 as part of the first wave of the covid19 pandemic therefore the cohort was defined as all the uk biobank participants diagnosed with an incident cancer and confirmed to be alive on 16 march 2020 figure 1 shows the study flowchart including 89 covid19 positive cases and 18917 controls cases were defined as all incident cancer patients tested for covid19 with a positive result controls were defined as the complete cohort of incident cancer cases from the uk biobank study we assume that nontested controls do not develop the disease cancers 2021 13 x 3 of 15 mation from the hospital episode statistics showed that the completeness of case ascertainment in english cancer registries exceeds 98 14 from the selected subcohort of incident cancer we then identified our cases as all those who tested for sarscov2 with a positive result based on data from the phes second generation surveillance system it is a centralised microbiology database covering english clinical diagnostics laboratories that provides national surveillance of legally notifiable infections bacterial isolations and antimicrobial resistance 15 through the individuallevel linkage of these two systems phe provides a regular and exhaustive feed of new covid19 test results for the uk biobank participants 16 the majority of samples tested for covid19 among uk biobank participants were from combined nosethroat swabs while in intensive care units lower respiratory samples may have been taken 17 inpatient tests arise from specimens collected from an acute care provider an emergency department or an inpatient location 17 samples were analysed using a reverse transcriptase polymerase chain reaction test for sarscov2 17 casebase constitution and casecontrol definition the first covid19 test results were released from 16 march 2020 onwards until the 31 august 2020 as part of the first wave of the covid19 pandemic therefore the cohort was defined as all the uk biobank participants diagnosed with an incident cancer and confirmed to be alive on 16 march 2020 figure 1 shows the study flowchart including 89 covid19 positive cases and 18917 controls cases were defined as all incident cancer patients tested for covid19 with a positive result controls were defined as the complete cohort of incident cancer cases from the uk biobank study we assume that nontested controls do not develop the disease sociodemographic characteristics and risk factors at baseline the following potential covid19 risk factors were identified and referred as timefixed covariates at baseline the townsend deprivation index age sex ethnicity employment status smoking status body mass index in kgm 2 and type of cancer the tdi was the main risk factor defined as an areabased measure of socioeconomic deprivation and a proxy of individuals socioeconomic deprivation tdi scores were calculated using data from the uk 2011 census the tdi score combines information on car ownership household overcrowding owner occupation and unemployment aggregated for small areas of residence 18 higher tdi equates to a higher level of socioeconomic deprivation we computed the quintiles of tdi and categorised it as q1 for the least deprived and q5 for the most deprived group age was calculated from dates of birth to baseline assessment ethnicity was selfreported and categorised as white or white british black or black british asian or asian british and others including mixed ethnicities and all other ethnic groups smoking status was categorised into never former and current smokers the who criteria were applied to classify bmi as underweight normal weight overweight and obese 19 however due to data sparsity we recategorised bmi as obese vs nonobese employment was categorised as employed or selfemployed retired and unemployed or unpaid types of cancers were classified as haematological nonhaematological melanoma of the skin and other types of cancer this categorisation was not based solely on clinical characteristics and largely on the number of positive covid19 cases per each distinct cancer type finally we included the duration of time following the cancer diagnosis classified as being diagnosed with a malignant tumour less than five or more than five years ago statistical analyses we described the categorical variables using counts and proportions and the continuous variables using medians and interquartile ranges by case control status afterwards we estimated the risk of testing covid19 positive by all the sociodemographic employment status bmi and cancer type and time duration after the cancer diagnosis due to the use of the complete cohort as main control source for analysis we did not include weights to correct for the sampling design however the variance estimates were adjusted to account for the inclusion of the cases as controls in the overall cohort 20 therefore we computed univariate risk ratios and their respective robust 95 confidence intervals 2021 to assess the association between socioeconomic deprivation and the risk of testing positive for covid19 we fitted different multivariate regression models including one variable at a time to control for confounding the final model was adjusted for age sex ethnicity employment marital and smoking status cancer types and years of cancer diagnosis from each model we derived the risk ratios and 95 cis using a generalised linear model with the family poisson and link log and robust error variance estimation 2021 from the final adjusted model we derived the adjusted marginal probabilities of testing covid19 positive by levels of deprivation stratified by gender and across the levels of bmi given the low proportion of missing data we first performed a completecase analysis adopting the missing completelyatrandom assumption however to assess the consistency of our results for the socioeconomic deprivation we developed a multiple imputation by chained equations we imputed 50 datasets for the variables ethnicity smoking employment and marital status the multiple imputation results were combined using rubins rules 22 these estimates were presented in model 9 cancers 2021 13 1514 5 of 14 furthermore in sensitivity analyses we explored different modelling specifications and the assumption that nontested controls do not develop the covid19 we used stata v16 for statistical analysis ethics approval and consent to participate this uk biobank study was approved by the north west multicentre research ethics committee all participants provided written informed consent for data collection data analysis and record linkage results the characteristics of the test positive and the entire cohort are detailed in table 1 the overall incidence in our study was 47 cases per 1000 incident cancer patients overall 4090 participants were in the most deprived category and 3604 in the most affluent group the median age of the test positive group was 74 years and 528 were male the majority of them were white while 45 were black 74 of 89 testpositive patients had nonhaematological cancer of which malignant neoplasm of the breast prostate colorectal and urogenital were the most common primary tumour sites we did not find statistically significant differences between the cases and controls regarding the distributions of cancer types or the duration of time following the cancer diagnosis in univariate analysis black patients had nearly four times higher risk of testing covid19 positive than whites individuals living in more deprived areas had approximately 4 times higher risk of testing positive for covid19 than those individuals from the least deprived areas vs the most affluent quintile was 340 95 ci 156738 furthermore being unemployed or unpaid current smoker or exsmoker having high bmi or being diagnosed with haematological cancers were strongly associated with an increased risk of testing positive for covid19 in multivariate analysis we controlled for confounding adding successively one variable at a time in the multivariate regression model our final completecase model found a consistent and independent association between being socioeconomically deprived and testing positive for covid19 with an adjusted risk ratio of 252 black patients had almost 6 times higher risk of testing positive for covid19 in comparison with white patients furthermore this risk among unemployed was two times higher than among employed patients and increased by 41 for each 5 kgm 2 increase in bmi based on the risks estimated from model 8 we predicted the probabilities of testing positive for covid19 for the most and least deprived individuals of the studied cohort given their respective observed distribution of the covariables included in the model the probabilities are stratified by sex and bmi overall we found a clear deprivation gap but the figures show no evidence of significant differences in covid19 positive tests between men and women differences between the two sexes were however more pronounced among the most deprived group figure 3 shows a constant deprivation gap in the probability of testing positive between the most and least deprived cancer patients that widens with increasing levels of bmi and even strengthens among obese cancer patients results of the sensitivity analysis are detailed in supplementary technical notes 1 and table s2 the effect estimates for being most deprived were consistent in sensitivity analyses based on controls consisting of either test negative or nontested participants cancers 2021 13 x 10 of 15 based on the risks estimated from model 8 we predicted the probabilities of testing positive for covid19 for the most and least deprived individuals of the studied cohort given their respective observed distribution of the covariables included in the model the probabilities are stratified by sex and bmi overall we found a clear deprivation gap but the figures show no evidence of significant differences in covid19 positive tests between men and women differences between the two sexes were however more pronounced among the most deprived group figure 3 shows a constant deprivation gap in the probability of testing positive between the most and least deprived cancer patients that widens with increasing levels of bmi and even strengthens among obese cancer patients results of the sensitivity analysis are detailed in supplementary technical notes 1 and table s2 the effect estimates for being most deprived were consistent in sensitivity analyses based on controls consisting of either test negative or nontested participants based on the risks estimated from model 8 we predicted the probabilities of testing positive for covid19 for the most and least deprived individuals of the studied cohort given their respective observed distribution of the covariables included in the model the probabilities are stratified by sex and bmi overall we found a clear deprivation gap but the figures show no evidence of significant differences in covid19 positive tests between men and women differences between the two sexes were however more pronounced among the most deprived group figure 3 shows a constant deprivation gap in the probability of testing positive between the most and least deprived cancer patients that widens with increasing levels of bmi and even strengthens among obese cancer patients results of the sensitivity analysis are detailed in supplementary technical notes 1 and table s2 the effect estimates for being most deprived were consistent in sensitivity analyses based on controls consisting of either test negative or nontested participants discussion we found a consistent and independent association between socioeconomic deprivation and the risk of covid19 positive test results among incident cancer cases in the uk biobank study participants with an increased risk of testing positive for covid19 during the first wave of the pandemic in the uk had a black ethnic background lived in the most socioeconomically deprived areas were obese unemployed and diagnosed with a haemopoietic cancer for less than five years our results are consistent with the stark ethnic inequalities evident in the recent estimates of covid19 mortality during the first wave of the pandemic by ethnic groups in england and wales 2324 as published by the office for national statistics in the uk the rate of covid19 related deaths was 27 times higher for black african men then for white men 23 thus we argue that an increased risk of testing covid19 positive among black ethnic groups may partially explain the increased mortality risk observed in the uk furthermore the incidence rate in our study was consistent with the reported figure for the whole uk the total population in the uk was 66796800 and the total number of cases as of the 1st august 2020 was 303942 2526 corresponding to an incidence rate was 46 per 1000 people covid19 incidence was similar in both populations while external contacts were lower for cancer patients the is likely to be due to cancer patients caution dramatically reduced delivery of noncovid19related care by the nhs during the first wave of the pandemic the fear of healthcare interactions during the covid19 pandemic or misunderstanding that healthcare services were not available to all but limited to covid19 patients only 2728 health surveys in the uk have shown that unemployment smoking and obesity are most common among ethnic minorities 2429 stress associated with an unhealthy lifestyle or lack of financial security may result in a proinflammatory condition increasing susceptibility to infections 3031 in a study by shree et al 3233 longterm cancer survivors have experienced increased incidence of many infections have particularly viral and fungal infections among diffuse large bcell lymphoma and hodgkin lymphoma survivors the immune dysfunction can be related to longlasting changes in the functioning of the immune system due to cancer diagnosis and past treatments the increased risk for covid19 infection found among the most socioeconomically deprived incident cancer patients could point to a potential role for proinflammatory and metabolic condition in combination with cancerrelated immune dysfunction leading to increased vulnerability to infections socioeconomic status is a multifaceted construct and therefore not only determined by the individuals income we argue that the disparities in testing positive for covid19 we found during the first wave of the pandemic reflect the health environmental and occupational effects of socioeconomic inequalities these disparities may be partially explained by the higher likelihood of ethnic minorities to work in lower paid occupations that demand proximity to other people or work colleagues offering less flexibility to work from home or living in cramped residential settings that preclude social distancing 34 35 36 37 38 39 our study highlights the necessity of reporting data on socioeconomic determinants of covid19 disease especially information about ethnicity to identify highrisk populations and develop equitable public health prevention measures guidelines and interventions a multisectoral approach would reduce disparities by considering the vulnerabilities at a social educational economic and provisionofcare levels furthermore findings from our study may help to prioritise future covid19 preventive strategies especially vaccination priority among cancer patients undergoing active treatments however more research is needed regarding comparative risk assessment for covid19 infection among cancer and the overall population and the cancer specific survival after covid19 infection uk biobank has been meticulously tracking the health status of its participants for over a decade many participants are now in the age range likely to be most vulnerable to covid19 infection as well as at higher risk of being diagnosed with cancer using the casecohort approach we derived risk estimates for positive covid19 test results based on a valid and consistent methodological approach 4041 however there are possible issues around generalisability of the uk biobank data which was previously criticised 42 although the uk biobank might not be completely representative of the uk population and therefore the results may not be entirely generalizable or suitable for identifying disease prevalence or incidence rates its large size and heterogeneity of exposure measures provide valid scientific inferences of associations between exposures and health conditions that are generalizable to other populations 42 furthermore we were unable to perform cancer specific analysis due to small number of confirmed covid19 cases by cancer sites however we were able to classify malignancies in clinically relevant categories ie haematological cancers nonhaematological cancers skin melanoma and other types of cancers the classification was not based on clinical characteristics rather it was based on the number of positive covid19 cases per each distinct cancer type finally we assume that controls that were not tested for covid19 do not develop the disease which may have induced a selection bias because some of the cancer patients might be asymptomatic 43 we argue that given their cancer status the majority of control patients developing symptoms compatible with covid19 they would have been tested also we have performed sensitivity analyses demonstrating consistency of results even if nontested patients were excluded from analysis furthermore in our sensitivity analysis the results were consistent when restricting the controls to only nontested patients excluding those testing negative on covid19 conclusions to the best of our knowledge this study is the first to highlight a consistent and independent association between socioeconomic deprivation and the risk of covid19 infection among incident cancer patients in the uk policy and practice improvements based on high ethical principles are needed to address the broad disparity and risk stratification among the most vulnerable cancer patients at risk for covid19 it is essential to develop effective preventive measures targeting cancer patients at highest risk such as an urgent vaccination of the underprivileged cancer patients to confront the future potential pandemic waves supplementary materials the following are available online at 1371514s1 table s1 distribution of incident cancer subtypes for the casecohort study at baseline in 16th march 2020 table s2 sensitivity analyses based on two modified versions of the control population scenario 1 where the controls were only those patients with a negative test result and scenario 2 where controls were only those patients nontested for covid19 excluding those with a negative result technical notes 1 sensitivity analyses funding malf was supported by a spanish national health institute carlos iii miguel serveti investigator grantaward grant number cp1700206eufeder and project grant grant number eufederfis pi1801593 the funders had no role in the study design data collection and analysis decision to publish or preparation of the manuscript data availability statement this research has been conducted using the uk biobank resource under application number 48860 granting access to the corresponding uk biobank biomarkers and phenotype data deidentified participant phenotype and genetic data from the uk biobank data are available via on application proposals should be directed to the uk biobank to gain access data requestors will need to sign a data access agreement institutional review board statement this uk biobank study was approved by the north west multicentre research ethics committee informed consent statement informed consent was obtained from all subjects involved in the study

there is limited evidence regarding the influence of socioeconomic factors on covid19 transmission severity and outcomes in the overall population furthermore there is an urgent need to identify and explore the most important socioeconomic risk factors associated with the covid19 disease among incident cancer patients one of the most vulnerable groups of the population findings from this study provide invaluable evidence needed for risk classification and stratification among incident cancer patients based on the information from the first pandemic wave in the uk we identified the clinical and sociodemographic profile of cancer patients at increased risk of covid19 infection the results from the study added knowledge on impact of the pandemic on the most vulnerable cancer patients in the uk and can shed light on possible treatment and prevention strategies for covid19 including future vaccination prioritisation policy

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in the digital world the expected consequence was the stop of many social platforms on free access to their data this has made the scenario of digital scholars much more complex because empirical research especially quantitative research relies on the availability of data the risk which i consider in this contribution is that the availability of data more or less easily affects so much the way digital research is done resulting in some platforms being overstudied others being neglected by research regardless of their popularity from this premise arise the three questions of the paper how much have constraints on digital data access changed research practices can we speak of an effective postapi era that is has there been an effective migration to other data scraping techniques finally what are the possible shared and sustainable solutions for the postapi scenario in the first case i intend to explore the possibility that the difficulties in accessing data from popular platforms such as facebook has actually radically affected how data is collected in the second case the hypothesis is that the scientific use of open platforms such as twitter exploded after 2018 in the third case this change since 2018 is possible that it has produced the need for a new consciousness toward data processing especially from an ethical perspective here for simplicity of language and to follow most of the literature in the field i mean by postapi simply the phase following the ca scandal and the consequences on data access limitations in addition i keep the concepts of apis and web data scraping quite distinct as for the former concept refers to the official applications provided by platforms for controlled data downloading the second on the other hand is a concept that also embraces either manual data retrieval practices or handcrafted devices for scraping data from the web digital data and methods for scraping the spread of web 20 and social media have accelerated the process of datafication of society they have become the information centers of our consumption habits and status therefore social media are suitable for studying human and social phenomena both for scientific research and for less noble issues such as marketing social research today is increasingly convinced that the study of society cannot neglect digital phenomena and the content of social platforms on the other hand it no longer makes sense to divide the real from the virtual in other words digital reality represents the evolution of our society that produces new data with which to interact through digital methods the epistemological issues surrounding digital data are particularly relevant to understanding the implications of api restrictions post2018 scholars such as kate crawford rob kitchin and törnberg törnberg have explored how the api stands for application programming interface which acts as an intermediary allowing websites and software to communicate and exchange data and information limitations on accessing and using digital data can have profound social and political implications for example crawford has argued that the rise of algorithmic decisionmaking based on limited data can have negative consequences for marginalized groups kitchin has also highlighted how the power to control and regulate digital data is not evenly distributed and can reinforce existing power structures törnberg and törnberg highlight the need to move beyond a technologically deterministic view of digital data and instead consider the social political and economic contexts of data production and use similarly evelyn rupperts work on the politics of data highlights how restrictions on data access and use can have farreaching consequences for both researchers and the broader public understanding these complex issues is crucial for researchers seeking to conduct digital research post2018 and navigate the limitations on api access and use it is a paradox but this wide availability does not result in easy access to data restrictive privacy policies and the very nature of digital data make it difficult to obtain techniques and software for building digital databases are now highly desired two major families of data collection in the world wide web can be recognized the first refers to digitized or virtual methods that is social research techniques adapted to the online environment for example web surveys or longdistance interviews implemented with online services on the other hand the second includes digital methods with web data scraping and techniques involving the use of application programming interfaces in general wds can be defined as the process of extracting and combining content of interest from the web in a systematic way wds helps to take raw data in the form of html code from sites and convert it into a usable structured format not only that manual extraction by simple copyandpaste from web pages is also part of wds activities because a huge amount of heterogeneous data is constantly being generated on the web wds is widely recognized as an efficient and powerful technique for collecting big data to accommodate a variety of scenarios current wds techniques have become customized moving from small adhoc humanassisted procedures to the use of fully automated systems capable of converting entire web sites into wellorganized datasets wds predates api extraction by more than a decade but it has often been marginalized by apis that have become easier to access it is more flexible than api extraction because it can be used on most web pages not just those that offer apis thus it is a more versatile technique and more importantly more durable than apibased techniques which as will be seen below are highly subject to the restrictive policies of platforms data scraping involves three main requirements that researchers must address first the scraping of social media data is a way to collect information from human subjects so it must meet ethical standards accepted by the scientific community such as preserving user privacy second connected with the first point a data scraping procedure should comply with the terms of service of the platform from which the data is collected third the data collected must comply with legal regulations that protect peoples data in particular as of may 2018 the european union has issued a new regulation for individual researchers and companies the general data protection regulation one of the most stringent data protection laws currently in place which provides a set of restrictions to which scientific researchers using human subjects must adapt and which as will be seen below is revolutionizing the way we approach data apicalypse now for many years the big corporate of the web such as google and facebook have been exclusive owners of much of our data handing it over to thirdparty companies with ambiguous goals up to that time research made extensive use of this data sometimes even with little care about privacy rules the uncontrolled downloading of data was allowed mainly through filtering devices with platforms called apis by which access keys were provided to the analyst to initiate scraping operations apis were the main tool by which researchers collected behavioral and digital trace data from facebook the scandal of ca the company that has been using facebook users data for speculative purposes has burst the bubble of precarious internet privacy in 2018 many web platforms have decided to beat a retreat on free data sharing shutting down the huge free flow of user data on major platforms has potentially reduced the prospects for studying an important slice of human society among the likely consequences discussed in the literature at least four of them deserve to be highlighted the first is that research would have flattened only on easily accessible data thus neglecting varied and mixed approaches on different online contexts at the expense of exclusively api friendly environments the second is that analyses are often conducted on secondary datasets sourced on web depositories and thus often constructed with other goals in mind finally frequent violation of tos has been reported a consequence of researchers attitude of circumventing social platform policies to retrieve data such as through the use of unclear scraping techniques also not insignificant is the possible contraction of databased approaches at the expense of less empirical approaches that bypass the burden of constructing digital data researchers who have asked this kind of question while exploring the characteristics of the postapi scenario come to almost the same conclusion the difficulty of finding data after 2018 has radically altered digital research and the consequences still in its infancy could be traumatic and lead to heavy biases for present and future digital research outcomes not everyone agrees with this negative hypothesis some data scientists and scholars of digital environments believe that this apocalyptic revolution has not occurred on the contrary the restrictions on platform data access probably can help improve the ethical and legal scenario on digital scraping on the other hand having unlimited data would have turned researchers away from their privacy obligations to users and encouraged ambiguous data collection practices in violation of social media rules given the changes in research practices since 2018 it remains unclear to what extent these changes have affected different stages of research prior to api restrictions independent researchers had easy access to public user profile information comments and reactions to public posts via thirdparty apis this facilitated studies on the societal impact of social media however the discontinuation of these apis has effectively prevented independent researchers from conducting observational studies on topics such as political and social behavior as well as the spread of real and fake news news network structure and political engagement dynamics on facebooks platform as facebooks apis were the only means by which third parties were authorized to collect data from the platform these restrictions have had a significant impact on research possibilities this has raised general concern among scholars and sparked a debate around alternative ways to access crucial data to pursue social research on facebook meanwhile if one looks at the scholarly output built on digital data one realizes that progressively this is shifting toward twitter with a significant jump since 2018 the year of facebooks closure the paradox however is that information has not disappeared from the web but instead is still publicly available scholars have also begun to discuss possible alternative methods of obtaining facebook data in what some scholars have already called the postapi era moreover it appears that other platforms will follow suit by making it more difficult if not impossible to collect behavioral data easily and securely materials and methods study and research questions the study was created to explore the postapi scenario presented in the literature and to give even if partially an answer to these three questions how have constraints on digital data access changed research practices can we speak of an effective postapi era that is has there been an effective migration to other data scraping techniques what are the possible shared and sustainable solutions for the postapi scenario to achieve this we formulated three openended questions that asked participants to reflect on their experiences with digital research methods the first question asked participants to identify any challenges they faced during the research process while the second question focused on the most commonly adopted strategy for collecting data online the third question sought to determine participants preferred social platform for data collection the use of openended questions in research is a common approach and is advocated by several researchers including patton and creswell patton emphasizes the importance of openended questions in qualitative research as they allow participants to express their experiences and views in their own words leading to a more complete understanding of the phenomenon under investigation similarly creswell notes that openended questions are useful in exploratory research as they allow the researcher to uncover a range of perspectives and experiences that may not be captured with closedended questions this method which used asynchronous questions encouraged the selected researchers to engage in an exercise of selfreflexivity on their digital research practices this approach allowed the researchers to explore issues indepth that are rarely reported in scholarly communications on digital research and are only mentioned in contributions to digital epistemology to provide more information on the methodology used to frame and analyze the responses we can draw on the approach of braun and clarke which is a widely used framework for thematic analysis this method involves several steps including familiarizing oneself with the data generating initial codes searching for themes reviewing and defining themes and finally producing the report study group the selection of researchers to be interviewed was done in the following way the query search of the scopus database was set up using certain keywords such as digital methods digital data web analysis and social media communication the top 18 italian researchers by number of publications were contacted considering the following quotas 6 researchers for each of the three prevailing methodological approaches within these quotas a precise selection criterion was not to include researchers from the same department an email was sent to the identified researchers with a brief motivation and with the survey form attached customized for each researcher with a brief presentation of my cognitive purposes guaranteeing the confidentiality of the responses the 18 researchers contacted the methodological placement of each scholar was decided by comparing myself with some more experienced colleagues in my department and of course by considering their scientific output all gave their willingness and returned the completed file within a maximum of 1 month results the three dimensions emerging from the responses what are the three main macrothemes that emerge from the analysis of the responses regarding digital research what are some of the challenges associated with collecting and interpreting data in digital research and what are some of the strategies used to construct digital empirical material the three main macrothemes that emerge from the analysis of the responses regarding digital research are the complexity of doing research in digital environments which involves dealing with different epistemological and methodological canons than traditional sociological research and the challenge of constructing data due to the volatility and mutability of big data the use of wds as an alternative method to apis which are secure but more constrained and the impact on the platforms studied such as the preference for social twitter as an easy data environment for analysis of social phenomena on the web the use of webscraping as a necessary evil for constructing digital empirical material which can sometimes circumvent the terms and conditions imposed by the platform and raise ethical issues related to data privacy some of the challenges associated with collecting and interpreting data in digital research include the accessibility of data due to apirelated difficulties the lack of cognitive access to the logic that governs algorithmic processes and the risk of banalization in interpretation due to naive overenthusiasm toward the potential of digital methods some of the strategies used to construct digital empirical material include the use of digital tools found on the net and mostly free learning mining scripts through programming software such as python or r and webscraping techniques which are sometimes seen as a necessary evil but raise ethical concerns related to data privacy the problematic steps of digital research collecting and interpreting data the design of digital research shares much of the structure of traditional design what changes is the way the different stages are processed which are affected by the radically different nature of digital data typically the formulation of research questions is different because they should consider new issues such as the digital divide or the indeterminacy of the population studied according to a postdemographic perspective in this very different scenario from traditional research information gathering emerges as the most problematic because it is affected by the peculiarities of online environments the limitations as revealed by multiple responses mainly concern the accessibility of the data ≪due to the restrictions of apis≫ apirelated difficulties are also epistemological what are the processes that govern such applications what impact do they have on the return of data and thus its fidelity this invokes the general theme of data as a social construct and not as an object in its own right it applies especially to algorithmic processes which are seemingly objective but certainly lack neutrality because they respond to predetermined logics the logic of how the api works is often unclear for example the standard 11 version of the twitter api states ≪ the search api is not meant to be an exhaustive source of tweets not all tweets will be indexed or made available via the search interface≫ so not all tweets are extracted and what criteria excludes some of them the data policy is unclear on this point it is clear then how the issue of not having cognitive access to the logic that governs these processes excludes the possibility of having total control over the data collection phase a condition this that cannot be ignored in the later stages of analysis and interpretation the issue of interpretation is precisely the other obstacle that insiders warn has a high risk of being oversimplified and losing its scientific rigor due to the ≪naive overenthusiasm toward the potential and gnoseological scope of digital methods≫ it is then pointed out that the real challenge is not ≪the possibility of retrieving a data or producing a result the real challenge for researchers is to actually extract meaning practical critical and theoretical knowledge≫ this is the question of absolute importance to the scientific community of not falling victim to totally datadriven views but of not being impervious to perspectives that can play a decisive role in the interpretation of results all this needs an adequate problematization of the data its limits and potential its actual quality and its real cognitive power when theorizing on it is built with the intention of intervening on the reality under study to improve it or to allow a better understanding of it not only to insiders but also to gradually broader and broader audiences that can potentially be involved the construction of digital data web scraping as a necessary evil what are the main strategies for constructing digital empirical material although some answers emphasize the relevance still of digitized methods via websurvey or digital ethnography the difficulty of accessing digital data via apis makes people devise a wide variety of webscraping strategies applications range from scripts in wellknown programs to digital tools found on the net and which depending on limitations or access have enabled data retrieval on different sides again digital tools available on the net and mostly free it is a fact that indeed the restrictions that started in 2018 have complicated scholars research tasks however this has by no means encouraged throwing in the towel while for some the solution has been to rely on digital tools hooked into social apis others on the other hand have had to rediscover skills as true data scientists learning mining scripts through programming software such as python or r still in other cases the need for doityourself solutions based on wds techniques emerged however well aware of the ethical sensitivity of certain issues webscraping is in fact always a risky data collection option as it can sometimes circumvent the terms and conditions imposed by the platform api querying which ensures that data is usedaccessed in a manner compliant with the terms and conditions and according to some always preferable it is equally true that webscraping is sometimes a ≪necessary evil as long as it is used under precise data collection and management conditions≫ here is where the ethical issue of data privacy may become an important issue for researchers as well greater awareness on the topic certainly could have positive effects on the quality of doing research twitter as the easy data platform among social media platforms twitter appears to be the most frequently studied by researchers simply because it is a platform from which data can be downloaded very easily quickly and in large quantities in addition the data and metadata available and downloadable through twitters api is in a format that is very easy to handle in analysis whether qualitative or quantitative twitters popularity among experts is due to the easy availability of the api as the researchers interviewed confirm they in fact are careful to point out that facebook has much fewer public data and has stricter limits on its application programming interface on the other hand tufekci calls twitter the model organism of big data precisely because the platforms developers have implemented easy submissions to request apis for tweets this data gold rush would lead researchers to use twitter content to examine all kinds of aspects of human interaction however the nonrandomness of the data acquired through these apis means that twitter studies have drawn conclusions based on substantially biased inferences none of the public apis guarantees the acquisition of all tweets matching the parameters of a query indeed twitters developer documentation makes it clear that the search api will not return all tweets and the streaming api limits captures when query parameters correspond to more than 1 of the total volume of tweets produced globally at any given time discussion the reflections that arise from this study can only be partial and above all not generalizable because the number of researchers interviewed is very limited and confined to the italian scene which could report even significant differences with the foreign world despite this this exploration has tried to give an answer although not definitive to three questions that i try to develop below how have limitations to digital data access changed research practices it is difficult to contest the thesis that restrictions to apis have complicated the researchers work in web contexts according to the direct accounts of those who get their hands dirty with digital data indeed there has been a setback to empirical documentation construction practices it has been perceived as the twilight of the data golden age on the other hand when it comes to the difficulties of retrieving data on the web the paradox is obvious on the one hand the humanities and social sciences are constantly increasing epistemological and methodological reflection on the availability of huge amounts of data however on the other hand the actual tools to retrieve these data are becoming more and more residual can we talk about an effective postapi era some platforms more than others have restricted access to their data the case of facebook is exemplary under the spotlight for the ca scandal it has decided to turn around its api release the closure of the data spigot by the most popular social media has evidently created discouragement and dissent in the scientific community the outcomes however did not include a mass migration to nonapi forms of extraction rather there was a shift to other more easy data platforms such as twitter as confirmed by some responses favoring certain platforms over others is also a predictable symptom of easier access to its data the risk is that all of this may direct digital research reducing the quality of scientific production what are the possible solutions for the postapi scenario web platforms that release their data easily and especially for free are becoming the preferred contexts of study on the other hand this invokes the epistemological urgency of having full knowledge of the construction process and theoretical foundations underlying digital data there are two proposals that between the lines those who responded put forward the first in the shortage of applications to exhaustively collect digital data research has sometimes been encouraged to bypass data privacy rules often violating the platforms terms of service it is important then to create awareness of the ethical issues surrounding digital search since it always involves data that refers to people the second might be to create synergies between academic institutions and large web platforms to promote the free sharing of data at least at the scientific level a few attempts have already been made in the past but the results are not very appreciable considering that the platform has the final say on research objects this suggests that the transition to the postapi research world should be nontraumatic and should not completely disrupt the practices of digital researchers as seen the limited availability in accessing platform databases is creating a competition for those few environments that still leave their apis open a really important point then becomes the integration of scraping tools and platforms to preserve the representativeness of the research object these mixed practices of data construction are gradually being consolidated the typology in table 1 summarizes these concepts that have emerged from the content analysis of responses on the one hand there is the degree of researcher intervention on the other hand there are the techniques four types of practices and related tools with predominantly adopted platforms emerge from the intersection this typology suggests that each practice probably fits well with specific platforms for example those studying twitter are more inclined to use programming scripts allowing the downloading of tweets whereas the known restrictions related to facebook have probably pushed researchers of this social to migrate toward manual copy and paste type wds strategies as can be imagined the methodological orientation of the researcher certainly plays a nonmarginal role in the choice of data extraction strategies while mixed researchers are comfortable among different modes of data retrieval quantitative researchers are more inclined to api forms of extraction on the other hand qualitative researchers are the ones who try experimenting with more varied forms of extraction to study emerging platforms such as reddit or tiktok constraints on platform data accessibility has certainly changed the scenario of digital research and digital methods it has been observed however that this change has not meant moving out of the api era rather the ways of doing digital research have been reconfigured apparently this change is resulting in a fragmentation of the ways in which digital data is being constructed which depending on ones inclinations and most importantly on the availability of time and money is directed toward extraction strategies over others conclusion this article stems from a path of reflection that has accompanied and is accompanying me and my professorial colleagues digital research work especially in relation to the construction phase of empirical digital material although the web is a gold mine of data the data we need are not always immediately available to us and readily available the cambridge analytica scandal of 2018 put a stop to the gravy train of digital data especially for those on social platforms today one has to undertake gyrations between applying for api access subscribing to web scraping software and good computing devices to create digital databases these difficulties have not infrequently encouraged researchers to choose easier paths perhaps reframing the questions and moving to analyse on the most datagenerous platforms platforms such as twitter for example still provide apis with ease putting doubts in the minds of proponents of the postapi paradigm this however may have created quite a few biases the most obvious one is that of the digital universe only that small segment of users active on easydata platforms would be studied therefore it is not secondary for scholarly research to reason about the changes that take place in the big platforms data policies because these as has been the case since 2018 can have very significant impacts on scholarly output and create relevant biases do we study what is of interest or what is easy to study api restrictions have had a major impact on academic research and there is no doubt about that however rather than seeing it as a major loss our research community can take advantage of this moment to critically reflect and improve this initial exploration of the topic should stimulate digital research to reflect and rethink its scraping tools and the nature of digital data these are pressing issues because as heard directly from the voices of key research there are indeed biases such as for example choosing one platform over another just because there is more accessibility therefore research should help explore new ways of scraping that are more ethical that is respectful of users privacy more sustainable that is open or lowcost and above all more shared between the research community and the big platforms data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction this article aims to investigate the potential impact of restricted social data access on digital research practices the cambridge analytica scandal exposed the exploitation of facebook user data for speculative purposes and led to the end of the socalled data golden age characterized by free access to social media user data as a result many social platforms have limited or entirely banned data access this policy shift referred to as the apicalypse has revolutionized digital research methods methods to address the impact of this policy shift on digital research a nonprobabilistic sample of italian researchers was surveyed and the responses were analyzed the survey was designed to explore how constraints on digital data access have altered research practices whether we are truly in a postapi era with a radical change in data scraping strategies and what shared and sustainable solutions can be identified for the postapi scenariothe findings highlight how limits on social data access have not yet created a postapi scenario as expected but it is turning research practices upside down positively and negatively on the positive side because researchers are experimenting with innovative forms of scraping negatively because there could be a mass migration to the few platforms that freely grant their apis with critical consequences for the quality of research discussion the closure of many social media apis has not opened up a postapi world but has worsened the conditions of making research which is increasingly oriented to easydata environments such as twitter this should prompt digital researchers to make a selfreflexive e ort to diversify research platforms and especially to act ethically with user data it would also be important for the scientific world and large platforms to enter into understandings for open and conscious sharing of data in the name of scientific progress

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introduction employment has many benefits that can contribute to the recovery of people with mental health problems 1 2 however in many countries participation and reintegration of people with mental health problems in the workforce is problematic 3 4 several factors cause this some are related to the individual and some to the environment an important barrier for full occupational participation and successful vocational integration is the stigma that is associated with mental health problems 5 stigma is a mark or sign of disgrace usually eliciting negative attitudes to its bearer and can be seen as a problem associated with knowledge attitudes and behaviour 6 several studies have shown that although some cultural differences may exist 7 overall employers in many countries commonly express a range of concerns about hiring a potential employee with mental health problems 8 9 10 concerns reported include the belief that people with mental health problems have limited productivity and job performance especially in tasks requiring cognitive skills 8 11 that they are unreliable and might pose threats to the safety of other strengths and limitations of this study ▪ depression is a leading cause of disability worldwide and for this study respondents with major depressive disorder from as many as 35 countries were interviewed ▪ this study examines the underresearched yet substantial problem of discrimination as a barrier to work participation of people with mdd ▪ interviews were used to gather direct selfreports rather than hypothetical scenarios or vignettes which are often carried out in research on stigma and discrimination ▪ limitations are the crosssectional design of the study and the fact that purposive sampling was used to recruit participants which limits the generalisability of the results employees customers or themselves 11 or behave in a strange and unpredictable manner and that there is potential for symptom relapse 8 in addition the anticipation of discrimination by people with mdd may lead them not to apply for a job in the expectation of failure or rejection whereas most studies on mental health problems and discrimination in the workplace have focused on severe mental disorders such as schizophrenia relatively few have focused on major depressive disorder 5 this is remarkable as mdd is one of the leading causes of the global burden of disease 12 it is one of the most prevalent of all causes of disability 13 14 and therefore an important public health problem across different countries and cultures stigma and discrimination form an important barrier to work reintegration although this topic has hardly been studied in this context the aim of this study was to assess 15 in a crosssectional survey people with a clinical diagnosis of major depressive disorder were interviewed in 35 countries the aspen countries included belgium bulgaria england finland france germany greece hungary italy lithuania the netherlands portugal romania scotland slovakia slovenia spain and turkey the countries participating through the indigo network included australia brazil canada croatia the czech republic egypt india japan malaysia morocco nigeria pakistan serbia sri lanka taiwan tunisia and venezuela the design of this study was intentionally pragmatic so that as many as possible low income and middle income countries could participate using only locally available resources because no external funding was available participants were recruited through local research staff who were asked to identify people attending specialist mental health services in the local area with a clinical diagnosis of mdd in the previous 12 months all were asked to apply the diagnostic and statistical manual fourth edition criteria in the same traditional way within centres site directors were asked to identify a minimum of 25 participants who were in their judgement reasonably representative of all people with a diagnosis of mdd attending specialist mental health services the minimum number of 25 for each site was defined for feasibility issues particularly for noneuropean sites with no grant support this method was intended to allow local staff to take into account the specific local service configuration and to draw participants from the whole range of appropriate local services staff at each site ensured that the sample had a spread across the adult age range working years older adults and a clear representation of female participants as mdd is twice as prevalent in women as men response rates were unknown since the present study focused on the working age population students and retired respondents were excluded from the analyses full details of the method have been published previously 15 procedure data were gathered during facetoface interviews in 2010 between 1 january and 31 december inclusion criteria were a clinical diagnosis of major depressive disorder during the previous 12 months as based on the dsmiv criteria ability to speak and understand the main local language and aged 18 years or older individuals who were receiving psychiatric inpatient care during recruitment were excluded the study was approved by the appropriate ethical review board at each study site after complete description of the study to the subjects written informed consent was obtained measures participants were assessed face to face by independent researchers not involved in the care process using the standardised discrimination and stigma scale a structured interview for recording the discrimination experienced by an individual with a mental health problem 16 17 the disc12 interview starts with the statement discrimination and stigma occur when people are treated unfairly because they are seen as being different from others this interview asks about how participants have been affected by discrimination and stigma because of mental health problems the instrument consists of 32 questions assessing discrimination in several life domains such as marriage parenting housing and leisure for the present paper only the items that referred to discrimination in the work environment are reported on for anticipated discrimination the items used in this study were because of how others might respond to your mental health problem have you stopped yourself from applying for work and because of how others might respond to your mental health problem have you stopped yourself from applying for education and training for experienced discrimination the items used were because of how others might respond to your mental health problem have you been treated unfairly in finding a job and because of how others might respond to your mental health problem have you been treated unfairly in keeping a job all questions were answered on a fourpoint likert scale for the second research question consistent with the methodology of a previous aspenindigo paper 18 countries were divided into groups according to the human development index the hdi is a summary measure of human development established by the united nations 19 which measures the average achievements of a country in three basic dimensions of human development long and healthy life access to knowledge and standard of living since data were gathered in 2010 the hdi statistic of that year was used countries with a very high hdi score were england australia finland germany canada italy portugal belgium france japan greece the netherlands scotland slovakia slovenia spain the czech republic taiwan and hungary countries with a high hdi score were turkey malaysia brazil serbia bulgaria venezuela tunisia lithuania romania and croatia since few countries had a low hdi the medium low and low hdi group were taken together as one group for the analyses this mediumlow hdi group included egypt india morocco nigeria pakistan and sri lanka internalised stigma one of the independent variables included in the analyses for the third research question was measured with the internalized stigma of mental illness scale 20 internalised stigma refers to the inner subjective experience of stigma and its psychological effects resulting from applying negative stereotypes and stigmatising attitudes to oneself the ismi is a 29item instrument for selfrated assessment of the subjective experience of stigma with higher scores indicating higher internalised stigma here the total score on the ismi was used statistical analyses all analyses were performed using spss v 19 all p values were twotailed with an accepted significance level of 005 for the first research question percentages of anticipated and experienced workplace discrimination were reported per country for the second research question two separate anovas were conducted the first of which was with anticipated workplace discrimination as the dependent variable and hdi level as the independent variable a second anova analysis was conducted with experienced workplace discrimination as the dependent variable and hdi level as the independent variable for the first and second research questions answers to the questions on anticipated and experienced workplace discrimination were dichotomised into no and yes for the third research question multivariate logistic regression analysis was performed using work status as the dependent variable and 10 independent variables including experienced workplace discrimination first univariate analyses were conducted including the following independent variables that were expected to be related to job outcome experienced workplace discrimination gender age ethnicity level of education marital status previous psychiatric treatment age of first contact with mental health services internalised stigma and hdi second all variables that showed a significant relationship with the dependent variable on a univariate level were included in the multivariable logistic regression analysis results a total of 834 people with mdd across 35 different countries were individually interviewed for this study about half of all participants were married or cohabiting and twothirds of the participants were women characteristics of the sample are shown in table 1 although there were differences in employment rate across sites the employment rates per hdi group did not differ significantly as shown in table 2 for each separate question about 4050 of the participants indicated that discrimination was not a problem for them however when looking at the four items combined about twothirds of the total sample reported anticipated andor experienced discrimination in the work setting due to their mental health problem almost onethird of participants indicated to have stopped themselves from applying for work because of anticipated discrimination regarding the second research question significant differences were found between the groups with different hdi levels specifically participants in countries with a very high hdi reported significantly more often anticipated p 001 and also experienced p 005 discrimination than participants in countries with moderatelow hdi as can also be seen from figure 1 in all three groups the anticipated workplace discrimination scores were higher than the experienced workplace discrimination scores concerning the third research question as can be seen in table 3 several variables were not related to work status on a univariate level for which reason they were not included in the multivariable model results from the multilevel logistic regression analysis showed that experienced workplace discrimination was independently and positively related to unemployment other variables that were significantly related to unemployment were low educational level and having ever been admitted to psychiatric treatment discussion the results of this study show that as many as 625 of participants reported having anticipated andor experienced discrimination in the work setting anticipated workplace discrimination was reported more often than experienced workplace discrimination participants from countries with a very high hdi reported significantly more often anticipated and experienced workplace discrimination although even in the mediumlow hdi group about onethird of participants reported discrimination in the work setting regarding the third research question it was found that experienced workplace discrimination was indeed independently related to unemployment these findings show that discrimination in the workplace is a common problem in many countries worldwide considering that inpatients were excluded from the study for the total group of people with mdd these percentages may even be much higher these findings are consistent with those of a recent review 21 and 19 †total score on the internalised stigma of mental illness scale 20 scale ranges from 1 to 4 with higher scores indicating higher internalised stigma ‡combination of would like to work but afraid to loose benefits unable to work choose not to work that of a large australian study on the experiences and perspectives of people with mdd 22 here participants indicated that stigma was a considerable problem particularly regarding employment in a similar german study 815 of the 55 participants who had experienced a depressive episode anticipated stigmatisation in the occupational setting 23 these studies from the depressed individuals perspective are in line with results of studies from employers perspectives such studies have shown that employers tend to have negative attitudes towards people with mental health problems 5 6 7 an important finding of this study was that participants anticipated workplace discrimination more often than they had actually experienced it in another study uçok et al 8 found that anticipated discrimination was not necessarily associated with experienced discrimination similar to our results angermeyer et al 23 also found anticipated discrimination to be higher than experienced discrimination and suggested that it could result in a tendency to avoid situations with a high risk of stigma corrigan et al 24 described this why try effect as an overarching phenomenon encompassing selfstigma followed by low selfesteem and selfefficacy and a diminished behaviour to pursue life goals however not only people with mental ill health themselves anticipate to be discriminated in the workplace a recent populationbased survey of working adults in canada showed that a third of workers would not tell their managers if they experienced mental health problems mostly out of fear of damaging their careers 25 hence findings from these studies and this study underline the clear need for interventions focusing on the empowerment of people with mdd in the work environment peer support plays an important role in enhancing empowerment and decreasing selfstigma 20 and may be useful in such programmes since mental health problems are highly prevalent 13 26 but people with these disorders are often reluctant to disclose their condition 21 22 27 28 employers usually are not aware of the fact that many of their employees have mental health problems although this is a major impediment for work adaptations authors of a recent vignette study concluded that concealment of mental health problems may actually be wise as employers tended to think more negatively about a worker with depression than with a physical disorder under the exact same circumstances 29 recently several studies have been conducted on the topic of disclosure of mental illness in the workplace 21 27 28 30 for instance a decision aid for employees on whether or not to disclose their mental health problems to an employer has been developed 31 32 which has been shown to effectively reduce decisional conflict in employees with mental health problems 31 the findings of the present and other studies 21 25 suggest that future programmes aimed at reducing stigma and discrimination should also involve stakeholders from the environment such as employers and occupational health professionals as they play a major role in for instance whether or not temporary workplace reasonable adjustments or accommodations are made boot et al 33 showed that workplace adjustments are associated with a reduction in sick leave duration and that 43 of workers with mental health problems reported a need for work adjustments the results of this study indicated that in very highly developed countries significantly higher percentages of workplace discrimination were reported as compared to countries with a lowmedium developmental score these findings differ from those of an intercultural study on employers attitudes towards hiring and accommodating a person with disabilities at work 10 here it was found that chinese employers were less likely to endorse hiring people with psychiatric disabilities than employers from the usa or hong kong however it should be noticed that within one hdi group many different countries and cultures are represented which limits generalisability whereas the size of this study including 35 countries is a considerable strength the number of people interviewed per country was too small to draw any conclusions at country level nevertheless the results indicated that even in countries with a medium to low developmental score about onethird of participants reported discrimination in the work setting future research should focus on differences between countries and study for instance the effects of legislation however legislation will not entirely solve the problem as legislation does not address selfstigma and also in countries with more advanced equality legislation experienced workplace discrimination rates were still high we also found that experienced workplace discrimination was significantly related to unemployment these findings are similar to those of a large household interview survey in six european countries specifically they found that in participants with a mental health problem perceived stigma was significantly associated with being unemployed as well as with a decreased quality of life higher work and role limitations and higher social limitations 34 an explanation for the finding that experienced workplace discrimination was independently related to unemployment is that the social stigma attached to mental health problems among employers may hinder them from hiring an employee with mdd 11 29 alternatively this finding may be explained by the fact that during job interviews applicants with mdd may not get the position because mdd is characterised by a variety of symptoms that may be disadvantageous during job interviews such as markedly diminished interest in activities impaired ability to think concentrate or make decisions fatigue increased irritability and low selfworth 20 these symptoms may influence both applicants verbal and nonverbal behaviour thereby diminishing their chances of being appointed when considering the results of this study several limitations need to be taken into account first apart from the four items on the disc questionnaire that measured anticipated and experienced workplace discrimination little additional information was available on how participants perceived their work setting and why they felt discriminated future qualitative and longitudinal studies are needed to address this in more detail focusing on the role of stakeholders such as supervisors employers colleagues and occupational health professionals a second limitation is that the design of the study was crosssectional for which reason no causality can be assumed hence workplace discrimination may lead to unemployment but unemployment may also lead to feelings of being discriminated against third purposive sampling was used to recruit participants this limits the generalisability of the results as participants do not necessarily represent true prevalent cases in the community in conclusion the results suggest that anticipated and experienced discrimination in the workplace is a highly common phenomenon in higher as well as in lower developed countries across the world the topic of overcoming stigma and discrimination has been underresearched so far 35 but may offer new ways to improve work participation of people with mdd in many countries mental health problems such as mdd are associated with high costs for society due to unemployment absences and atwork performance deficits 36 37 38 previous studies have called for research addressing workplace environment issues to improve work participation of people with mdd 36 38 stigma and workplace discrimination are such issues and there is a clear need for effective interventions 2024 by guest protected by copyright bmj open first published as 101136bmjopen2015009961 on competing interests none declared patient consent obtained ethics approval the study was approved by the appropriate ethical review board at each study site provenance and peer review not commissioned externally peer reviewed data sharing statement no additional data are available open access this is an open access article distributed in accordance with the creative commons attribution non commercial license which permits others to distribute remix adapt build upon this work noncommercially and license their derivative works on different terms provided the original work is properly cited and the use is noncommercial see creativecommonsorglicensesbync40

objective whereas employment has been shown to be beneficial for people with major depressive disorder mdd across different cultures employers attitudes have been shown to be negative towards workers with mdd this may form an important barrier to work participation today little is known about how stigma and discrimination affect work participation of workers with mdd especially from their own perspective we aimed to assess in a working age population including respondents with mdd from 35 countries 1 if people with mdd anticipate and experience discrimination when trying to find or keep paid employment 2 if participants in high middle and lower developed countries differ in these respects and 3 if discrimination experiences are related to actual employment status ie having a paid job or not method participants in this crosssectional study n834 had a diagnosis of mdd in the previous 12 months they were interviewed using the discrimination and stigma scale disc12 analysis of variance and generalised linear mixed models were used to analyse the dataoverall 625 had anticipated andor experienced discrimination in the work setting in very high developed countries almost 60 of respondents had stopped themselves from applying for work education or training because of anticipated discrimination having experienced workplace discrimination was independently related to unemployment conclusions across different countries and cultures people with mdd very frequently reported discrimination in the work setting effective interventions are needed to enhance work participation in people with mdd focusing simultaneously on decreasing stigma in the work environment and on decreasing selfdiscrimination by empowering workers with mdd

19549_0

background climate change is the greatest threat to global health in the 21st century rising sea levels are one particularly concerning manifestation of this many of the worlds largest cities are vulnerable to sea level rise thus urban climate adaptation and mitigation policies are vital to protect population health this study aimed to assess the drivers of citylevel climate action to guide ongoing efforts to motivate climate action assess public health preparedness and identify research gaps methods this is an ecological crosssectional study that combined secondary data from cdp the urban climate change research network the world bank and united nations cities the study population consisted of 517 cities that participated in cdps 2019 cities survey multivariable logistic regression was utilized to assess the relationship between the risk of slr and climate action and to assess the wider determinants of climate action citylevel climate action was represented by three outcome measures a climate risk assessment an adaptation plan and a mitigation plan results there were crude associations between the risk of slr and completion of a risk assessment having an adaptation plan and having a mitigation plan in the adjusted analysis these crude associations disappeared world region national income status and population were shown to be independent predictors of climate action conclusions cities that are at risk from future slr are not more likely to be undertaking climate action relative to cities that are not at risk this could indicate that urban governance is unaware of the risks posed by slr and climate change key messages it is concerning for population health that there was no association shown between risk of slr and climate action to fulfil their health protection responsibilities it is essential that public health practitioners take a leading role in advocating climate action background reducing greenhouse gases emissions requires drastic changes in dietary patterns notably reducing meat consumption as the process of change can be experienced as stages we might wonder what actual changes in dietrelated ghge result from each stage of meat reduction we therefore aimed to describe levels of dietrelated ghge and their change over time according to the individual readiness to reduce meat consumption methods food consumptions of 13635 nonvegetarian french adults participating in the nutrinetsante ´cohort were assessed using a food frequency questionnaire at two time points in 2014 and 2018 dietrelated ghge were assessed using life cycle assessment a questionnaire in 2018 allowed us to characterize participants by their level of readiness to reduce meat consumption using the stages of change from the transtheoretical model precontemplation contemplationpreparation action maintenance energyadjusted dietrelated ghge were compared according to stages in 2014 and 2018 using ancova and compared over time using student test dietary intakes and their contribution to dietrelated ghge were also described results individuals in the maintenance stage had the lowest dietrelated ghge with an average of 373 kg co2eqday in 2018 representing a difference of 26 compared to the precontemplation stage only participants in the action and the maintenance stages decreased their dietrelated ghge over time specifically ghge from ruminant and monogastric meat decreased over time for the last two stages while their ghge from cheese increased conclusions the last two stages of meat reduction resulted in a reduction of dietrelated ghge as this reduction is not sufficient to meet ghge reduction objectives further efforts are needed and new levers combined with public health guidelines must emerge to enhance the transition key messages individuals with higher readiness to reduce meat consumption actually reduce their overall ghge mostly due to reduced consumption of ruminant meat but also pork and poultry observed reduction in dietrelated ghge is not yet sufficient to meet ghge reduction objectives and further efforts are required 4f workshop supporting present policy making to address future challenges foresight and public health policies abstract citation id ckad160235 organised by euphafs chair persons henk hilderink claudia habl contact the covid19 pandemic and its impact on health showed that we were not prepared for uncertain health events and its uncertain consequences and impact in society to be prepared for the uncertainty of the future foresight provides a systematic participatory and visionbuilding process that explores the future to anticipate trends and support presentday actions foresight explores possible futures and their impact on society and population health foresight can enable better informed presentday decisionmaking and thereby better shortterm and longterm preparedness in european union member states and the european region for possible future health crises with foresight experts and policy makers can explore longterm decisions that need to be made in the present to be prepared for the future using foresight to formulate longterm decisions can allow setting priorities planning budgets and spending to address health threats and challenges and learning how to cope with challenges while keeping resilient and sustainable health systems in this workshop we will focus on how foresight can be integrated into the policy cycle to support policy makers to be prepared

the highest daly rate per 100000 ischemic strokes was in bulgaria 701681 followed by north macedonia 577340 montenegro 511961 and georgia 496742 the highest daly rate attributable to air pollution was in north macedonia 146261 followed by bulgaria 124013 montenegro 105221 and serbia 103741 the highest percentage of ischemic stroke attributable to air pollution was in bosnia and herzegovina 2566 north macedonia 2532 serbia 2123 and montenegro 2055 air pollution is a significant contributable factor in the prevalence of ischemic stroke in observed countries more than 20 of the ischemic stroke burden is attributable to air pollution the highest daly rate attributable to air was in balkan countriesthe highest daly and the highest percentage of ischemic stroke attributable to air pollution were in balkan countries there is an emerging need for public health regulations and policies in order to reduce air pollution and stroke

19550_0

older adults who experience chronic pain face many challenges from their illness which can affect their personal and healthcare relationships research indicates the importance of relationships on health and quality of life outcomes in older adults with cp however minimal research has explored their perspectives on the relationships they have with their healthcare providers healthcare system their cp and familyfriendscommunity objective to understand how older adults cp impacts their relationship with the healthcare system and how older adults cp impacts their personal relationships methods adults 50 years of age with pain were eligible to enroll in virtual focus groups andor interviews audio recordings were transcribed coded and analyzed via a mixed inductivedeductive framework approach using atlasti microsoft descriptive statistics were performed using stata 16 results sixteen participants participated in a focus group or an interview participants identified as white female and were between the ages of 5564 years old most participants held an associates degree or higher and reported private medical insurance coverage sessions lasted between 3090 minutes participants described complex relationships that could have positive or negative impacts on their ability to manage their cp and their overall quality of life relationships explored included the healthcare system clinician family other patients and cp discussion the relationships of older adults living with cp are multidimensional and can support or adversely affect pain management mental health and quality of life utilizing geographic information system techniques and a composite index this project delves into the intricate geographic patterns of property tax burdens in pennsylvania with a specific focus on older residents contemplating aging in place amidst limited financial resources the study scrutinizes various factors including property tax rates home values income demographics and other housingrelated variables to comprehensively grasp their effects on the financial feasibility of aging in place pennsylvania displays notable disparities in property taxes averaging approximately 15 of home value across counties due to distinct assessment systems and varying assessedtomarket ratios tax rates are also influenced and specified by smaller administrative and geographic entities including municipalities and school districts despite alternatives aging in place remains the preferred choice for most older americans this accentuates the significance of assessing property tax affordability that facilitates potential aging in place particularly for financially constrained but healthy seniors who may not qualify for tax rebates or local freezes moreover escalating housing prices and assessed values further emphasize the urgency cartographic and tabular findings from the study unveil challenging situations for seniors in specific county clusters of pennsylvania encompassing not only expensive urban but also typically affordable rural settings additionally areas with the highest tax rates are not always the most financially burdensome with all other factors taken into account this study offers practical insights that have the potential to inform adjustments in housing and tax policies aimed at benefiting older adults in pennsylvania florida united states

ageism continues to impact healthcare professionals attitudes toward older adults older adults are often assumed to be frail weak or a burden on society addressing ageist attitudes and myths about ageing which often lead to discrimination can impact policy decisions knowledge of opportunities available to older adults to increase healthy ageing is vital in any healthcare training program recognizing the growing needs to prepare health professionals to work with the increasing numbers of diverse older adults this research survey conducted for the college of health and human sciences chhs to examine the students attitudes and perceptions of ageing interest in ageing careers knowledge gaps in ageing and ageing topics of interest this survey resulted in 141 respondents who helped provide an informed baselines of chhs student misconceptions about ageing baseline of learning needs and topics and practice opportunities of interest this poster will share the unique results of this survey providing insight into students attitudes and perceptions on ageing additionally this poster will provide a brief picture of the colleges response to the survey including curriculum development and systemic changes

19551_0

i introduction conventional wisdom regarding marriages between older men and younger women assumes that financially successful men have the advantage of being able to attract and retain younger partners recent discussion of cougars older women paired with younger men likewise suggests that the improving economic status of women has freed them to partner with younger men economic models of age of marriage and marital age gaps mostly generate similar predictions that pairings between an older and younger spouse require financial success on the part of the older partner in direct contrast this paper presents robust empirical evidence of negative selection into differentlyaged couples in national longitudinal survey of youth 1979 cohort data men and women married to differentlyaged spouses have lower cognitive skills scores compared to those with similarlyaged spouses in census data men and women with differentlyaged spouses have lower educational attainment and conditional on educational attainment work in lowerwage occupations and have lower annual earnings finally in the national longitudinal study of adolescent health men and women with differentlyaged spouses received lower ratings of physical appearance in high school1 ii marital age gap and cognitive ability the nlsy79 is based on annual surveys of men and women who were 1421 years old on january 1 1979 this analysis uses data on first marriages through 2006 in 1980 nlsy79 respondents took a cognitive skills test that produced armed forces qualifications test scores this cognitive skills measure is collected sufficiently early in the lifecycle that it is unlikely to be endogenous to marriage market outcomes a prevalence of differentlyaged couples the first two columns of table 1 report the distribution of withincouple age difference from the 1960 and 2000 integrated public use microdata series data using samples of married couples ages 2560 we measure the age difference as the mans age minus the womans the category 8 or more contains couples in which the man is at least 8 years older than the woman and the category 8 or more contains couples in which the man is at least 8 years younger than the woman marriages between older men and younger women have become less common over time while marriages between older women and younger men have slightly increased the remaining columns of table 1 provide unweighted descriptive statistics from the nlsy79 column 3 reports the distribution of age difference for our sample of first marriages columns 4 and 5 report mean afqt scores by age difference separately for males and females mean afqt scores decline with age difference regardless of whether the man is older or the woman is older b regression analysis the regression specification is afqt i β 0 ∑ j 1 6 β j agedi f f i j α 1 hs i α 2 coll i α 3 adv i α 4 agemarr i α 4 agemarr i 2 race i α 5 yrbirth i δ ε i agediff is a vector of 6 indicator variables for the categories of age difference from iiii marital age gap and education occupation and earnings analysis of education and labor market outcomes is conducted using the 1980 1970 and 1960 censuses data from these years contain controls for age of marriage and number of marriages which are absent in later census years analysis is conducted separately for men and women using samples of married couples ages 2560 the male regressions are estimated only using men in their first marriage and the female regressions are estimated only using women in their first marriage for education outcomes the logit model is specified as log pr y i 1 pr y i 0 β 0 ∑ j 1 6 β j agedi f f i j race i α 1 α 2 agemarr i α 3 agemarr i 2 spousemarrno i α 4 ∑ a 1 a γ a age ia ∑ s 1 s ϕ s state is ∑ s 1 s ψ s state is urban i where y is either an indicator for high school completion or college completion agediff race and agemarr are the same as defined in equation spousemarrno contains indicators for spouse previously married one or two or more times age contains singleyear age indicators there are state fixedeffects and state fixedeffects interacted with an urban indicator2 to test average hourly earnings in occupation conditional on education the regression is occearn i β 0 ∑ j 1 6 β j agedi f f i j race i α 1 α 2 agemarr i α 3 agemarr i 2 spouse marrno i α 4 ∑ a 1 a γ a age ia ∑ a 1 a δ a age ia hs i ∑ a 1 a η a age ia coll i ∑ a 1 a λ a age ia adv i ∑ s 1 s ϕ s state is ∑ s 1 s ψ s state is urban i ε i where occearn is average earnings per hour in individual is occupation γ a δ a η a and λ a trace out a flexible ageearnings profile for each level of educational attainment 3 samples of fulltime workers in the 1980 1970 and 1960 censuses are used to calculate average hourly earnings by occupation using 3digit soc codes 4 these are calculated separately by sex college education and 10year age interval and are matched to each individuals report of occupation in most recent job in the past five years5 individuals who have not worked in the past five years are excluded from the analysis 6 column 1 of table 3 reports the marginal effects from equation for high school completion marginal effects are calculated as the difference in predicted probability between an agedifference category and the omitted category with control variables set at sample means for both men and women in all census years individuals married to differentlyaged spouses whether older or younger are less likely to have a high school degree column 2 shows that among high school graduates individuals married to differentlyaged spouses are less likely to have completed college in results not reported here we obtain very similar estimates using the 1990 and 2000 census data7 column 3 of table 3 reports the occupational wage results using equation for men all of the agedifference categories have lower occupational wages relative to the omitted similarlyaged group and the wage gap increases with age difference the results likewise show that women with differentlyaged spouses tend to work in lower wage occupations than women married to similarlyaged spouses column 4 of table 3 reestimates equation using individual earnings observations with zero earnings are included and we estimate a standard tobit model 8 men married to differentlyaged spouses have lower earnings and the effects are again surprisingly symmetric between men married to younger and older women women married to older men earn more than women married to similarlyaged husbands despite the fact that they do not work in higherearning occupations additional analysis available in the online appendix shows that these higher earnings are largely generated by higher hours of work not by higher wages these higher hours of work likely reflect the fact that these women married to older men on average have lower fertility and lowerearning husbands estimates from equation using the 1990 and 2000 censuses are consistent with those in table 3 and available in the online appendix iv marital age gap and physical appearance the national longitudinal survey of adolescent health is a longitudinal study of a nationally representative sample of adolescents in grades 712 during the 199495 school year there have been four waves of interviews the most recent in 2008 when the sample was aged 24329 measures of physical appearance and body mass index recorded in the first round of the data predate entry into marriage eliminating any concern about endogenous responses to marriage market outcomes interviewers rated the respondents appearance on a scale from 1 to 5 where 5 is very attractive we use a binary indicator for attractive equaling 1 for ratings of 4 or 5 roughly 45 of men and 60 of women in the sample are rated as attractive bmi is also used as an appearance measure the control variables are the same as those in equation a logit model is used for the attractive indicator both models are weighted using wave 4 grand sample weights the first column of table 4 reports marginal effects for the attractive appearance rating10 individuals married to differentlyaged spouses are less attractive with the possible exception of men married to older women the estimates are only statistically significant for those in older manyounger woman marriages the bmi estimates in column 2 suggest that women married to differentlyaged husbands had higher bmi in high school than those married to similarlyaged husbands v discussion the disagreement between our results and the theoretical literature cannot be resolved solely by changing the specification of preferences from a preference for younger partners to a preference for similarlyaged partners if individuals prefer similarlyaged spouses then both highquality and lowquality individuals should match with similarlyaged spouses there is no way to explain why lowerquality individuals fail to match with similarlyaged spouses unless they are harder to meet we suggest that higher quality individuals spend more time in agehomogenous settings at ages when marriages most often form they spend more years in school and are more likely to attend highquality postsecondary schools with agehomogenous student populations when they enter the workforce they are often in jobs with high upward mobility so that other individuals who share their same job description are similarlyaged in contrast lower quality individuals receive fewer years of education and attend more ageheterogeneous postsecondary institutions lower quality individuals tend to work in occupations with limited upward mobility producing greater age variation among coworkers while we are not able to formally test this mechanism we confirm several empirical facts that are consistent with this mechanism first in general social survey data from 1985 and 2004 we find that individuals with lower educational attainment have more agediverse social networks second we find that the relationship between marital age gap and afqt scores is weaker for those who marry at later ages when this mechanism is likely less important the same is true for the relationship between marital age gap and occupational wages third consistent with the presence of job ladders we confirm that higher wage occupations have less age heterogeneity in a given wage decile finally we confirm that age dispersion in individuals own job is positively related to age gap with spouse these results all appear in the online appendix in marriage models education and occupational wage have traditionally affected matching through the marital surplus our findings suggest they may also affect matching through the social interactions they facilitate by changing the set of prospective mates with whom one interacts at lowest cost supplementary material refer to web version on pubmed central for supplementary material

in direct contrast to conventional wisdom and most economic models of marital age gaps we present robust evidence that men and women who are married to differentlyaged spouses are negatively selected empirical results show lower cognitive ability lower educational attainment lower occupational wages lower earnings and less attractive appearance among those married to a differentlyaged spouse these results obtained using samples of first marriages and controlling for age of marriage are consistent with a model in which individuals with more schooling and more upwardlymobile occupations interact more heavily with similarlyaged peers and are ultimately more likely to marry similarlyaged spouses

19552_0

of some degree substantially higher than the rate in other highincome countries 7 most of which is conductive hearing loss these figures may be influenced by high rates of otitis media observed in populations in australia with limited access to healthcare including aboriginal and torres strait islander children a retrospective study of ear and hearing screening data conducted between 1998 and 2004 in three primary schools in western australia showed that up to 42 of aboriginal children living in urban areas had middle ear disease and 191 of all children exhibited hearing loss 8 more than double the rate in the nonindigenous population 9 prevalence risk of middle ear disease and hearing loss typically increases with remoteness however a comparative study of 408 urban and 438 regional aboriginal primary school children from western australia showed evidence of om in 307 of the urban cohort and 155 of the regional cohort 10 other studies have shown that up to 91 of aboriginal children living in very remote areas have a middle ear abnormality 11 the recently launched world health organization world report on hearing 12 recommends that all countries implement school screening programs to ensure throughout a childs early years undetected hearing loss during the critical period of neurocognitive development can have significant consequences for their speech and language development educational achievement and neurocognitive and socialemotional growth 1 2 3 newborn hearing screening programs can reduce the burden of congenital hearing loss on the individual and society by mitigating many downstream effects 4 however approximately half of childhood hearing loss remains undetected by such programs 5 either because of the insensitivity of the test in detecting milder forms of hearing loss or because of progressive or infectionrelated hearing loss australian data showing the age of first hearing aid fitting of children with permanent hearing loss support this two predominant peaks can be seen 1 within the first year of life attributed to the success of newborn hearing screening and 2 a broader peak observed across the early educational years a recent systematic review estimated that 34128 of australian primary school children have hearing loss • stronger partnerships across health and education can support children with hearing loss and those at risk of hearing loss there were no differences between those from nesb and those with english as a first language between the aboriginal population and nonaboriginal population or between those who resided within or outside a major city quarter of the year in which they were tested is shown in table 1 introduction referral pathways referrals for health checks were managed centrally by the charitybased organisation to ensure that all results where a child did not pass were integrated into a single referral before they were sent to the childs general practitioner family andor other health providers referral pathways for hearing and middle ear checks were as follows 1 children with middle ear dysfunction who did not pass the hearing screen were directly referred to their gp and advised to have a full audiological assessment after medical review of middle ear function 2 children with normal middle ear function who did not pass the hearing screen were directly referred to hearing australia and 3 children with middle ear dysfunction who passed the hearing screen were provided with a letter to their gp requesting a medical review of middle ear function study design audiometric screenings were administered by postgraduate audiology students under the direct supervision of a professionally accredited audiologist screenings were conducted in two quiet rooms within the centre and noise levels were recorded daily using a sound level meter levels were consistently lower than the maximum sound pressure levels allowable for background noise in audiometric rooms a hiene mini 3000 otoscope and an interacoustics titan middle ear analyzer tympanometer were used to conduct otoscopy and tympanometry an interacoustics ad629e audiometer and passive attenuating sennheiser hda200 headphones were used for audiometry results for otoscopy were qualitatively recorded the normative values used for tympanometry were adapted from jerger classification guidelines for adults that is ear canal volume of 052 cm 3 static compliance 0218 cm 3 and middle ear pressure 150 dapa a screening level of 20 decibels hearing level was selected for audiometry and the tested frequencies were 500 1000 2000 and 4000 hertz each child was presented with an initial 60 db hl tone followed by a 40 db hl presentation and three consecutive 20 db hl presentations at each frequency in each ear a pass was defined when the child responded correctly to two of the three presentations at 20 db hl at all tested frequencies in both ears if the child failed to respond to the two screening presentations at any frequency their threshold was determined using the standard hughsonwestlake technique children were deemed to have failed screening audiometry if their threshold exceeded 20 db hl at any frequency in either ear early detection of ear disease and hearing loss the current absence of these programs can be attributed to the costs associated with administering screening programs and the relative perceived benefit of newborn hearing screening programs already in place in many highincome countries 1314 universal preschool or schoolbased hearing screening programs may not be economically viable and may be logistically burdensome in highincome countries such as australia 15 however targeted screening of populations with lower levels of socioeconomic advantage may provide a more costeffective approach to identifying hearing loss and middle ear dysfunction where the risks of these conditions are high 16 certainly there is an unequal burden of ear disease and hearing loss in children from lower socioeconomic settings 17 the combination of increased prevalence and increased cumulative duration of living with middle ear disease is likely to pose significant risks for educational outcomes for example aboriginal children up to 14 years of age experience cumulative middle ear disease for approximately 2 years across their lifetime compared with approximately 2 months for nonindigenous children 9 australian bureau of statistics data 18 show that in 2018 aboriginal children made up 59 of the total child population and about 1 in 5 of all children lived in the lowest socioeconomic areas targeted solutions can alleviate the social and economic burden for individuals their families and society this retrospective study aimed to determine the risk of middle ear dysfunction and not passing a hearing screening test in 2489 schoolage children attending a charitybased program providing health and wellbeing services for underserved populations method discussion to better understand the factors associated with risk of failing an ear and hearing screening program we assessed 2489 children as part of an integrated health check for children from underserved populations the results suggest that middle ear dysfunction is more likely to occur in younger children and that there is seasonal variation with a higher risk of failing hearing screening and having middle ear dysfunction in the later quarters of the year this has implications for targeting resources for ear and hearing screening to maximise opportunities to address ear disease and hearing loss as soon as possible particularly in populations with lower socioeconomic advantage although relatively few studies have assessed outcomes of school ear and hearing screening programs in australia compared with other highincome countries results of the current study are in line with three other australian studies 7 minor differences between the studies in the pass fail rates of hearing screening are likely to be attributable to differing screening test levels with failure rates decreasing with an increase in threshold levels used to define the passfail criteria for referral for hearing loss similarly differences in rates of middle ear dysfunction between the current study and those conducted previously in australia 179 20 statistical analysis frequencies means and proportions were calculated to ascertain the characteristics of the study sample multinomial logistic regression was used to investigate risk factors for two ear conditions hearing loss and middle ear disease one outcome variable with three levels was used in the analysis the levels were passed and hearing loss or middle ear dysfunction with passed being the reference category the predictor variables were entered in one step with continuous variables entered as factors and categorical variables as covariates odds ratios 95 confidence intervals and p values were calculated for each predictor variable all statistical tests were two tailed with alpha 005 statistical analyses were performed using ibm spss version 26 conclusions om and hearing loss are more prevalent in populations with lower levels of social and economic advantage including those living in rural or remote areas first nations populations and lowincome households 17 even mild hearing loss often not detected by parents but the most common hearing loss resulting from om 30 is associated with educational risk 31 coupled with other risks of poorer educational outcomes in these populations om increases the likelihood of reduced early educational outcomes 32 the impact of the coronavirus disease 2019 pandemic in disrupting classroom learning may widen the gap in the future school hearing screening programs can effectively identify those with middle ear disease and hearing loss early although the costeffectiveness of rolling out such programs across a population remains debated and poorly understood 33 nonetheless targeting opportunities for middle ear and hearing screening based on the increased educational risks of an individual or a population attending a school in an area at increased risk of educational disadvantage could reduce the costs of implementing screening programs programs could be provided for children in the early years of schooling such as preschool or the beginning of primary school targeted screening programs could be further improved by giving teachers information about how to detect a child at risk and when the risk of middle ear disease and hearing loss is greatest enabling greater opportunities for putting in place surveillance and educational supports for screening or surveillance programs to be effective a robust pathway to care must exist so that children who are detected with ear and hearing problems have an accessible pathway to treatment and the necessary support strengthened partnerships across health and education are important to support a child with hearing loss or at risk of hearing loss from middle ear disease schools can optimise a childs access to learning with costeffective supports including priority seating at the front of the classroom behavioural management strategies to reduce classroom noise and classroom amplification systems scaffolding childhood development in the early years provides significant benefits to the individual the family and society peer review and provenance externally peer reviewed invited cmm is a guest editor of this themed issue of public health research practice she had no part in the peerreview process for this paper competing interests none declared of those tested vary across studies however similar estimates have been observed elsewhere for example crosssectional populationbased findings from the 20122013 canadian health measures survey showed that 77 had any hearing loss 22 a systematic review of children with hearing loss 25 db hl from the us showed that the average prevalence of any hearing loss was 31 ranging from 17 to 55 23 with increasing prevalence for lowerincome households a crosssectional survey of primary school students in zimbabwe with screening thresholds of 30 db hl showed a prevalence rate of 24 with sensorineural hearing loss found in 10 of children 24 in this study age was a significant predictor for the middle ear dysfunction group lower rates of middle ear dysfunction were seen with increasing age consistent with previous studies 1722 this may be a function of the downwards shift in the orientation of the eustachian tube with age which increases the efficiency of drainage of the middle ear for example a study conducted in iran compared conductive hearing loss rates in school children in grades 15 and the results revealed a decrease in rates with an increase in grade level 25 on the other hand in the current study age was not a predictor for hearing loss a similar finding was demonstrated in a population of schoolage children in the solomon islands 26 although other studies have found an association between younger age and hearing loss 527 seasonal differences in middle ear disease are consistent with previous studies which have revealed higher rates of middle ear dysfunction in winter and spring months 27 higher rates of om have been identified in winter because of the association with colds and other respiratory infections and higher rates of om abnormal middle ear pressure and eustachian tube dysfunction have been identified in spring because of the increase in hayfever and pneumonia cases 28 it is important to note that there was no difference in risk between those who selfidentified as aboriginal and nonaboriginal children the risk of middle ear disease is associated with social determinants of health and is therefore higher in indigenous children refugees children in remote areas and those in lowincome countries 1517 within australia region was not identified as a predictor for either hearing loss or middle ear dysfunction however the assessment of remoteness was broadly categorised and based on schools locations rather than the location of the childrens homes which is a limitation of the current study further limitations include the lack of information about other exposure factors for children such as exposure to cigarette smoke and overcrowding that may be associated with higher rates of middle ear disease and hearing loss 29 although icsea data was missing for 347 of 2489 participants the very tight confidence intervals suggests that this would probably not significantly affect the outcomes ethics approval parental consent was obtained for all children to complete hearing screening as part of a general health check because of the retrospective analysis direct parental consent for children to participate in this study was waived and the project was approved by the macquarie university human research ethics committee results participants comprised 2489 children aged 55174 years of these 273 identified as aboriginal and 9 were from nesb when reported participants were generally from belowaverage socioeducational advantage schools median icsea value was 9570 50 of the schools that children attended had icsea values in the range 528957 icsea values are calculated on a scale that has a median of 1000 and an sd of 100 icsea values typically range from approximately 500 to about 1300 19 approximately 58 of children were from a major city similar numbers of children were tested during three of the quarters of the year a higher proportion was tested between july and september of the 2489 children tested more than 40 did not pass the hearing screening assessment participants were grouped into three subcategories based on their results 1 pass 2 did not pass hearing screen with or without middle ear dysfunction and 3 current middle ear dysfunction alone overall 285 children did not pass the hearing screen and 719 presented with middle ear dysfunction alone in the multinomial logistic regression model

• understanding the risk of hearing loss in socioeconomically disadvantaged children can enable earlier targeted and more effective care • a retrospective study of school children from atrisk populations found that higher risks of middle ear dysfunction were associated with younger age and seasonal variation • targeted screening programs can identify hearing loss during critical learning years mitigating longerterm educational social and mental health outcomes

19553_0

than a decade after he made this observation the he systems of ceec have undergone extensive reforms linked to their integration into the bologna process in the educational sector the ceec have been subjected to the assistance programmes of various international organisations including ones with a mandate to monitor educational policies and others that have progressively gained authority in this area 2 this article analyses the selective uses of bologna process principles of recommendations of the european commission and of the abovementioned ios in domestic policymaking it will focus on issues relative to he governance and structure diversification of hei and funding but also on national qualification frameworks as all these elements have been considered as important preconditions for quality improvement in both the polish and ukrainian cases the reform and modernization of higher education were considered as indispensable elements to improve the position of the domestic system on the global educational market the idea according to which universities should be competitive acquires a double meaning first it refers to the global academic competition for students and academic rankings secondly it triggers pressure among domestic universities which have to fight more fiercely to attract students in a context of demographic decline and to gain a better position in the domestic academic categorizationrankings which may be vital for their funding the article shows that combined external and domestic pressures affect higher education systems in multiple and sometimes contradictory ways on the one hand european processes such as the building of a european higher education area provide opportunities to domestic reformers on the other the polish and ukrainian case studies remind us that the political configuration should be taken into account at the domestic level ultimately the announced diversification of hei appears as a longerterm process whose outcome remains uncertain in sum europeanization and internationalisation are neither uniform nor linear processes poland and ukraine differ in their sociopolitical background both countries have followed different historical trajectories and their democratisation processes have varied in timing poland deliberately turned to the west after 1989 whereas ukraines geopolitical situation has remained more complex since its independence in 1991 ukraine has been marred by political instability with several governmental crises followed by a serious economic crisis in 2009 more dependent on the russian market ukraine finally signed an association agreement with the eu in 2014 albeit at a very high political cost as the russian annexation of crimea and the war in the separatist eastern territories followed the maïdan revolution triggered by president yanukovychs refusal to sign the agreement these differences notwithstanding the polish and ukrainian cases exemplify the impact of external recommendations and of domestic political power relations in he policymaking despite their heterogeneous research and he systems it is possible to identify three rough patterns that go some way towards explaining the potential receptiveness of ceec to external advice first they share a communist past with a high degree of centralisation ideological structuration of higher education curricula and a sovietinspired distinction between research and teaching yet these systems differed in many ways for example regarding the access to he some countries like the czech republic or poland were able to rely on their interwar democratic experience and their acquaintance with the humboldtian model of research university autonomy the second pattern is the shared experience of postcommunist transformation increasing these countries receptiveness to foreign assistance and international recommendations the 1990s were a time of exposure to neoliberal reforms applied to the economic sector but also to sectors such as education or health leading to a farreaching privatisation of the public sector a third development that affected countries in the region unequally is the process of eu accession in this respect a distinction must be made between the countries which have completed the negotiation process and accessed the european union and those which have stayed out of it the timing of the bologna process launch explains why many policymakers from the new eu member states tended to consider its successive recommendations as part of a more general eu package the eu accession process involving conditionality and the allocation of financial resources has had a noticeable impact on he policies this contribution argues that the transformation process supported by international and european organisations has affected he institutions i investigate how definitions of the university objectives promoted by international and european organisations in terms of competitiveness and internationalisation are used in domestic contexts while this trend has been well documented in western countries in some countries of central and eastern europe it has taken a distinct form due to the limited timespan of the implementation of reforms and the differential perceptions of western academic models instead of reducing complex he reforms to a unilateral adaptation to an external constraint in line with the literature on europeanization and diffusion i propose to apprehend the relations between the european institutions and national academic spaces in their reciprocity i therefore follow a sociologicalconstructivist approach of the european political field as it interacts with domestic political arenas a first added value of a european political sociology is to shed empirical light on actor configurations and power relations in the construction of public problems a second contribution of this approach is to seize the relationship between external and domestic actors in their dynamics through the political uses of european recommendations the article is structured as follows in the first part i discuss the relationship between internationalisation and europeanization from a theoretical perspective i propose an analytical framework that pays attention to the temporalities of he reform and their domestic context in the second part i apply this framework to the central and eastern european countries and discuss the main policy responses to external recommendations in terms of diversification of hei and regarding the issue of fees in the third part i shed light on domestic actor configurations and show how policy entrepreneurs used european but also other external models based on the polish and ukrainian cases i higher education internationalisation and europeanization revisited the term internationalisation used in both academic and applied policy analysis can be defined in various ways in view of the resurgence of internationalisation altbach describes the international imperative as growing international forces that are influencing higher education however the question remains open as to how and by whom this imperative is voiced and in which conditions it materialises and leads to direct consequences jane knight defines internationalisation as the process of integrating international intercultural or global dimension into the purpose functions or delivery of postsecondary education she notes the polysemy of the term which may relate to international practices the integration of an intercultural or global dimension into curricula or the commercial trade of he services the author suggests adopting a combined bottomup and topdown perspective to analyse the processes which take place at the national and institutional level while topdown implementation studies focus on refractions failures or deficits in policy implementation bottomup studies recognize the inevitability of mediations by professionals combining both approaches may be useful to shed light on the mechanisms of globalisation of europeanization without taking them for granted a political sociology approach provides a useful way to seize both the topdown and bottomup dimensions of he reform through the domestic uses of external recommendations the european factor under debate in the past decade academic debates have largely focused on the relative importance of the european commission vs governmental representatives in he coordination at the european level some authors have presented the bologna process as an example of resisting the eu critical scholars have for their part drawn attention to the structuring role played by eu institutions and processes such as the lisbon strategy in promoting a marketbased logic in various public sectors including higher education a number of authors tend to agree that european educational initiatives constitute an eu policy increasingly dominated by the commission and structured by the open method of coordination my own research shows that the commission has been a vital player of european he policy coordination since it became a member of the bologna followup group board in 2003 due among other things to the eu programmes and funds earmarked for he it is difficult to consider the bologna process and other exclusively eu initiatives as entirely distinct although the bologna process has been presented as an intergovernmental process supranational agencies played an important role in the preparations for the meeting in bologna whereas the european commission has developed its own higher education strategy building upon the lisbon process but skilfully bringing on board elements of the bologna process the commission supports most of the bologna action lines eg through initiatives ranging from the european credit transfer and accumulation system label to the erasmus mundus programme these measures which are part of the overall eu approach to educational matters and thegeographically wider bologna process reinforce each other improving the chances of the genuine implementation of declared objectives across the various higher education systems such synergies are illustrated for instance by the impact of eu mobility actions on the call for more transparency and recognition of qualifications in europe the latter in its turn supports the eus broader reform agenda under the lisbon strategy 3 clearly the power of the purse of the european commission makes a difference in he templates and reforms in the ceec where the eu funds were an especially welcomed resource in a context of shrinking public funding beyond this eucentred debate the international dimension of the bologna process and of the european he reform agenda is manifold policies coordinated at the european level have deeply influenced he systems on the european continent and elsewhere the process is based on the idea of tertiary education harmonisation and thus on a transnational comparison of he systems which entails the principle of competition while acknowledging the increasingly competitive orientation of the he international market many experts from ceec consider that their country should fully participate in the bologna process to earn a better position in this field 4 still it is difficult to isolate the effects of the bologna process which has built on circulating trends and instruments promoted by international and supranational organisations such as the council of europe unesco and the european commission including diploma recognition student and staff mobility facilitated by a credit transfer system as well as quality assurance to name just a few this relationship between european and international factors of change requires further research the complex impact of international incentives regarding the international dimension of he reforms several authors have pointed out the need to consider the education system within a broader international context scholars have heralded the emergence of a global educational policy field in which the extent of the autonomy of public policies implemented at domestic level depends on the strength of specific national capitals in the case of ceec and their situation on the margins of the european union we may ask whether their relatively weak resources compared with western european countries make them more dependent on international pressures while internationalisation seems to be an allencompassing term its academic definitions and considerations vary altbach describes the bologna he harmonisation approach as a regional version of the globalisation process discovered in the 1990s he acknowledges the power of the western model as the american university so influential worldwide constitutes an amalgam of international influences influential global players in the field such as the world bank and the world trade organization fuel the economic dimension of he transformation thus he internationalisation mirrors the inequalities linked to the economic globalisation process such as the domination of dependent peripheries by northern academic production centres according to rizvi and lingard globalization cannot be viewed as a generalised phenomenon but rather needs to be seen as a dynamic phenomenon expressed in particular histories and political configurations this approach is useful to avoid reifying globalisation and to analyse the mechanisms and agency of this process which may be understood through its practice ideology and social imaginary while some authors trace back the increased activity of international organisations in education policymaking to the early 1990s and consider them as new arenas of education governance others suggest a more refined historical perspective according to karen mundy educational multilateralism developed in the aftermath of the second word war in several phases firstly embedded liberalism marked by keynesian policies and the promotion of the right to education by unesco in the cold war context secondly starting in the 1960s the growing role of the oecd its development assistance committee but also its annual review of member countries educational performance thirdly neoliberal policies calling for privatisation and the limitation of state intervention in which the world bank has taken the lead followed by the oecd the eu and the world trade organisation with its general agreement on trade and services negotiations bridging the european international divide a way to bridge the gap between explanations in terms of globalisation or europeanization is to recognise that there is no obvious divide between both notions for some authors the european union is just one among other international organisations involved in educational multilateralism still the autonomisation of policies promoted at the european level has to be acknowledged on the one hand eu policymakers reappropriate preexisting references and give them a distinct regional meaning as was the case with the european qualification framework on the other hand eu policies have a scope and binding power that other international organisations do not enjoy another manner of refining the europeanization perspective is to examine alternative explanations of change such as the inspiration drawn from models outside the european union or references to narratives of global competition promoted by international organisations furthermore a way to escape a narrow perception of europeanization as the mere uploading downloading of policy templates and to refine the europeanization internationalization relationship is to take into account the transnational channels of circulation of policy ideas government agencies such as the british council or private organisations such as the soros foundation were active in promoting he reforms focusing on transparency accountability and quality assurance in the eu neighbourhood the german rectors conference and the german academic exchange service have been active in this field and have promoted the bologna process in the european candidate and neighbourhood countries 5 finally although the external dimension of policy transformations can hardly be denied it should not be taken for granted the ceec case reminds us that a policy transfer can be uninformed incomplete or inappropriate according to the literature on policy diffusion terminology existing scholarship on the he reforms in the region tells us that domestic political fields and actors are main sites of policy translation it is not only difficult to isolate european models from other external inspirations but also to disentangle perceptions of appropriateness from strategic uses of these external models ii unpacking the external dimension the centraleastern european perspective the transformations of higher education systems in central and eastern europe are a case in which international dynamics can hardly be disentangled from the european agenda thus it would be difficult to analyse internationalisation dynamics in the region without taking into account the way in which the prevailing european schemes have shaped academic programs teaching methods mobility evaluation practices and governance in the case of the ceec european policies have played a major role over the last decades first of all the bologna declaration was not a stunde null of he transformations in the region as it capped a whole decade of he reforms in the aftermath of 1989 the 1990s were the heyday of international assistance to the ceec hence in the first reform stage external references and sources of inspiration interfered and varied depending on national situations international organisations such as the world bank and the oecd were active in the field providing funds loans and expertise to the educational sector the domestic reform strategies fuelled an internationalisation process of he institutions which could also be called westernisation as the outside references lay usually within the western space and especially angloamerican countries however the early 1990s were also a peak period for the european commission which emerged as a leader in the coordination of western assistance to the transition countries in particular through its poland and hungary assistance to the restructuring of the economy programme before analysing these converging external references i will briefly outline some contextual elements relative to the academic landscape in the region several analyses have shown that in central and eastern european countries the academic systems have been affected by changes in this sector in a distinct way in comparison with western european countries the challenges have been both similar and more impactful because of their speed and of local patterns the massification of higher education took place largely in the 1990s while public funding allocated to the sector decreased the concurrent he privatisation process reached much higher proportions than in western europe with peak numbers registered in poland and romania all in all the private sector enrols around 27 of the student population in ceec while it averages 6 in western europe in the polish case the marketisation of the he system that started in the beginning of the 1990s the demographic explains the trend towards higher education deprivatisation while the overall number of students decreased from nearly 2 million in 2006 to 2016 the decrease of the number of hei is due not only to demographic reasons but also to the loss of the crimean territory to russia and the armed conflict in the eastern part of ukraine 7 both in poland and in ukraine the statutory differences between private and public hei do not explain the issue of fees as many students enrolled in public tertiary education institutions still pay fees notwithstanding their specificities these domestic processes can hardly be disentangled from evolutions that take place in the western world as reformers at the national level have constantly referred to foreign academic models the overarching european framework of reference as far as the ceecs are concerned there is still a debate on how endogenous and exogenous dynamics combine in reform implementation for some authors european pressures have resulted in a growing convergence between their he systems others persistently note no significant europeanisation of the he system they analyse varying levels of analysis and choices of data selection contribute to these contradictory results as far as the new eu member states are concerned three phases are generally identified after 1989 the first was the decade of liberalisation and westernisation where exposure to foreign models could be expected a second phase began with the eu accession negotiations followed by the launch of the bologna process suggesting openness to solutions developed at the european level finally the third postaccession phase is marked by further cooperation within the ehea as well as the publication of international rankings and the increasing use of international comparisons however beyond this global scheme the intensity of reforms and the relative influence of international organisations vary according to the domestic political context countries that were not part of the eu enlargement such as ukraine were less dependent on the temporality of the accession process western scholars and academic managers in ukraine the tempus iv edition focused on the implementation of bologna principles such as the three cycle system and curricula reforms connected to the labour market as well as quality assurance tools for the management of internationalization this illustrates the difficulty of separating the bologna process itself and the eu educational initiatives as they feed off each other in the eu candidate countries european references became more visible in the context of eu accession while some he institutions implemented measures aimed at facilitating student mobility on a bottomup basis as early as in the 1990s the perspective of accession provided an opportunity for more directive interpretations of the formally nonbinding bologna principles the interviews with polish experts show that the bologna process and the international incentives as a whole were not only considered as a nonnegotiable package these instruments were associated with modernity and progress and considered as tools to transform society 10 the overarching belief that a country in transition cannot afford to opt out from the process was similar to the attitudes observed in other new eu member states such as romania this domestic framing of the bologna process which seems characteristic of the new democracies from central and eastern europe explains why the different provisions of the process have systematically been transformed into legal acts and detailed regulations looking for the impact of international organisations before the growing focus on the eu level countries from central europe had been exposed to the influence of international institutions active in the education sector the interest of these organisations in the region did not start in 1989 as is shown for instance by unescos 1972 initiative of opening a european centre for higher education in bucharest both unescocepes and the world bank have been actively involved in the transformations of the romanian he system after 1989 while international organisations active in the educational field have implemented several projects in poland their policy impact has been limited these projects have led to the publication of several reports which have fuelled public debate as a legitimate point of reference however these reports did not directly serve as a basis for reform while international organisations called for the introduction of tuition fees for all students this politically sensitive reform has never been explicitly implemented in poland where he is constitutionally free yet in practice nearly half of all polish students pay some kind of tuition fee the 2011 he act introduced compulsory fees for students who pursue a second major but the constitutional court ruled against this practice in june 2014 this shows that domestic priorities and institutional legacies make it possible to bypass the recommendations of international organisations which have repeatedly called for the diversification of he revenues in ukraine noneuropean organisations such as the world bank usaid and the soros foundation have played an important role in he reform assistance 11 their resources and expertise have been welcomed by local policymakers even if domestic constraints provide the most direct explanation for the adopted reform frameworks in ukraine where he has suffered from underfunding roughly half of the student body currently pay fees including in public hei the strong budgetary pressure linked to the financial crisis and the cost of war in the eastern part of the country have reinforced the trend of reducing the number of statesubsidised contracts for the higher education training of specialists 12 while this trend had already begun in 2010 under the controversial minister of education dmytro tabachnyk the proeuropean government that came to power in 2014 has further decreased the funding earmarked for these subsidised he institutions this decision resulting from domestic material constraints resonates well with the objective of diversify ing funding sources drawing to a larger extent on private funding included in the commissions modernization of higher education agenda however it might conflict with the objective of increasing attainment levels in he featured in the europe 2020 strategy this may also be detrimental to the socalled social dimension of he mentioned by the bologna process another set of policy trends prioritised by international organisations has been reflected in various reforms that converged with commission and oecd recommendations they have introduced mechanisms enabling closer ties with the economic environment as well as quality assurance measures following these external recommendations the polish government invested in applied marketoriented courses such as environmental protection in 2014 it introduced an ambitious data collection system to obtain information about the income of former students from the national social security office despite this much of he organisation has remained unchanged as no radical reform of university governance has been imposed upon the universities in ukraine the very idea of state contracts for the training of specialists in strategic branches which has its origins in the soviet period shows a correlation between the investments in hei and the job market with a central role still played by the state a law that aimed at facilitating entry into the labour market for young holders of a he degree was adopted in 2004 several external assistance programmes have focused on the market relevance of he curricula the strategy of reforming higher education by 2020 identified a lack of mechanisms of interaction of high school with the labor market and called for attracting professional public employers to control heis and determine the content of learning and for basing educational standards on professional standards however this strategy which has been developed with the assistance of the united states agency for international development has yet to be officially adopted by the government 13 these cases show that the decision to adapt to external policy recommendations may cause tensions between divergent policy objectives side effects as well as a discrepancy between the declared policy direction and its implementation in countries outside the eu the policy translation of international academic competition could lead to a greater stratification of the academic community policies aimed at diversifying hei and the emergence of institutions targeting the label of worldclass university are not so much a direct answer to the institutional recommendations of an io but rather a political recognition of the growing significance of global university rankings even countries that seemed the most isolated from the international community such as belarus which was denied admission in the bologna process until 2015 have made several initiatives to attract foreign students the ukrainian government has also joined the trend and launched a policy aiming at differentiating its higher education institutions with the ambition to create national research universities but above all to tackle corruption low quality of teaching and research problems measures undertaken to promote the internationalization of the domestic he system may thus illustrate a domestic effort to participate in the international academic exchange iii the political dimension of he reforms the polish and ukrainian cases focusing on the domestic interpretations of the bologna process and of the eu recommendations on he provides an opportunity to approach the europeanization process through the prism of the political uses of european recommendations furthermore the polish and the ukrainian cases offer an opportunity to empirically refine the recent thesis on the political dimension of higher education reforms in this section i argue that it is important to take into account the configuration of each national political field to examine the extent to which existing cleavages influence the domestic framing of western recommendations the point is not to compare the structure of both party systems as such as they diverge and result from different historical evolutions in poland the leftwing parties have been marginalised over the past decade even if their leaders tried to distance themselves from their authoritarian and communist roots since 2005 the nationalconservative law and justice and the liberal civic platform have dominated the party landscape in ukraine there is a strong geographical and linguistic component which accounts for the greater presence of the prorussian party of the regions in the eastern part of the country but also a strong personalisation of political parties according to some authors it is difficult to speak of a functioning party system in ukraine as most parties are weakly institutionalised and many of them appear as channels for converting economic capital into political capital following the maïdan revolution the russian annexation of crimea in 2014 and the military conflict in the eastern part of the country the cleavage between proeuropean and prorussian forces has come to the fore the bologna process has been a challenge to the approach which considers the politics dimension as an important explanatory variable of change in many countries the tendency to harmonise he systems seems to be shared regardless of the political majority in office in the french and polish cases for instance over the past fifteen years noticeable changes in the policy interpretation of the bologna process have been mainly rhetorical with centreleft wing majorities stressing the importance of public funding for he and the social dimension and centreright governments emphasising the hei 16 the idea of reducing the number of universities through mergers consolidation clustering and specialisation reflects the priorities of the european commission formulated in the education and training 2020 strategy 17 in ukraine internationalisation appears as an important criterion to claim the status of research university as the latter considers the heis level of integration in the global education and research space the place in the national industry andor international rankings as well as the number of publications by indexes of recognized international scientometric databases and international peer reviewed journals law on ukraine higher education 2014 p 35 however the implementation of these provisions remains unclear not only because few ukrainian scholars are active in international publication channels but also due to the dire budgetary situation of the ukrainian state as the available funds are prioritised for the conflict that is tearing the eastern territories apart the educational sector is struggling to maintain its level of funding 18 as far as the bologna process is concerned the ukrainian 2014 he law refers to the european higher education area with provisions on the ects learning outcomes a national quality assurance agency for higher education alignment of the national qualifications framework with the qualifications framework of the european higher education area however several structural problems hamper the implementation of these provisions the problem of corruption persists even though the government intends to address it by setting up more transparent mechanisms of student and staff recruitment on the domestic level the principle of an independent quality assurance agency is new yet this agency could not launch its activities by the time of the legal deadline because elected members did not meet the required anticorruption standards 19 this shows that the proeuropean orientation of the central government is however although it is considered as a committed member of the bologna process polands position in the european higher education area has raised some international concern after the october 2015 parliamentary elections won by the nationalconservative party law and justice in the weeks following the electoral victory leading pis representatives publicly expressed their scepticism towards the bologna process yet the new minister of science and higher education jarosław willing and capable of convincing larger parts of the academic community of the usefulness of the bologna process which is remote from their direct material problems also remains to be seen all in all in ceec the domestic retranslation of policy patterns and the governments attitude towards european integration have to be taken into account in order to better understand shifts and stagnation periods in he policy reforms dorota dakowska professor of political science university lumière lyon 2 ens triangle institut universitaire de france competitive allocation of public funds however a closer look should be taken to see whether the party political dimension can be an explanatory variable that helps understanding differences in policy interpretation and outcomes recent studies have reevaluated this dimension albeit focusing exclusively on western european countriesand privileged a leftright divide as the main variable this cleavage does not necessarily apply to ceec where other dividing lines can intervene such as the divide between the socioeconomic liberal and illiberal parties or between a proeu and prorussia majority therefore it is worth asking whether and to what extent a governments attitude towards european integration and the countrys relationship towards the eu can be an indication of its stance toward the bologna process and he reforms in general europe as a window of opportunity for ukrainian reformers after the beginning of the conflict in the east and the russian annexation of crimea the new ukrainian government launched an ambitious higher education reform the law on higher education adopted in 2014 is based on three projects that had been discussed since 2008 it was only after a proeuropean government came to power in february 2014 that a window of opportunity opened for this ambitious reform led by the minister of education and science the former rector of kyiv mohyla academy serhiy kvit and his colleagues since ukraine joined the bologna process in 2005 this is the first comprehensive attempt to align the domestic he on the european higher education areas functioning mechanisms the last comprehensive law on higher education dates back to 2002 in 2011 a national qualifications framework was approved by the council of ministers of ukraine 14 the 2014 law announced priority treatment for national higher education institutions and research universities which are entitled to extra budgetary support in tune with the objective of quality and relevance of higher education included in the eus he modernisation agenda the ukrainian government has planned to reduce the number of hei 15 for this purpose hundreds of technical schools and colleges were supposed to be relabelled as vocational education institutions this met with widespread opposition from technical

this contribution examines the domestic reinterpretations of international and european recommendations in central and eastern european countries ceec it asks under what conditions these institutional recommendations but also global processes such as the university rankings affect domestic public policies the countries of central and eastern europe which have experienced a farreaching reform process since 1989 have been particularly affected by new standards promoted at the european and international level the article shows that the combined external and domestic pressures affect hei in multiple and sometimes contradictory ways based on the polish and ukrainian cases it reassesses the party political factor in the reorientation of he reforms it shows that europeanization and internationalization are neither uniform nor linear processes ultimately the announced diversification of hei appears as a longerterm process whose outcome remains uncertain

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introduction online locationbased social networks have recently attracted millions of users experiencing a huge popularity increase over a short period of time thanks to the widespread adoption of locationsensing mobile devices users can share information about their location with their friends among the biggest providers there are foursquare and gowalla while other hugely popular social networking services such as facebook and twitter have also introduced locationbased features location is increasingly becoming a crucial facet of many online services people appear more willing to share information about their geographic position with friends while companies can customize their services by taking into account where the user is located as a consequence service providers have access to a valuable source of data on the geographic location of users as well as to online friendship connections among them the combination of these two factors offers a groundbreaking opportunity to understand and exploit the spatial properties of the social networks arising among online users but also a potential window on real human sociospatial behavior copyright c 2011 association for the advancement of artificial intelligence all rights reserved spatial networks have been extensively studied particulary when dealing with transportation and mobility networks internet router connections power grids urban road networks and other systems where nodes are embedded in a metric space in general metric distance directly influences the network structure of such systems by imposing higher costs on the connections between distant entities social networks instead have been largely studied from a purely topological perspective focusing on the structural position of their nodes and on structural mechanisms that describe their evolution sociologists have studied the effect of distance on social ties with the underlying assumption that most individuals try to minimize the efforts to maintain a friendship link by interacting more with their spatial neighbors nonetheless the connection cost that heavily affects other types of spatial networks may not be as important in social systems particularly when focusing on online interactions as proposed by cairncross distance may cease to play a role because of the increasing availability of affordable longdistance travel and new communication media resulting in the inevitable death of distance social ties and geographic distance one fundamental spatial property of social networks is the probability p of having a social connection between two individuals as a function of their distance d even though there is universal agreement on the fact that p decreases with distance the exact relationship between these two variables is still unclear however it conveys interesting information about how geographic distance constrains social ties lambiotte et al have found that it decays as p ∼ d 2 in a mobile phone communication network while libennowell et al have found a different relationship p ∼ d 1 among online bloggers on livejournal in the usa being a constant probability which acts on online communities regardless of distance in another study backstrom et al have similarly found spatial scaling p ∼ 1d among online interactions they show how this association appears so strong and important that it can be safely exploited to infer where facebook users are only from the location of their friends it has also been proposed that the spatial structure of social networks might be scaleinvariant with a universal distribution p ∝ d 1 at the same time the effect of online communication tools on such relationship is still under debate even though initial results tend to confirm that distance is still an important factor that shapes human online interaction with some individuals engaging preferentially with spatially close acquaintances across different online and offline communication media analysis of locationbased services locationbased social platforms represent the ideal systems to investigate the spatial properties of social networks arising among online users for three main reasons first of all they uniquely provide data on both social connections and geographic locations making sociospatial analysis possible then user location information in these services is often more accurate than textbased descriptions usually available in other online systems as it is acquired through sensing devices whenever users willingly checkin that is when they share with their friends information about the place where they are finally they have quickly accumulated hundreds of thousands and sometimes millions of users thus enabling largescale studies which can uncover general properties and trends among the many research questions that arise apart from the fundamental one about understanding the effect of distance on online relationships there is the need to understand whether space homogeneously affects users or if instead some individuals prefer connecting to people further away leading to a heterogeneous system moreover social networks are often characterized by a large number of social clusters where triads of individuals are mutually connected although social triangles seem to generally appear across different geographic scales different users may exhibit varied preferences towards shortrange or longdistance triads spatial properties of online social networks we will address these questions by analyzing three different popular lbsns brightkite foursquare and gowalla we have collected data about all of them and extracted the social networks among their users we are able to assign a home location to each user in order to embed the nodes in a 2dimensional metric space then we design two randomized null models of a spatial network which allow us to investigate the statistical significance of the empirical properties found in these networks we observe heterogeneity in the characteristic distance of interaction across users with some of them exhibiting preference towards shortrange rather than longdistance ties in addition we study the geographic properties of social triads again we find nontrivial heterogenities across users with some of them belonging mainly to geographically small triads and others to wider ones spanning thousands of kilometres in particular users with more friends tend to create triangles with individuals further apart far more than expected by chance we discuss how user heterogeneity seems compatible with mechanisms akin to gravity models with the likelihood of connection between two users depending both on their popularity and on their distance this work constitutes the first largescale study to investigate the spatial structure of online lbsns observing robust and universal properties across three of these social services the observed features may be the signature of social processes happening regardless of the particular online tool adopted by users while previous research has been focusing on defining new measures to take geographic distance into consideration when dealing with social networks and on exploiting simple sociospatial properties to predict user location our contributions are different we shed new light on how these sociospatial properties arise from social and spatial factors and how user heterogeneity is related to both of these aspects we adopt a methodology based on statistical comparison with two different random null models and we focus explicitly on locationbased social networks we believe locationbased features will become ubiquitous in online social services our findings may then inspire how systems and applications are designed and implemented on these services data collection in this work we study three spatial social networks acquired from different popular online locationbased social services we extract the social networks arising among users and a single geographic home location for each user brightkite brightkite was founded in 2007 as a social networking website which allows users to share their location with their friends it is available worldwide and it is based on the idea of making checkins at places where users can see who is nearby and who has been there before brightkite users can establish mutual friendship links and they can push their checkins to their twitter and facebook accounts we study a dataset collected in september 2009 which includes the whole brightkite user base at that time with information about 54190 users since this dataset was collected brightkite has gathered more than 2 millions members nonetheless this dataset represents a complete snapshot of a popular locationbased service in its initial evolution phase foursquare foursquare was created in 2009 and it has quickly risen as the most popular locationbased service with more than 6 million users as of january 2011 users utilize the foursquare application on their mobile devices which allows them to checkin sharing with their friends the place where they are foursquare provides game features since the user with the highest number of checkins in the last 60 days becomes the mayor of a place acquiring foursquare data requires user authorization to collect personal information and has rate limitations set in place however many foursquare users choose to automatically push their checkin messages to twitter which pro vides a public api to search and download these messages thus we have recorded approximately 4 million tweets each one containing a checkin sourced by a foursquare user during june 2010 those messages come from about 250000 different users and cover about 15 million locations on the planet we estimate that our sample contains approximately 20 to 25 of the entire foursquare user base at collection time each tweet provides a url to the foursquare website where information about the geographic location of the venue can be acquired since foursquare does not provide unathorized access to user friends list we have acquired friendship ties that foursquare users have among them on twitter where they are publicly available extracting a social network while the resulting social graph is not expected to be identical to the original foursquare graph it provides a reasonable approximation and we will show how it conveys meaningful information comparable to the other datasets finally we extract as home location of each user the geographic location of the place where heshe has more checkins overall dataset n k n gc k c d ef f d l gowalla gowalla is a locationbased social network created in 2009 its users checkin at places through their mobile devices checkins are shared with friends as a consequence friends can check where a user is or has been conversely it is possible to see all the users that have recently been in a given place the friendship relationship is mutual requiring each user to accept friendship requests to allow location sharing however there is a small number of user accounts that represent companies or other organizations and appear to automatically accept every friendship request these accounts can become hugely popular and collect thousands of connections gowalla provides a public api to let other applications integrate with their service in particular they provide information about user profiles friend lists user checkins and place details we have collected a complete snapshot of gowalla data in august 2010 for every user we have gathered the user profile the friends list and the list of all the checkins the user has made finally for each place we have collected its geographic location as specified in gowalla described as a latitudelongitude pair since users are identified by consecutive numeric ids we were able to exhaustively query all user accounts as in foursquare we define the home location of each user as the place with the largest number of checkins network sociospatial properties we first address the spatial properties of the social networks under analysis focusing on the main topological and geographic measures we discuss the fundamental relationship between likelihood of friendship and geographic distance and finally we define two randomized spatial networks models which will help later assessing the statistical significance of the properties we observe in these systems sociospatial properties more formally a spatial social network is a social network whose actors are positioned in a space equipped with a metric in our case online users are located over the 2dimensional surface of the earth and we adopt the greatcircle distance as metric the distance d ij between any two nodes i and j is then computed given their geographic coordinates then the social network can be represented as an undirected graph g with n nodes and k links with users as nodes and where a link exists for each social tie we associate a length l ij to each social link so that l ij d ij the general properties of these three datasets are reported in table 1 the social networks are heterogeneous in size ranging from 54190 nodes in brightkite to 258706 in foursquare the average degree is lower in brightkite and gowalla respectively 788 and 948 than in foursquare where users have on average 2207 friends thus foursquare presents a much denser and bigger social network a consequence of its dominance of the lbsn market all networks present a giant connected component which contains the vast majority of the users the degree distributions for the three networks are reported in figure 1 they all show a heavytail with some users having thousands of friends rescaling the degree distributions by their average values results in a common trend as shown in the inset these networks also exhibit high values of average clustering coefficient between 018 and 026 and short topological distances among their nodes with 90 of all couples being less than 6 hops away these properties confirm the smallworld nature of lbsns as found in other online social systems the average geographic distance between users d is consistently larger than the average distance between friends l across all the datasets while the first value ranges between 5600 and 8500 km the latter has much shorter values between 1400 and 2000 km this already provides evidence that the probability of having a social link between two users decreases with distance we will further investigate this relationship later the distribution of social link length is comparable across the three datasets as shown in figure 2 about 40 50 of all couples of friends are within 100 km with more than 3 of all links being shorther than 1 km instead the distribution of distances among users also shown in figure 2 has a different behavior about 50 of users are at distances larger than 4000 km across all the networks online friendship and distance to further investigate how social links appear more likely to exist between close rather than distant users we study as shown in figure 3 our datasets present noisy patterns and furthermore brightkite and gowalla exhibit an almost flat probability in the range 110 km while all curves then decrease as distance grows and then they reach another steady probability between 1000 and 4000 km maybe denoting a background probability that affects individuals within this distance threshold similar constant trends at short and long geographic ranges have also been found in other online systems the appearance of social ties longer than 4000 km becomes constrained by the fact that both europe and north america where a large part of users are based are not large enough to allow such longrange connections and their mutual distance is about 6000 km surprisingly we find that our data are closer to a law with α 05 whereas larger exponents have been found in other similar studies hence in lbsns longrange social ties have a higher probability of occurrence than in other social systems a potential explanation of this behavior is that lbsns are relatively new so they have mainly attracted early adopters these users tend to be techsavy with many already existing longdistance online friendship ties which they bring to these services this might not happen in other social networks such as mobile phone networks or facebook which have already undergone through an initial phase and are already mature indeed mobile phone connections show a larger exponent α than online social networks phone conversations are much more constrained by geographic distance than interactions on facebook it might be possible that as locationbased services become more mainstream their user audience may broaden and include individuals which are affected by distance in a stronger way network randomization after these initial investigations we will assess the statistical significance of the empirical spatial properties of these networks using two randomized models which capture either the geographic or the social properties of the original social networks and randomize everything else • geo this null model keeps the user locations unmodified and then assigns every social link between two users at distance d according to the relative probability of friendship p • social this null model keeps the social connections as they are shuffling at random all user locations the overall properties of these models are a direct consequence of their definition both models result in a network with exactly the same number of nodes and on average the same number of edges the social model has the same social properties of the original network such as degree distribution clustering coefficients and topological network distances but link lengths are distributed as the pairwise user distances as a result the average link length becomes higher than in the original network with l soc d on the other hand the geo model has the same distribution of link lengths of the original network so that l geo l but the social properties are now lost the degree distribution is peaked and has no heavytail while the average clustering coefficient is much lower since there are less social triads nonetheless the two network models present similar distribution of topological distances with 90 of all couples of nodes always within 6 hops we will exploit these two null models in the following sections by comparing their properties to the ones of the real networks in order to better understand whether the observed sociospatial characteristics might be explained in terms of simple geographic or social factors every analysis performed on a randomized model will be averaged over 50 different realizations of the model itself sociospatial properties of individual users we now focus on individual users studying how their social ties stretch across space we define w i 1 k i j∈γi l ij as the average friend distance of user i where γ i is the set of neighbors of node i and k i γ i is its degree the overall distribution of w is reported in figure 4 for the original social network and for the two randomized versions the existence of values over all geographic scales is due to the existence of users with different characteristic lengths of interaction for instance about 10 of users have connections with an average length of just 10 km whereas about 20 of users exhibit distances above 2000 km since this distribution closely matches the aggregated link length distribution in figure 2 links with different geographic lengths do not appear homogeneously across all users instead there is heterogeneity between users with some of them with only shortrange connections and others with longdistance ties these correlations are stronger than one would expect by chance in fact the two randomized models show how values of w should be more peaked around the average instead of over a large range of magnitudes another interesting result is obtained by studying the correlation between the average friend distance w i and the degree k i we study the user distance strength defined as s i j∈γi l ij k i w i and then we compute the average distance strength s for all users with degree k in absence of any correlation this measure should be scaling linearly with the degree s ∼ k l while a relation of the form s ak β with β 1 or a l would imply correlation between the distance strength and the degree in particular β 1 signals that users with more friends tend to have longer connections than users with fewer friends while β 1 would imply the opposite correlation with users with more friends having shorter social links this relationship is reported in figure 5 for the three datasets under analysis we obtain values of β in the range 110118 across the different networks showing weak posi figure 6 probability that a social link belongs to a triangle as a function of its geographic length for the three datasets under analysis the solid lines show the average probability that a link belongs to a triangle for each network tive correlation real data show a pattern much closer to the social model which has s ∼ k with β 1 rather than to the geo model which instead has much lower values of β in the range 02 04 denoting negative correlation between node degree and average friend distance as users add more and more friends on average their link length slightly increases in contrast to what found in the null models providing evidence that users with more connections tend to have friends further away sociospatial properties of social triangles we now shift our attention to understanding the geographic properties of social triangles social networks usually present several triads resulting in high values of clustering coefficient our networks also exhibit similar patterns with clustering values between 018 and 026 we extract 377438 triangles in the brightkite social networks 18764129 in foursquare and 1327559 in gowalla between 70 and 86 of all links in each social network belong to at least one triangle given their highly clustered structure we find that social triangles arise at a wide range of geographic lengths however investigating the probability that a link belongs to a triangle as a function of its length provides a surprising result since this probability is largely unaffected by distance as shown in figure 6 as a consequence a link is equally likely to belong to a social triangle regardless of its length a related result was found by lambiotte et al many spatially local clusters of people appear in mobile phone communication networks with social links below 40 km more likely to belong to social triads but then this likelihood reaches a constant value for longer links as we have already seen online behavior appears less sensitive to distance than mobile phone communication overall the trend that longer links equally participate to social triangles holds also in our datasets to assess user heterogeneity we compute the geographic mean length l δ of the three links of each triangle and then we compute the average triangle geographic length l δ i for each user i by considering all the triangles heshe belongs to this value does not take into account how many triangles users belong to as the clustering coefficient does instead we aim to assess merely the geographic span of a users social triangles whatever their number might be in figure 7 we show the distribution of l δ over all users triangles with different geographic span are not equally arising among all users but instead there are users with smaller triads and users with wider ones for example there are at least 20 of users with an average triangle length less than 100 km while the top 20 have values above 2000 km this heterogeneity is much higher than one would expect if space did not matter as the social model shows mainly values in the range 100010000 km nonetheless if social mechanisms were not taking place at all then social triads should have been smaller as the geo model exhibits the existence of both local shortrange triads and global longdistance ones needs to be related to both the influence of geographic distance and of social processes such as homophily triadic closure and focus constraint we further study this heterogeneity arising among users by computing the average l δ as a function of the node degree in these social networks l δ increases with the number of friends as shown in figure 8 this effect is not present in the randomized networks the social model shows no correlation at all while the geo model exhibits the opposite trend with smaller triangles appearing among users with higher degrees apparently there are both social and geographic factors influencing social triangles since having only one type of factors does not capture the empirical data this signals that users with less friends tend to generate social triangles on a smaller geographic scale while users with many more friends belong to triangles with longer links this suggests that there might be strong connection between the social properties of a given user and the geographic distance of hisher friendship connections discussion we have seen how users exhibit different characteristic geographic scales of online interaction with weak positive correlation between number of friends and their average distance also a similar heterogeneity appears with respect to social triads with users participating in geographically wider triangles as their degree increases our findings are robust across the three lbsns under analysis as they arise regardless of the particular service we consider the data collection methodology the time elapsed since the creation of the service or the size of the social network however the properties we observe in the real systems are not appearing in the two randomized versions of these networks therefore their sociospatial structure can not be explained by taking into account only geographic factors or social mechanisms indeed this claim can be further supported by considering the average length of a link l ij as a function of the product of the degrees k i k j as observed in figure 9 longer links tend to arise between users with more friends while links connecting users with fewer friends tend to be much shorter this effect signals significant correlations between users social properties and their spatial behavior in fact it is not appearing at all in the social model this denotes how there might be an underlying spatial process taking place which results in this correlation since social ties are not equally likely to appear regardless of their geographic length on the other hand the geo model exhibits the opposite trend with shorter links appearing mainly among wellconnected users hence distance is not the only factor affecting the link formation process in other words when only mechanisms which depend on geographic distance are in place a user accumulates many friends only where there are many potential friends living nearby ie if heshe is located in an area with high density of users furthermore such geographic model can not explain how some users accumulate thousands of friends creating a heavytail in the degree distribution a more accurate modelling of these networks requires the incorporation of processes mingling social and spatial factors an interesting possibility is related to gravity models which have long been used to model connections in spatial networks such as trade flows across countries in this formulation the intensity of interaction between two spatial nodes i and j is proportional to n i n j f where n i is the importance of node i d ij is their distance and f is a deterrence function which captures spatial effects a gravity model balances the effect of spatial distance with other node properties the underlying assumption is that longer ties will appear mainly between important entities while a node will connect to an unimportant one only if they are close to each other gravity models are only a first tentative step as they are expected to fail at reproducing some of our observations in particular gravity models only focus on pairs of nodes without taking into account social effects such as triadic closure and focus constraint furthermore any notion of node importance in a social network appears vague and uncertain thus making the definition of a sound social gravity model hard to specify such individual importance may be an exogenous variable which affects the sociospatial structure such as being a wellknown celebrity or any other type of individual popularity or social influence measure as people spend more time online more and more data will be available regarding their spatial behavior and their social connections allowing more reliable and precise models to be built such models present many potential applications in the design of any type of locationbased service but also important implications for other systems such as security mechanisms user identification techniques and recommendation engines conclusions and future work in this work we have studied the sociospatial properties of users of locationbased services our methodology is based on two randomized null models and highlights how observed properties deviate from what would be expected by chance with purely social or geographic mechanisms we find that lbsns present universal spatial features across them regardless of the service its number of users or the adopted sampling method we observe and discuss heterogeneity in user sociospatial behavior users exhibit friendship connections across a wide range of geographic distance showing similar variability in the social triads they belong to an interesting direction for further work is understanding how such heterogeneity arises in correlation with the temporal evolution of the social network as users spend more time on the service this may lead to a better understanding of the generative mechanisms behind these properties and to new predictive models

the spatial structure of largescale online social networks has been largely unaccessible due to the lack of available and accurate data about peoples location however with the recent surging popularity of locationbased social services data about the geographic position of users have been available for the first time together with their online social connections in this work we present a comprehensive study of the spatial properties of the social networks arising among users of three main popular online locationbased services we observe robust universal features across them while all networks exhibit about 40 of links below 100 km we further discover strong heterogeneity across users with different characteristic spatial lengths of interaction across both their social ties and social triads we provide evidence that mechanisms akin to gravity models may influence how these social connections are created over space our results constitute the first largescale study to unravel the sociospatial properties of online locationbased social networks

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introduction cervical cancer ranks as the fourth most prevalent malignancy among females globally exhibiting the highest prevalence in underdeveloped and developing nations incidence rates standardized by age demonstrate considerable variation ranging from 75 per 100000 women in highrisk countries to fewer than 10 per 100000 women in lowrisk countries approximately 90 of cervical carcinomarelated mortalities arise in lowand middleincome countries where the fatality rate is twice as high as in underdeveloped and developing countries the global burden of cervical carcinoma is projected to escalate reaching 700000 cases and 400000 deaths by 2030 these escalating figures predominantly pertain to lowand middleincome countries posing a significant global health challenge addressing this disparity in cervical carcinoma incidence and mortality is of utmost importance for the global health community data from the cancer registry of the republic of serbia in 2020 reveal a standardized incidence rate of 292 per 100000 women and a standardized mortality rate of 107 per 100000 women indicating a substantial burden of cervical cancer in serbia effective reduction of cervical cancer incidence and mortality requires strategic measures encompassing the implementation of a costeffective screening technology most countries governments have already incorporated cervical carcinoma screening into their healthcare systems in this context the republic of serbia has made significant strides introducing organized cervical cancer screening in 2012 thereby expanding preventive healthcare services for women in the realm of reproductive health thus far a total of four 3yearlong screening cycles has been carried out in the population of women aged between 25 and 64 years the current screening coverage for cervical cancer on the territory of serbia varies between 35 and 68 and it is regionally dependent however various impediments to screening implementation persist primarily related to demographic socioeconomic and cultural factors some studies explaining the socioeconomic and demographic factors associated with cervical cancer screening have been recently published factors including lack of awareness and knowledge about cervical cancer lack of access to information excessive cost of cervical cancer screening low risk perceptions and poor health seeking behaviors were major barriers for women seeking cervical cancer screening social networks sociocultural norms and perceptions of the role of men and stigma also engender negative attitudes and behaviors barriers to cervical cancer screening included poorly equipped health facilities and a lack of national cancer prevention policies and programs there are also ongoing challenges related to the availability and accessibility of screening services promoting awareness among women is imperative to empower them to take control of their health access to primary healthcare is pivotal in expanding cervical carcinoma screening coverage collaborations with professional associations and academic institutions civil society nongovernmental organizations womens groups media and public opinion leaders play a vital role in promoting preventive initiatives enhancing health literacy and removing socioeconomic barriers to screening service utilization identifying socioeconomic factors influencing womens participation in screening will enable the development of interventions to surmount these barriers improve screening service accessibility and availability and intensify primary and secondary prevention efforts among the target population the aim of the study was to determine the socioeconomic factors associated with cervical cancer screening among women in serbia the results of this study are expected to help decision makers health care providers and community to design strategies in order to effectively reduce inequalities in cervical cancer screening methods study type the study is a part of the population health research of serbia conducted in the period from october to december 2019 by the institute of statistics of the republic of serbia incooperation with the institute of public health of serbia dr milan jovanović batut and the ministry of health of the republic of serbia the study is cross sectional survey on a representative sample of the population of serbia population to be included present total number of participants analyzed in survey 6747 collection a twostage stratified sample was used for the study data were stratified by type of settlement and by geographical areas the 2011 census conducted in the republic of serbia was used as a framework for sample selection the sample size was calculated based on the precision requirements for the evaluation of the standard error of the indicator proportion of people prevented from performing daily activities according to the recommendations of eurostat for conducting population health surveys this research is planned to be used for obtaining statistically reliable ratings at the level of serbia as a whole and then at the level of four regions belgrade region vojvodina region šumadija region and western serbia southern and eastern serbia region and the population of cities and other settlements as a compromise between the required assessment accuracy and the cost of conducting the survey a sample size of 6000 households was established which were expected to cover about 15000 members aged 15 and over and about 1500 children aged 514 in calculating the sample size children ages 514 were not included it was decided to select 10 households in each survey county reserve households were provided for each survey county in case a large number of households in the survey county refused to cooperate by dividing the total number of households by the number of households in the sample per census district it was calculated that 600 census districts should be selected a sample of 5114 households was selected registering a total of 15621 people of whom 13589 were aged 15 and older and 1493 were children aged 514 the survey was conducted over 3 months 2019 in accordance with the recommendations of the european health surveythird wave according to which the period of data frontiers in public health 03 frontiersinorg collection in the field must last at least 3 months of which atleast 1 month must be in the period septemberdecember ie in autumn ethical standards in the health research of the serbian population are in line with the international declaration of helsinki adopted at the general assembly of the world medical association in 1964 and amended in 2013 as well as with the legislation of the republic of serbia in order to maintain the privacy of research participants and the confidentiality of information collected about them all necessary steps were taken in accordance with the general data protection regulation a new european legal framework that prescribes the handling of citizens personal data as well as the national personal data protection act the personal data protection strategy and the official statistics act with the application of the principle of statistical confidentiality the existing database was transferred to the university of kragujevac with an official letter from the serbian institute of public health of serbia this study was approved by the competent territorial ethics committees of the four main regions of serbia with headquarters in the national institute of public health in belgrade research instrument standardized questionnaires constructed according to the european health interview survey and adapted to the specific regional characteristics served as the research instrument three types of questionnaires and one measurement form were used facetoface interviewingrecording responses to questions during oral communication between the interviewer and the respondent selfcompletion of the questionnaire by the respondents without the involvement of the interviewer measurement of basic anthropometric characteristics and blood pressure in a facetoface interview with an individual the interviewer completed a structured and semistructured research instrument in the presence of the interviewee the use of a selfcompletion questionnaire meant that the interviewee was given a structured questionnaire and instructions and completed it themselves without the assistance of an interviewer the questionnaire completed by the respondent was then passed on to the interviewer according to a predefined procedure computerassisted personal interview and paperandpencil methods were used to complete the questionnaire variables measured in the study the independent variables encompassed demographic age marital status never married community divorce separation death of a partner and marriagenonmarital union education working status region and selfassessment of health the demographic and health survey wealth index was used as an indicator of material condition according to which households or respondents were classified into five socioeconomic categories or quintiles of the welfare index first quintile second quintile third quintile fourth quintile and fifth quintile to create this index variables related to living conditions and the possession of various durable goods were used the number of bedrooms per household member the material from which the floor roof and walls of the living space are made the type of water supply and sanitation the type of fuel used for heating owning a color television a mobile phone a refrigerator a washing machine a dishwasher a computer air conditioning central heating and a car for the purposes of this research according to the wellbeing index the respondents were divided into three categories of material status rich middle class and poor on the other hand the dependent variable of interest was the utilization of cervical cancer screening by papanicolaou smear test the frequency of the cervical cancer screening and upon whose initiative it was done statistical methods all data of interest were presented and analyzed by adequate mathematicalstatistical methods appropriate for the data type χ 2 test was applied to test the difference in the frequency of categorical variables prevalence of cervical cancer screening crude and adjusted odds ratios with 95 confidence intervals were calculated to examine demographic and socioeconomic factors associated with inequalities in utilization of cervical cancer screening all results with a probability equal to or less than 5 were considered statistically significant statistical analysis was performed using a commercial standard software package spss version 19 results a total of 6747 women aged 15 years and older were surveyed average age of 5202 ± 1912 the majority of the respondents were either married or living in cohabitation hailing from vojvodina and having completed secondary education the highest percentage of respondents belonged to the lowincome category approximately 672 of the female participants had undergone the pap test at least once in their lifetimes among these a considerable subset accounting for 461 had undergone cervical cancer screening within the preceding 3 years a total of 243 of women had never undergone a pap test the largest percentage of respondents underwent the pap test based on the advice of their doctors followed by 213 who sought the test on their own and only 22 who did so in response to a doctors recommendation within an organized screening program over the previous 12 months the pap test was most commonly conducted among women aged 3544 years those who were married residents of southern and eastern serbia who had completed secondary education who were employed who belonged to the richest part of the population and those who perceived their health as good and very good when analyzed by demographic and socioeconomic characteristics a statistically significant correlation was observed between all the features and the frequency of screening females aged a substantial proportion of women particularly those who rate their health as good or very good opt for selfinitiated pap testing whereas those who perceive their health as poor or very poor more frequently participate within the context of organized screening in univariate linear regression model the probability of never having a pap test have the youngest age group is 13 times more likely than the oldest age group unmarried women 03 times more often than married women respondents with basic education 09 times more often than married women the women of lower socioeconomic status 05 times more often than respondents of high socioeconomic status women from the region of vojvodina 06 times more often than respondents from southern and eastern serbia as well as 09 times more often those who assess their health as very good regarding selfinitiated pap testing the probability of not having it middleaged women have 17 times more often compared to the oldest unmarried 07 times more often than married those with low education attainment low education 13 times more often than high education attainment the women of lower socioeconomic status 05 times more often from the respondents of high socioeconomic status from sumadia and western serbia 05 times more often than those from the regions of southern and eastern serbia and women who asses their health as bad 11 times more often than respondents who asses their health as good within the context of multivariate regression analysis paramount predictors surface concerning women who have abstained from undergoing a pap test as well as those who voluntarily undertake such testing encompass age marital status educational level wellbeing index regional demographics and selfappraisal of health status discussion while the occurrence of cervical cancer is diminishing in developed nations due to robust screening and vaccination initiatives the ailment persists as a significant contributor to cancerrelated morbidity and mortality in regions constrained by limited resources the accessibility of technologies for averting cervical cancer remains uneven laboratories frequently lack adequate infrastructure to employ them and hpv awareness is not universally disseminated the consensus within the scientific community is that this disease is eminently preventable offering a potent opportunity for successful intervention when identified during precancerous and early malignant stages swift and effective treatment delivery is crucial for ensuring a favorable prognosis countries adeptly executing organized screening initiatives exhibit a pronounced reduction in both the incidence and mortality rates of cervical cancer their experiences can serve as instructive paradigms for nations yet to institute organized programs or those grappling with suboptimal levels of execution and quality primarily encompassing underdeveloped and developing countries where exposure to risk factors remains conspicuously elevated and preventive endeavors are limited the burden of cervical cancer continues to linger at a significant threshold lowtomiddle income countries burdened with a heightened prevalence of cervical cancer persistently confront financial and logistical constraints in ensuring the availability of both cervix cancer screening and human papillomavirus vaccines to their populace the pivotal challenge lies in orchestrating screening program strategies attuned to the unique circumstances of these nations thus attaining widespread coverage within the target demographic through assessments of appropriate efficacy such endeavors are paramount for wresting control over the escalating trajectory and for achieving the stipulated decline in both incidence and mortality rates over the forthcoming decades in august 2020 the 73rd world health assembly supported the who global strategy to accelerate the elimination of cervical cancer as a public health problem 20202030 achieving the strategy goals by 2030 could reduce incidence rates from the current average of 133 to less than 4 new cases per 100000 women to ensure that cervical cancer is no longer a worldwide public health issue interventions need to be strategically designed on three main pillars with a comprehensive approach immunization screening and disease treatment the recommended strategy is to vaccinate 90 of girls under the age of 15 with the hpv vaccine screen 70 of women at least twice once before the age of 35 and again before the age of 45 with an appropriate test and treat 90 of premalignant and invasive malignant lesions which will lead to decrease incidence rates of cervical cancer about 42 by 2045 and 97 by 2120 saving about 62 million human lives cumulatively in spite of the endeavors pursued by the international community a multitude of investigations have substantiated the persistence of several impediments to cervical cancer screening these barriers encompass a spectrum of sociodemographic determinants encompassing elements such as awareness attitudes beliefs perceived risk psychological considerations selfefficacy prior experiences temporal constraints household dynamics cultural influences fatalistic outlooks social support networks access discrepancies cost considerations safety concerns insurance parameters and the overall healthcare framework consequently a study conducted among a cohort of czech women illuminated that predominant factors underpinning the nonattendance of screening initiatives included the absence of discernible symptoms apprehension toward the procedural aspect and anxiety regarding a prospective cancer diagnosis an additional study revealed that despite possessing a commendable level of cervical cancer knowledge and maintaining a favorable stance regarding screening the actual implementation of screening remained limited due to the imposition of social stigma findings stemming from an inquiry conducted among a cohort of indian women demonstrated that 4364 exhibited a constructive disposition toward screening 2031 were familiar with screening via the pap test and a mere 1322 engaged in the practice of screening the results of our research showed that approximately 672 of the participants had undergone a pap test at least once in their life among them 213 in the last 12 months and 154 less than 2 years ago a total of 243 of women had never undergone a pap test the largest percentage of respondents did the pap test based on the doctors advice followed by 213 who requested the test themselves and only 22 who did it in response to a doctors recommendation within an organized screening program a survey conducted on a sample of hungarian women aged between 25 and 65 years revealed that 74 had undergone screening examinations within the preceding 3 years either as part of or outside an organized screening program more than half of the target population had not sought information about cervical cancer screening at all among those who sought screening information the majority obtained it from gynecologists while onethird obtained it from media sources and health service brochures and 21 from general practitioners furthermore the results indicated that general practitioners had been successful in motivating women who initially declined to participate in the screening program a significant portion of hungarian women had not been informed about cervical cancer screening beyond the invitation letter with only 353 of women aged 2565 being invited to organized cervical cancer screening the challenges in achieving comprehensive screening coverage even within nations with established national cervical cancer screening programs are highlighted by the findings of the national health survey conducted in japan the survey revealed that screening rates for cervical cancer are notably low ranging from 151 for women aged 2024 years to 494 for women aged 3034 years with an overall screening rate across all age groups of 21 in spite of the establishment of estonias national cervical cancer screening program in 2006 the cc incidence within the country remained among the highest in europe by 2020 the lifetime uptake prevalence of pap smears witnessed a notable escalation from 506 in 2004 to 867 in 2020 a vast majority of american women report undergoing at least one pap smear within their lifetime among women without a history of abnormal smears 55 engage in annual pap smear screenings 17 opt for a biennial screening interval and16 adhere to triennial screenings while 11 do not partake in regular screenings remarkably even among the older adult population a considerable proportion engages in frequent screening38 of women aged 7584 and 20 of women aged 85 and older reported undergoing annual pap smears high levels of education employment and stable interpersonal relationships are positively associated with papanicolaou test utilization among women in brazil data pertaining to papanicolaou test performance and socioeconomic variables were gathered from 559 women in mato grosso do sul as well as 338 women in paraíba among women in pb with a low educational level and unemployment status the chances of having undergone the papanicolaou test ≥ three times or once within the last 3 years were in denmark 74 of women participated in organized cervical cancer screening similar results have been observed in our study indicating that 672 of women have undergone the pap test at some point in their lives of whom 461 have undergone cervical cancer screening in the past 3 years moreover a slight increase in the percentage of women undergoing the pap test has been noted compared to the results of the national health survey conducted in 2013 suggesting intensified efforts to enhance screening coverage in serbia nonetheless demographic and socioeconomic barriers identified in 2013 still persist underscoring the necessity of studies of this nature to identify these factors and formulate strategies for mitigating the identified obstacles systemic personal and cultural barriers as well as the lack of decisionmaking guidelines are also contributors to disparities in cervical cancer screening in numerous countries such as latin america subsaharan africa and thailand where reasons for nonscreening include shyness and time constraints literature reviews reveal diverse barriers to accessing healthcare services at large along with specific hindrances encompassing sociodemographic factors such as age education employment and marital status cultural distinctions past traumatic personal experiences and healthcare worker competencies these complexities contribute to varying effects on womens participation in cervical cancer screening thus considerable efforts are warranted to augment womens participation in cervical cancer screening healthcare systems must reinforce resources to meet the evolving needs achieving screening program efficiency necessitates the enhancement of educational interventions professional and interprofessional collaboration and the formulation of health and social policies targeted at barrier elimination womens education about the importance of cancer screening is imperative general practitioners could play a pivotal role in mobilizing women to utilize preventive services involving general practitioners in organizing cervical cancer screening programs could increase participation rates among women who typically decline services strategies and requisite interventions should be devised to support vulnerable groups explore barriers among women in screening utilization and mitigate disparities in preventive examination usage the significance of this study lies in its endeavor to enlighten decisionmakers in the republic of serbias public health domain that despite efforts to enhance screening coverage it remains suboptimal necessitating ongoing education and awareness campaigns regarding the importance of preventive examinations our study has several limitations crosssectional design which does not permit inferences about potential causal relations between the explanatory variables and disorders of interest and selfreporting which is always prone to recall biases in describing further research in the field is also needed in order to explore longitudinal trends and identify other potential factors of inequalities in cervical cancer screening conclusion implementation of populationwide health education programs and enhancement of the existing ccs would be the appropriate public health approach to decrease the incidence and mortality of cervical cancer in the republic of serbia the ongoing ccs program established in accordance with eu regulations and in line with who recommendations is a good starting point for developing the necessary strategy to meet the aforementioned longterm goals facilitating active engagement of the vulnerable female demographic in screening and ensuring the protection of their reproductive health requires collaborative efforts across various sectors encompassing both healthcare and nonhealthcare domains as well as active involvement from civil society data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author ethics statement ethical standards in health research of the serbian population are in accordance with the international declaration of helsinki as adopted at the general assembly of the world medical association in 1964 and amended in 2013 as well as with the legislation of the republic of serbia in order to maintain the privacy of research participants and the confidentiality of information collected about them all necessary steps were taken in accordance with the general data protection regulation a new european legal framework that prescribes the handling of citizens personal data as well as the national personal data protection act the personal data protection strategy and the official statistics act with the application of the principle of statistical confidentiality number of ethical approval is 77031 from the 8th december 2021 issued by the ethical committee of the institute of public health of serbia 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

objectives effective reduction of cervical cancer incidence and mortality requires strategic measures encompassing the implementation of a costeffective screening technology serbia has made significant strides introducing organized cervical cancer screening in 2012 however various impediments to screening implementation persist the aim of the study was to estimate the socioeconomic factors associated with cervical cancer screening among women in serbia methods data from 2019 national health survey of the population of serbia were used in this study the study is cross sectional survey on a representative sample of the population of serbia present total number of participants analyzed in survey 6747 results in serbia 672 of women have done a pap test at any time during their lives of which 461 of women have undergone cervical cancer screening in the past 3 years about a quarter of women have never undergone a pap test in their life 243 the probability of never having a pap test have the youngest age group 1524 years is 13 times more likely than the oldest age group or 131 unmarried women 03 times more often than married women or 037 respondents with basic education 09 times more often than married women or 098 the women of lower socioeconomic status 05 times more often than respondents of high socioeconomic status or 056 enhancement of the existing ccs would be the appropriate public health approach to decrease the incidence and mortality of cervical cancer in the republic of serbia

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sexual violence and intimate partner violence are pervasive public health issues in the united states sv and ipv are not limited to adults these forms of violence affect youth at concerning rates these forms of violence lead to a host of negative effects for youth that can impede their development and future goals moreover sv and ipv tend to cooccur and share a number of risk and protective factors thus considering their prevention together can be a resourceeffective strategy similarly bullying cooccurs with sv and ipv due to shared risk and protective factors and thus prevention programs that target sv and ipv specifically could also reduce bullying which is an important area of research indeed effective prevention programs for a number of forms of violence include bystander approaches that aim to reduce perpetration and to increase the helpful intervention of thirdparty bystanders who witness risk can model proactive norms and can support victims in the current study we examined the impact of a communitybuilding prevention program green dot community on adolescents perceptions of community social norms collective efficacy actionism and experiences of sv ipv and bullying using a matched comparison group design early efforts to prevent sv and ipv focused on trying to build awareness and change attitudes with the expectation that such changes would reduce perpetration many researchers critiqued these programs for approaching individuals only as potential victims or perpetrators and demonstrating minimal effectiveness in actually reducing rates of violence the next generation of prevention efforts sought to give all community members a role to play and focused on training actionists actionists are third parties who can be alert to risk for svipv in others and who can model proprevention and antiviolence norms early actionist programs focused mainly on changing individual attitudes that would lead to greater helping including rape myth acceptance sense of responsibility for prevention and confidence as an actionist with a particular emphasis on college or high school students in school settings training focused on helping when the risk for violence was present using the situational model of bystander behavior that highlights the importance of recognizing a problem situation feeling responsible for acting and having the tools to act results from these evaluations are promising for outcomes including attitudes about sv ipv bullying harassment rates of actionism victimization and perpetration more recently researchers have noted that bystander or actionist training may also be more proactive in nature actionists can help change broader community processes by being trained to diffuse and model positive norms about healthy relationships stepping in to address risky situations and promoting respect all behaviors that are important for prevention and consistent with the diffusion of innovation theory of prevention in this way actionists become mechanisms for changing social processes like individual perceptions of collective efficacy and social norms variables that also reciprocally promote more positive actionism that are connected to rates of ipv and sv as well as bullying to date examination of the impact of actionist training on these social process outcomes has been understudied social norms are a foundation of social connectedness as individuals develop perceptions of what they think groups to which they want to belong do and approve of a social norms approach to prevention has been widely used in areas like substance use where researchers and practitioners work to correct perceptions that peers are engaging in high levels of risky behavior in the violence field negative norms such as youths perceptions of peers endorsement of rape myths or support for the use of violence are related to greater dating violence perpetration and a number of violence prevention programs focus on trying to change norms perceptions among youth this work focuses heavily on norms that promote negative or risky behaviors through perceptions of peer support or endorsement theories of positive deviance on the contrary stress the value of positive connections it may be that promoting more positively framed normssuch as norms that support talking about healthy relationships or helping to reduce the risk of violence as an actionistwill enhance prevention more positive norms in ones community are related to more frequent positive actionism preventionpositive attitudes and greater intent to help others they have also been recently linked to lower perpetration of sv bullying and harassment social norms interventions are welldeveloped for problem drinking prevention but are gaining in use for sv and ipv prevention another key social concept collective efficacy is often measured at the individual level as perceptions of social connections collective efficacy is a protective factor against sv and ipv and associated with greater actionism to date sv and ipv evaluation research has rarely examined the impact of prevention programming on youths perceptions of social norms and collective efficacy green dot is a program that aims to address ipv and sv by diffusing social norms that state that sv and ipv will not be tolerated and that everyone has a role to play in prevention green dot also aims to build collective efficacy for addressing interpersonal violence by training actionists to step in and work together to end violence in their school or community green dot is grounded in principles of actionism and promotes proactive diffusion of prevention messages evaluations of green dot with college and high school students demonstrated that it is a promising program for increasing actionism and reducing sv ipv and bullying in schools but a focus only on schools is an overly narrow approach the social ecological model and research on risk and protective factors for sv and ipv remind us that sv and ipv take place at high rates outside of schools and that prevention work should also engage communities to date there are few evaluations of sv and ipv prevention work that takes place outside of educational settings especially prevention work that takes place in towns and seeks to engage both adults and youth as influencers of community norms and behaviors green dot community is a prevention strategy designed to bring together a coalition of key town stakeholders to work together at reducing problems like sv and ipv through increasing collective efficacy and changing social norms to be more supportive of actionist intervention and intolerant of sv and ipv adults are trained as actionists to work together on svipv prevention social marketing campaigns and town action events that are potentially visible to everyone who lives and works in town these trained adults become influencers over communitywide norms that sv and ipv will not be tolerated and that everyone has a part to play in preventing sv and ipv that occur in families among adults or among youth these goals are achieved through three key strategies that bring people together for skills training and community building to increase collective efficacy related to sv and ipv prevention first capacitybuilding trainings for community leaders and volunteers using a trainthetrainer model are offered so that community leaders and individuals recruited by community leaders can provide overview talks and actionist training throughout the town specific skills in actionism are taught and practiced as are skills in presenting to groups and training others to be actionists businesses and community organizations can be encouraged to have their entire workplace staff attend overviews and bystander trainings second local town action events planned by neighbors and organizations are designed to bring people together to promote collective efficacy diffuse prevention messages and provide opportunities for citizens to practice working together to solve problems a booth on violence prevention at a townwide festival is an example of an action event as is holding a green dot bingo night simultaneously at bars restaurants and coffee shops all across town third a broad range of social marketing strategies are used to increase basic awareness about sv and ipv reinforce key green dot community program content and build mainstream social acceptance of the core language and principles of green dot community one community created a system where local businesses could become green dot spots by doing tasks like linking their website to the campaign and putting up signs about violence prevention in their front window whereas these three strategies largely targeted adults as actionists in the preventionenhanced town youth were targeted via a 1day youth summit for high school students in the second year of implementation the summit is designed for a group of youth leaders who learn to create their ideal town through being actionists building healthy relationships and strengthening their leadership and communication skills the present study is the first outcome evaluation of green dot community in the current study we examined the impact of the green dot community prevention program among youth on key outcomes that follow from the programs behavior change model perceptions of collective efficacy sv and ipv prevention norms reactive and proactive actionist behaviors and victimization experiences we used two sources of data to fully capture these outcomes as described in the method section specific research hypotheses were as follows hypothesis 1 youth in the preventionenhanced town will show increases from baseline to followup 3 years later on perceptions of collective efficacy and cohesion perceptions that people in their town support playing a role to prevent sv and ipv and perceptions that people in town actually do take action to prevent sv and ipv relative to youth in the comparison towns hypothesis 2 youth in the preventionenhanced town will report increased actionist helping behaviors compared with youth in the comparison towns hypothesis 3 youth in the preventionenhanced town will show decreases in sexual and physical dating violence as well as bullying compared with youth in comparison towns method the model of green dot community is that adults are the focus of the intervention with the goal of changing community norms and efficacy and thus promoting the town as the ultimate unit of change in this pilot study we did not have enough towns for a multilevel model design with towns as the unit of analysis for outcomes rather we designed the project to include two data sampling methods to better examine the full range of potential impacts of the program on youth who are in a key atrisk age group for sv and ipv initiation part 1 addressed hypotheses 1 and 2 while part 2 addressed hypothesis 3 we used a matched comparison group quasiexperimental design to evaluate youth in a preventionenhanced town that received green dot community compared with youth in two comparison communities who did not receive green dot community across both studies part 1 used inschool surveys collected by the current research team and was designed to enable us to look in depth at the collective efficacy social norms and actionism outcomes part 2 was a secondary analysis of youth risk behavior survey data collected every 2 years by the state department of health in the high schools of sites included in this study the yrbs survey collected indepth data about victimization but did not contain variables related to community social processes a combination of methods across parts 1 and 2 allowed us to evaluate the full range of outcomes implicated in green dot communitys model of change the comparison towns did not participate in green dot community and could be considered a prevention as usual condition as they were in the catchment area of ipv and sv advocacy centers that did awareness and fundraising events mostly related to response to sv and ipv to our knowledge there were no communitybased bullying or violence prevention programs being used specifically in these towns youth across communities reported some schoolbased prevention exposure part 1 method study sample each town only had one high school participants were high school students in each of three towns in northern new england preventionenhanced and comparison communities were matched based on similar demographics as other variables of interest were not available when towns were selected more details on how communities were selected can be found in banyard et al but all are rural towns with populations between 13000 and 31000 analysis of baseline data showed the three towns differed from one another on community perception measures overall the preventionenhanced town started this study with lower levels of youth perceptions of community cohesion and both descriptive and injunctive norms high schools were recruited in each participating preventionenhanced and comparison town parental consent and youth assent for research was obtained for each of the two waves of data collection participant data were not linked rather separate samples of students across grades 9 to 12 were surveyed at two time points spring 2016 and fall 2018 about 254 years apart at time 1 one comparison school elected to use active consent whereby parents opted their student in to participate in the survey with a returned form two schools elected to use passive consent whereby parents opted their student out of the survey with a returned form by time 2 a new state law required active consent in all schools thus parental consent procedures for active consent were followed in all three participating schools this resulted in lower participation rates for the two previously passive consent schools while the third school had a higher participation rate possibly because school staff were more practiced at the active consent process the study was conducted with university of new hampshire human subjects review board approval and oversight there were no significant demographic differences in the samples collected in the three towns at time 1 or 2 on age sex or race rather there were age differences over time between the panels of students within each town with time 2 students being slightly younger than the sample from time 1 age was used as a covariate in the analyses presented for the remainder of this article we have combined the two comparison towns into a single group there were differences between the preventionenhanced and matched comparison towns at baseline on perceptions of community measures community perceptions all perceptions of norms and collective efficacy were answered with response options that ranged from 1 to 4 both the community cohesion and collective efficacy constructs were created from items adapted from the neighborhood support scale community cohesion was operationalized as perceptions of community members to be closeknit and trusting of each other using five items internal reliability was high collective efficacy for town improvement emerged from psychometric analyses on this sample and was operationalized as perceptions that people in town are willing to work together to make the town safer for everyone using two items internal reliability was acceptable both of the injunctive norm constructs and both of the descriptive norm constructs were created using previously validated measures which were also validated by our research team community personal injunctive norms were measured as youths belief that people in their town should directly engage in actions and discussions to prevent and respond to ipv and sv using five items internal reliability was high in the current sample community public injunctive norms were operationalized as youths beliefs that people in their town should support local events efforts and groups that work to prevent ipv and sv using three adapted items internal reliability was high in the current sample individualoriented action descriptive norms reflect youths perception that people in their town demonstrate disapproval for ipv and sv this was measured using five items internal reliability was adequate communityoriented action descriptive norms reflect youths perception that people in town support local organizations whose mission is related to ipv or sv prevention or victim support this was measured using two items internal reliability was adequate outcome variables compared across prevention and comparison groups are reported in table 2 overall baseline norms were higher in comparison towns reactive actionist behavior participants answered a variety of questions regarding their past actionism including questions about reactive actionist behaviors such as the number of opportunities they had to intervene and how many times they responded to those opportunities for reactive actionist behavior we calculated actionist consistency which accounts for the amount of opportunity as well as the number of times an actionist has intervened in the past six reactive svipv situations were included in the survey for each situation participants first answered an opportunity question and then only answered a reaction question if the opportunity answer was greater than 0 an example item pair is during the past year how many times did you hear another teen bragging or making excuses for forcing someone to have sex and how many times did you speak up to someone who was bragging or making excuses for forcing someone to have sex with them responses ranged from na 0 to 4 participants reaction answer is divided by their opportunity answer and multiplied by 100 to indicate the percentage at which the participant consistently acted to help prevent svipv in each situation based on this ratio we categorized participants for each situation as either a nonhelper or a helper only participants who indicated at least one opportunity to respond to a given situation were categorized in this way proactive behaviors participants also answered questions about three proactive actionist behaviors that do not require a certain situation to arise to act these questions were use social media or texting to show that domestic violence and sexual assault are not okay talk with your friends about being safe in dating relationships and talk with your friends about things you all could do that might help stop domestic violence and sexual assault participants responded to each item on a 5point scale ranging from 0 to 4 using participants proactive behavior scores we categorized each participant for each behavior dichotomously as having done the proactive behavior or not prevention exposure to assess whether participants had been exposed to green dot community a single item was included have you heard anyone in town talk about green dot if so what did they say participants who answered yes and then described any materials or events were coded as 1 all other participants were coded as 0 data analysis the primary analyses aimed to understand individual perception changes in norms and collective efficacy by town as measured by crosssectional samples at baseline and followup differences by time sample by town for actionist behaviors among those with opportunity were also tested different samples of high school students responses to surveys at two time points in each town served as the data source as students completed these surveys anonymously there was no way to link students responses over time thus townlevel crosssectional analyses were performed the two comparison towns were combined given overall similar demographics adjusted regression analyses were performed for preventionenhancedlevel group comparisons controlling for age individual perceptions of communitywide norms were analyzed using multivariable linear regression models with predictors including town or preventionenhanced group indicators age time and interaction terms for each town or preventionenhanced group indicator and the followup time variable separate multivariable logistic regression models with the same predictor set were employed to examine the proactive and reactive actionism among those with opportunity adjusted odds ratios with corresponding 95 confidence intervals were also calculated for these outcomes based on the logistic regression models all statistical analyses were done in r using twosided tests and a pvalue threshold of 05 was used to determine statistical significance results overall 342 of youth in the preventionenhanced town reported that they knew about green dot community on the followup survey which reflects expected early diffusion numbers according to rogerss diffusion of innovation theory fifteen high school students attended the green dot community youth summit representing about 3 of high school students in the school hypothesis 1 youth in the preventionenhanced town will report increases in perceptions of collective efficacy and social norms compared with comparison towns table 3 presents these findings for six of the outcomes there were significant green dot community by time effects with the preventionenhanced green dot community youth reporting improvements in two measures of collective efficacy two types of descriptive norms and two injunctive norms we interpret the beta coefficient for the interaction term as the score change value for those in the preventionenhanced condition groups at the followup time point the values of r 2 suggest a medium effect size for community cohesion but small effect sizes for all other outcome analyses hypothesis 2 youth in the preventionenhanced town will report greater actual actionist helping behaviors compared with comparison towns overall there were no significant differences between times 1 and 2 by group on reports of reactive actionist behaviors and thus they are not presented here results for proactive behaviors are in table 4 youth living in the preventionenhanced green dot community town were more likely over time to report having talked about ipvsv with family friends or people at school one indicator of proactive actionism and a large effect size part 2 method procedures the yrbs is a nationally organized and representative stateadministered survey conducted every 2 years by the division of adolescent and school health at the us centers for disease control and prevention to monitor an array of health and behavior risks among adolescents in high schools throughout the united states among the six core areas that the yrbs focuses on is behaviors that contribute to unintentional injuries and violence this analysis utilized yrbs 2015 and yrbs 2017 data from the state of new hampshire for the three towns in the current study passive consent parent permission procedures were followed prior to survey administration student responses were anonymous both school and student participation were voluntary the data consisted of selfreport responses to the questions of the paperandpencil yrbs packet hispaniclatinx and native hawaiian or other pacific islander ipv did not differ by preventionenhanced versus matched town at time 1 but bullying victimization was reported at lower rates in preventionenhanced towns at time 1 furthermore a close examination of demographic data by category indicated that our highschool sample from part 1 and the yrbs sample from part 2 differed at most by 4 from enrollment numbers publicly available from the new hampshire department of education of note our highschool sample tended to have slightly higher representation of minority racial identities than enrollment numbers but this was still a difference of 4 or less measures ipv victimization two items from the yrbs were repeated on both the 2015 and 2017 surveys and related to experiencing ipv these items asked about experiences within the past 12 months how many times did someone you were dating or going out with force you to do sexual things that you did not want to do and how many times did someone you were dating or going out with physically hurt you on purpose responses were dichotomously recoded to 0 did not experience any ipv in the past year and 1 experienced ipv at least once in the past year bullying victimization two items from the yrbs on both the 2015 and 2017 surveys related to experiencing bullying from a peer these items asked about experiences within the past 12 months regarding have you been bullied on school property and have you ever been electronically bullied participants were dichotomously recoded to 0 did not experience any bullying in the past year and 1 experienced bullying at least once in the past year descriptive statistics of outcome variables for part 2 are presented in the supplemental appendix data analysis the secondary analysis conducted with the yrbs data examined the townlevel changes between two crosssectional samples for the treatment versus comparison towns in experiences of ipv victimization and bullying victimization separate multivariable logistic regression models with the same predictors were used to examine ipv victimization and bullying victimization using sex and grade as covariates for the ipv analysis only participants who indicated they were in a dating or romantic relationship at some point in the past 12 months were included in this analysis adjusted odds ratios with corresponding 95 confidence intervals were also calculated for each outcome based on the logistic regression models all statistical analyses were done in stata using twosided tests and a pvalue threshold of 05 to determine statistical significance results regarding hypothesis 3 there were no significant differences between times 1 and 2 by town for ipv although bullying was marginally significant at p 09 with the preventionenhanced town showing significant reductions in bullying there were significant main effects of town time grade and sex overall the preventionenhanced town reported higher baseline rates of both forms of violence girls reported higher victimization than boys being in a higher grade was associated with lower victimization for bullying and reported bullying was lower at time 2 than at time 1 but there were no significant intervention effects on ipv and a marginally significant effect on bullying note or odds ratio ci confidence interval discussion this study represents a preliminary pilot study of the green dot community actionism program to prevent sv and ipv the prevention strategy itself targeted mainly adults in the town and included action events and social marketing strategies which focused on diffusion on main street by adults in communities rather than schools nonetheless youth could be exposed to green dot community in these settings green dot community uses theories of bystander intervention to build collective efficacy and diffusion of innovation to promote positive sv and ipv prevention social norms in towns we saw significant differences between prevention and comparison towns on these two core outcomes of the green dot community program this pilot study represents one of the first evaluations of a communitybuilding actionist and social normsfocused prevention strategy it is promising that youth in the prevention town reported increases over time in rates of talking to friends family and people at school about prevention this was the one behavior change finding and may be an easier behavior to engage in it may also be the case that the presence of green dot community in the town spurred school personnel as well as parents and caretakers to bring up prevention topics more frequently in school and other settings that include youth the findings are consistent with previous research on the impact of actionistfocused prevention for youth in that we found significant changes among youth in the preventionenhanced town but not in the matched comparison communities these changes were mainly related to preventionoriented attitudes including collective efficacy and perceptions of descriptive and injunctive norms about being a helpful actionist these are important intermediate outcomes given research demonstrating that perceptions of social norms and community efficacy are linked with lower rates of sv and ipv research on social norms also shows that higher perceptions of both descriptive and injunctive helping norms may be an important correlate or precursor to enhanced actionism the current study supports the theory that the green dot community program helped create some of these improvements in community social process protective factors that other research highlights are significant for enhancing prevention behaviors as part of the green dot community program influential leaders from diverse segments of the town were trained on how to change sv and ipv norms and diffuse this information the action events and social marketing materials were used to help not only reinforce the changes in those norms but also to enhance a sense of social bonding thus promoting changes in collective efficacy given that it is not surprising that youth in the preventionenhanced town demonstrated changes on these variables especially because it appeared that green dot community messages had diffused to more than one third of youth in the town our data showed that diffusion of green dot community among youth as indicated by their noted awareness of it on survey questions reached the approximately one in three individuals who could be considered innovators and early adopters according to rogerss diffusion of innovation theory this represents an important first step in prevention implementation however it may also explain why we did not find significant behavior change in actionism or victimization rates overall it takes time for these innovators to diffuse prevention messages to others and to reach the widespread community saturation that may be needed for widespread behavior change research on the high school version of green dot which also used training events and social marketing diffusion strategies showed that it took about 3 years to fully saturate a high school with prevention messaging so that effects of the program could be detected given that we were working in communities and not schools we anticipate that diffusion to a full town of 15000 to 20000 people would take longer than the period of this study this could have affected our findings regarding rates of violence examined in part 2 suggesting that it may take more time to see changes on those indicators than actionism and social norms future efforts might involve continued tracking of these communities using yrbs and other community surveys also we do not know in detail the extent to which the youth who for example attended the youth summit were also influential leaders in their subcommunities future work using methods such as social network analysis to nominate youth to attend the summit may lead to more robust outcomes also social network analysis allows researchers to understand the extent to which prevention messages and skills are being diffused throughout social networks it may also be that youth in the preventionenhanced town saw messages related to green dot andor heard adults discussing prevention and this changed norms perceptions but that this was not enough to change behavior indeed few youth would have been exposed to any skillbased prevention work as part of the green dot community project and we know from previous research that skill building is critical for behavior change furthermore the youthspecific summit activity did not train the 10 to 20 of the population that scholars who use popular opinion leader training models for prevention recommend future research is needed to understand much more about how diffusion of prevention innovations happens across subcommunities in geographic towns although we found in the current study that more than one third of youth in the preventionenhanced town had heard of green dot community we have no details on how this diffusion occurred research in other areas of health behavior have documented that diffusion can happen in a variety of different ways and is influenced by many factors including recent uses of social media like facebook and twitter despite the importance of these findings for future research and practice several limitations should be noted the use of active consent particularly at followup reduced our sample and made it more selective than a full census would have provided those who received consent may have more involved parents who may in turn be more engaged in their communities and thus be more likely to have heard about green dot community selection bias is a concern in the sampling particularly for part 1 of the study although the samples in parts 1 and 2 both overall resemble the demographics for the local high schools however two of the high schools in part 1 of the study had reduced response rates at the second time point due to state policy changes in parental consent procedures it is possible that the sample of students from these schools at the second time point were more likely to be students who care about prevention and who have stronger prevention attitudes the racial and ethnic diversity of the communities involved in both parts of this project was limited indeed we chose not to include questions about race and ethnicity on the survey because of concerns that it might make some student participants identifiable replication and extension of these findings in more racially and ethnically diverse communities is needed furthermore given developmental differences between early and later adolescence a broader age range of youth would also be important to include in future research there are also important measurement limitations for example given that reactive actionist behavior could be examined as an outcome only for students who had opportunity small cell sizes in those analyses likely underpowered our ability to detect any differences over time within towns some of the measures used in part 1 had low reliability part 2 used secondary data which allowed us to examine rates of victimization but only for select forms of violence and that dataset did not contain measures of community perceptions outcomes the current pilot study illustrated a number of challenges to doing prevention program evaluation in a community we need to continue to refine and improve our outcome measures we need to overcome the survey fatigue that often results in low response rates and parental concerns about school surveys that result in low rates of parental consent ultimately we found utility in a multiplemethods approach using several different datasets the current study used two crosssectional samples rather than following students over time this meant that we could not directly track changes among individual students in each town therefore we cannot conclude any causal relationship between green dot community exposure and changes in attitudes a larger study with a longer followup randomization at the town level and the ability to match participants over time will be important next steps in establishing the effectiveness of this innovative prevention strategy indeed it is likely given the townwide nature of the prevention strategy assessed that a 2to 3year followup was insufficient to expect the kind of broadscale diffusion needed to change behavior largerscale studies should examine the impact that green dot community and other programs have on reducing rates of violence within communities we also have a minimal understanding of the ways in which green dot community messages diffused throughout the town which future research using social network analyses could examine given the importance of multipronged strategies for community change future studies should examine the impact of pairing green dot community with inschool versions of green dot that focus more on youth in the context they are most likely to inhabit this may be particularly important given that the current green dot community strategy focused mainly on adults in town and thus may have targeted diffusion efforts on places like main street businesses that were less relevant to youth audiences while the prevention town did use social media for some diffusion efforts not having youth on the prevention steering committee may have meant that social media outlets and platforms most often used by youth were not appropriately targeted in the intervention we did not see changes in youth behaviors on the outcome of using social media for prevention and this may be because youth and adults use social media differently future communitywide prevention approaches may need to think more specifically about how to engage all sectors of a town or neighborhood not just either adults or youth the findings may inform practice first communitydelivered actionistfocused sv and ipv prevention may have spillover effects into the schools given that most sv and ipv prevention programs to date are schoolbased and focus on youth an important innovation in the green dot community approach is that it is delivered largely in the town to an adult audience based on our findings that more than a third of students heard about green dot community it appears that at least some exposed adults engaged in conversations with youth about the green dot community prevention messagesor that youth attended community action events or saw social marketing messages on main street wholecommunity approaches to prevention are likely more effective than programs that focus exclusively on students within a school context moreover the fact that green dot community includes adults in prevention conversations is a critical part of sv and ipv prevention strategies for the effective engagement of youth in programming especially out of school programming is an important topic of consideration identifying prevention approaches outside of school settings that can promote protective social norms and decrease tolerance for ipv and sv within the broader communities where we live work and play has the potential to strengthen existing youthfocused prevention efforts in particular comprehensive prevention approaches that intervene in diverse settings across multiple levels of the social ecology have potential to achieve greater population impact on ipv and sv although additional research and rigorous evaluation is needed the current findings suggest that green dot community represents a novel communitybuilding approach that can promote protective factors for ipv and sv among youth authors note the findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention declaration of conflicting interests the authors declared no potential conflicts of interest with respect to the research authorship andor publication of this article data accessibility the data on which this manuscript is based are not publicly available orcid id victoria l banyard supplemental material supplemental material for this article is available online note 1 although four communities participated in the larger evaluation study reported elsewhere only three high schools completed both the preand postsurveys which are analyzed in this article author biographies victoria l banyard is professor in the school of social work at rutgers the state university of new jersey she publishes regularly on bystander intervention and the effectiveness of sexual violence prevention strategies

sexual violence sv and intimate partner violence ipv which often cooccur with bullying are serious public health issues underscoring the need for primary prevention the purpose of this study was to examine the impact of a communitybuilding sv and ipv prevention program green dot community on adolescents perceptions of community social norms and their propensity to intervene as helpful actionists using two independent data sources green dot community takes place in towns and aims to influence all town members to prevent sv and ipv by addressing protective factors ie collective efficacy positive prevention social norms and bystander helping or actionism in the current study one town received

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introduction primary health care provides to professional nurses a promising work space to develop communityoriented actions on health promotion and disease prevention in addition it expands the insertion of nurses who usually take on the frontline in relation to other health professionals when they develop care administrative and educational activities crucial to consolidate and strengthen the family health strategy in the scope of the brazilian unified health system the fhs in turn recommends the phc reorganization and the consolidation of the sus principles giving priority to actions aimed to promote protect and recover health in a comprehensive and consistent way focusing care on family health understood in the light of its physical and social environment in the fhs nurses serve as mediators in the structural and functional reorganization of the service in the micromacropolitical changes of the healthcare system to provide it with an important social and historical trait and also enable advances to the category and the social building of health in the light of the fhs work nurses take on the role of enabling agents so that individuals families and groups can develop skills and abilities to be consciously empowered in health issues and be capable of promoting the exercise of citizenship nurses should try to exercise health advocacy at different stages of interaction since this is a core component of the nursing practice in a broader view health advocacy may comprise different dimensions such as to communicate inform educate protect talk about build sound relationshiplink and also keep the focus on social issues through different actions developed by nurses on behalf of users and the community in the fhs context health advocacy is perceived as an integral part of the professional work of nurses to promote the users wellbeing and empower them health advocacy is not limited to the usernurse relationship it concerns a triad nurses users and other professionals who make up the multiprofessional health team therefore in addition to performing their care activities with excellence nurses are expected to maximize the situations that lead them to work as political agents pursuing changes as advocators of the users and communitys health this political view of nurses supports the work process innovation advocating for individual and collective health this practice should be permanently developed in phc thus healthcare practices should be strengthened through the work of nurses jointly with other healthcare professionals and users to build accountability plans and seek comprehensiveness in healthcare and advocacy for the right to health in the fhs when nurses work to improve the communitys quality of life they also aim to advocate for the users health fostering their empowerment as agents of their own health here empowerment refers to building responsible organizations and communities through a process in which the individual takes on control over hisher life and democratically participates in the everyday life through different collective arrangements and is skilled to criticize and change the environment it should comprise methods that enable the full achievement of the users rights used as a way to foster health promotion and individual and collective actions that entail efficient results advocacy for users as a subject of actions is closely related to power and empowerment power understood as something inherent to autonomy an individual need to manage physical and social demands or a relational building of actions and reactions capable of delegating representation to someone considering the aforementioned the research issue was the lack of knowledge about the barriers and facilitators of health advocacy of users by fhs nurses objective the objective of this study was to identify the barriers and facilitators of health advocacy of users by nurses working in the family health strategy method ethical aspects ethical aspects were fully complied and the project was approved by the local ethics committee this article is part of the macroproject named advocacia do paciente e coping na enfermagem possibilidade de exercício do poder mediante vivências de sofrimento moral process cnpq 47476120126 study type this is a qualitative descriptive and exploratory study methodological procedures study setting the study comprised nurses working in the fhs of a municipality with 210000 inhabitants in the south of brazil the city has 32 primary health care units of which 19 have fhs teams and 13 follow the traditional phc model data source the study participants were 15 nurses selected through snowball sampling based on previous knowledge of the primary health care units and workers in the investigated municipality emphasizing the education links previously established by the researchers university a nurse renowned for advocating for users was identified and selected to be interviewed after the interview he was asked to indicate another nurse with the features required to the study ie being renowned for advocating for users and so on until the respondents possibilities of nominating new participants were exhausted the inclusion criteria were as follows being a nurse and working in the fhs for at least six months being this the minimum length for professionals to fit into the working environment the study disregarded nurses on vacation or on leave in this study participants were identified by the letter e and a sequential number following the order of interviews health advocacy by nurses in the family health strategy barriers and facilitators figueira ab et al data collection and organization data were collected from january to may 2015 at different fhs units according to the participants working site and their preferences interviews lasted 40 minutes on average were recorded and included closedended questions to characterize participants and openended questions focusing on aspects related to health advocacy actions and users empowerment by phc nurses data analysis data analysis was based on the transcription of interviews using the discursive text analysis it was carried out in four stages unitization of texts establishment of relationships capture of the new emerging text building of a selforganized process unitization stood for the researchers immersion in the transcription of interviews through the deconstruction of texts and their division into units of meaning which were further rewritten to take on the fullest possible meaning this stage was followed by the coordination of similar meanings ie the process of establishing links or categorization during categorization relationships among units of meaning were found and further compared to gather similar elements of meaning in intermediary categories and then in two final categories after capturing the new emerging text the description and construing of the senses and meanings arising from the text were encompassed enabling the production of new understandings about the phenomenon of health advocacy and users empowerment in nursing results regarding participants ages ranged between 25 and 58 years all women 12 with a specialization course as their highest degree three holding a masters degree the length of professional experience ranged from 10 to 28 years and length of work as nurses in the fhs ranged from 9 months to 16 years through the analysis of interviews two categories related to the main barriers and facilitators perceived by nurses during their work in the fhs were identified organization of work bureaucracy and restrictions in the workplace when difficulties restrict actions of health advocacy overcoming barriers when the exercise of advocacy starts from personal and collective organization of work bureaucracy and limitations in the workplace regarding the barriers to the nurses work in relation to advocacy in users health in the fhs scope the following aspects were highlighted shortage of material and financial resources improper facilities that are not welcoming to users work overload with sharp bureaucratic demand lack of autonomy of nurses in the workplace lack of care continuity in phc regarding referralcounterreferral issues lack of political participation of users focused exclusively on the identification of traditional care models that do not perceive users as a subject with potential to decide what is better to their family and to their familys and communitys health a highlight is the low adherence by the community with little commitment and lack of coresponsibility of users it has also found professionals without the proper profile to meet the work dynamics in the fhs such as multiprofessional teamwork and consistent exchanges within the team in addition to professional disengagement of some fhs team members shortage of resources was pointed as a barrier that hinders actions of health advocacy by nurses at the fhs since it hampers or even prevents the development or planning of such actions demanding significant efforts to perform activities or even prevent them from happening so the shortage of resources available to us really restricts things and we must do our best to many times get almost nothing we could do much more but we are hindered in everything there is no vehicle to move in the community depending on the distance it is really tough similarly important among the hindering factors to the smooth development of nurses work as advocators in health in phc are unsuitable facilities due to lack of space light or comfort the inexistence of an adequate physical structure is a barrier to the interactions among nurse team and users frequently making users give up from attending the activities scheduled in phc we try to make things that are just beyond the possible but sometimes we miss the structure there is no space no material our development to the group is very hard there is no place to do it even here the group of chronic patients meets on monday afternoon everyone in a room with no windows i feel like in an oven here we miss structure to develop the dynamics so i always wonder ill assemble a group so you are there doing it they come once and find this they wont come the second time work overload bureaucracy and lack of autonomy have also been mentioned as barriers that impair nurses from performing their actions in the fhs mainly those related to users health advocacy when performing their work nurses must decide which activities they will perform and they end up leaving others aside like the bureaucratic ones thus worsening the lack of autonomy faced by nurses in given situations for example decisions that demand stronger engagement to be executed the difficulty is the shortage of personnel material and maintenance is also troublesome we send the order request and get no return and the personnel without personnel it is very difficult by the end we somehow leave the bureaucratic work aside and then you have to go after it to meet deadlines because bureaucracy abounds because we have the general productivity red tape and that specific to the strategy health advocacy by nurses in the family health strategy barriers and facilitators figueira ab et al many barriers regarding material and human material really bureaucratic issue i guess this is the main impairment to develop the work nurses must cope with care and administrative issues many times and most of the times this administrative and care issues are not restricted to your area they concern the unit mainly the administrative unit so work overload is prominent the lack of autonomy was also quoted as a barrier for nurses to perform their healthcare action in a comprehensive and decisive way despite being familiar with the means to perform their work the respondent nurses stated to find barriers related to the provision of information and care to users because they have to deal with contradicting decisions by other professionals regarding continuity of the action this hinders or even prevents their actions mainly health advocacy and users empowerment another highlight in the study was the short effectiveness between referralcounterreferral which disrupts healthcare delivery between services the respondent nurses stated to refer users to other instances other levels of complexity but when the patients return they bring no referral no feedback on the healthcare provided to them in other services which would allow more effective continuity of care we miss a directed flow where users come receive care and are referred in that sector then come back to you with feedback another negative factor for nurses to serve as health advocators in the fhs is the weak political participation of users it is worth mentioning that when nurses perform actions on health education and promotion they should share the responsibility of decisions on healthcare with users however users usually disregard the need for their political participation and their responsibility towards their health and community we perceive some resistance among the population to adhere to these programs so we have dropouts people get exhausted tired i have tried to implement the local health council but i just cant do it because they dont perceive the importance and in other places the council is assembled claim is present here no ive tried many times i invite them and nobody wants this community is very engaged but i guess welfarism is too strong health education simply doesnt exist with them they are used to place a responsibility that is not mine they want me to solve things for them so the community is not interested in fighting for improvements to themselves facilitators to the exercise of advocacy when the exercise of advocacy starts from personal and collective among the main facilitators referred to in the study it is worth mentioning the personal and collective elements that try to cope with the imposed restrictions such as interaction in the multiprofessional team adherence of users professional commitment with the phc model establishment of links between users and fhs professionals and the embracement dynamics users coresponsibility is likely to influence local health issues and also favors more effective health care focused on the communitys actual needs regarding facilitators of the nursing work as users health advocators in the fhs a highlight is the positive interaction with the multiprofessional team considering that exchanges among professionals foster the planning of different actions on health promotion prevention and care aimed to improve the local communitys quality of life i guess that in the fhs what facilitates our work is the team union having a group of persons working together taking things on together everybody is working exchange is really huge also as we work together things are closer which also facilitates a core facilitator is to have the team working as a team this is extremely important to have things working well we work in a team vision and although each one plays a role we work focused on the team we take the problem of that person and discuss it with the community agent to get to know the persons involvement with the family jointly with the physician the nursing aide because each team member has a different view of the user another facilitator of the exercise of health advocacy and users empowerment by nurses in phc is the adherence of some users and their active participation in healthcarerelated decisions in the unit coresponsibility in decisionmaking is a core factor for health advocacy since the effective participation of users denotes responsibility with their familys health and theirs and allows them to exercise their autonomy in healthcare by being active and engaged members in the community i guess this team engagement and the active community facilitate the work i recall a woman who didnt want to make use of insulin until she perceived she needed it through our talks to her health advocacy by nurses in the family health strategy barriers and facilitators figueira ab et al today she uses insulin with the syringe and manages it she took long to adhere but now she does it i guess this was a great achievement of all of us the team because just coming here attending the appointment and getting the prescription isnt enough users must be committed professionals committed to the phc work model enable health practices and the exercise of users health advocacy developing actions in line with the principles of comprehensiveness and community participation being attentive and available to listen to users and being knowledgeable here in the strategy we are always available to help to listen to clarify doubts we are available eight hours a day when they want to talk about personal matters even if in private we are totally available i used to keep everything wellorganized so i have my controls when i will inform the productivity i check the appointments for the month so this is something that makes things easier to me if i want to know how many pregnant women im taking care of it is on the records if i want to know how many children take childcare i must have the information always at hand the practices of health advocacy performed by nurses give rise to links between users and the fhs professionals these links are developed through continuous and local contact many times even in the home environment with greater openness and trust among participants and more effective exchanges focused on the actual needs of the community which allows providing comprehensive care i notice it when they feel at home health unit and we also empower them at home like in homecare we enter their homes knock the door and get into their homes as we are no strangers we have links with them ties are very strong as we continuously perform this work many times before getting pregnant they have participated through the family planning group or through a nursing appointment or through the pap smear test so they already have a link and when they come they participate more frankly spontaneously and this proximity enabled by the fhs is very good because we know where they live it is always the same professional providing care this facilitates the link and their confidence in the professional as well professional appraisal facilitates the nurses actions as health advocators in phc and all professionals may share the same room for considerations insights and opinions about the best conducts in each context we see there is no such an image of the physician of the psychologists everyone is equal their participation in the fhs is equally important it is the technician the nurse the physical education teacher it is the physician so all have the same importance because we are part of a team the strategy boosts our profession it allows us as nurses to do better for users as it places you in a multiprofessional team embracement of users was also mentioned as an important action that enables nurses to exercise health advocacy as it allows the fhs professionals to get to know and perceive the users needs as soon as they join the fhs the priority function of embracement in addition to improve health care quality is to expand the establishment of links to work with greater problemsolving capacity i try to embrace build good links links with the community and use these tools as instruments to improve the userteam relationship get to know the person better to be more attentive sometimes even when in a hurry listen effectively apply the strategy of embracementlink to improve this relationship users will come to the health unit more frequently will have better response to the treatment sometimes the person resists to recognize a diagnosis or to try to build links with the unit discussion among the barriers nurses found when fostering actions of health advocacy and users empowerment in phc there are impairments related to shortage of material and financial resources unsuitable facilities that hinder carrying out activities with users work overload added to the sharp bureaucratic demand nurses lack of autonomy traditional healthcare models that hinder the nurses political work in the community and lack of referralcounterreferral in services that interfere in health care continuity the shortage of material resources and teams hinders planning actions oriented to users and the delivery of proper health care to them as approached in a study with nurses that identified the social representations of vulnerability and empowerment in the context of relationships between professionals and the workplace there is an antagonism regarding the need to promote proper care and the structural political economic and cultural problems found in health which should be overcome to support and improve healthcare workplaces despite the nurses efforts to develop their actions they find barriers of institutional technological political and social nature that weaken professionals in their multiple dimensions the existence of communication barriers between the different health system levels was also appointed as a restricting factor to the nurses work as health advocators to a large extent this fact is characterized by double or no information between the unit professionals coordinators and the population associated with the consistent displacement of fhs nurses to perform managerial activities which causes work overload among the barriers to the exercise of health advocacy and users empowerment by nurses work overload stands out it is also related to the unsuitable physical structures and shortage of health professionals considering that in the absence of team members nurses have to perform other activities that prevent them from fulfilling with quality their core actions of health advocacy by nurses in the family health strategy barriers and facilitators figueira ab et al promotion prevention and protection to the health of users in the fhs work overload usually makes nurses cope with moral problems notably related to feelings of helplessness and lack of autonomy regarding the users wellbeing when delivering healthcare to users as well as in the issues they advocate on the users behalf nurses make their technicalscientific knowledge available and take on the responsibility for decisionmaking and for their actions however they may have to deal with impairments imposed by other professionals healthcare discontinuity regarding referralcounterreferral and the resulting lack of autonomy and moral suffering however as health advocators on behalf of users nurses bear the moral and professional responsibility of challenging thinking over defending the user and whenever required reporting practices by other professionals that could have negative effects on the patients healthcare these barriers impair nurses from being politically active in relation to users healthcare and to the fhs team interactions preventing them from advocating health issues the facts presented herein bring the fhs environment closer to the traditional biomedical model adopted by most hospital institutions where poor relations are translated into fragmented and onetime health actions that effectively disregard the users uniqueness it is worth mentioning that the nurses political action regarded as a crosscutting knowledge contributes to provide professionals with a broader view strong responsibility and commitment as agents of the organizational social and political change as the last challenge posed to the exercise of health advocacy by nurses care fragmentation should be noted the provision of health care that fails in appraising users as biopsychosocialcultural beings prevents users from exercising autonomy comprehensive health care in contrast is a holistic approach of the human being where users are perceived as a whole to understand health care beyond cure or disease nurses should take care of peoples health as a whole fostering users autonomy with an emphasis on the ethics of relationships among all players regarding facilitators of health advocacy and users empowerment in the fhs the study disclosed links among users nurses and the multiprofessional team that are crucial to promote positive exchanges among players in this sense research data are in line with a study carried out in phc which approached health promotion and community participation in the search for better health results which evidenced the important role played by the coordination between the community and the fhs team professionals to promote health notably the community engagement and interest to participate in organized local groups community participation in health issues leads to the promotion of community health still in the interactions with the community the fhs teams work mediates interpersonal relationships among professionals users and communities with high indexes of adherence through the participatory management of community actions consolidated through the communitys interest to to sustain and qualify them in terms of work conditions another crucial factor for nurses as community advocators is the embracement of users at the services entry door embracement as a strategic tool is completely opposite to the biomedical model that prevailed for decades as the only option without meeting the populations actual needs since it is characterized by individualized service focused on the complaint biological aspects care fragmentation having the hospital as the main health care setting embracement recalls issues of workplace organization with an emphasis on the ethical and political dimensions of professionals in contact with users as well as on the reformulation of the health care and managerial model to facilitate access to the service offered to relax and expand clinical care and favor interdisciplinary care embracement considers the spoken and nonspoken needs of users so that workers and users can focus on actions aimed at their singularities with guidance on how to do them demanding the multiprofessional team to use other technologies that allow the incorporation of users into actions as it fosters and maximizes an individuals autonomy in health care production the work of fhs nurses causes mutual fulfillment of the basic human needs in the interaction established between these professionals and representatives of local groups organized to allow the effective implementation of participatory management in health nurses step into the complexity of local health determinants advancing in terms of solving community problems moreover nurses are acknowledged for their huge potential to manage the fhs contributing to enhance the reliability and visibility of nursing as a reference in health care to the community as such nurses can exercise their professional autonomy and enhance their own satisfaction as well as that of the team and users increasing the profession visibility study limitations the limitations of this study are regard the fact that it was performed in one single context this evidences the need for new studies at other sites to verify whether these barriers and facilitators occur in other health spaces considering that this study was performed in one single city and in the brazilian context contributions to nursing the study found that nurses committed to health advocacy can positively intervene in the improvement of the communitys health mainly in issues related to users empowerment final considerations this study disclosed the barriers and facilitators that nurses find when exercising health advocacy and users empowerment in primary health care emphasizing the important role of this action to foster the communitys defense and autonomy most of the barriers faced in the nurses work are physical and material such as unsuitable structure shortage of human and material resources in addition to work overload as regards the facilitators found the most relevant ones related to links built between professionals and the community mutual respect collective participation in discussions and interventions on health professional commitment and embracement as a unique moment in phc to get nurses closer to users health advocacy by nurses in the family health strategy barriers and facilitators figueira ab et al the establishment of advocacy in primary health care by nurses passes by the need to change their attitudes taking on their autonomy singular knowledge and core role in health spaces in an attempt to associate nurses care actions and the establishment of affective links and to strengthen citizenship and the social rights of users

objective identify the barriers and facilitators of health advocacy to users delivered by nurses from the family health strategy method qualitative study carried out with nurses from the family health strategy of a city in the south of brazil study participants were 15 nurses who were interviewed the content of the interviews was recorded transcribed and analyzed in the light of the discursive text analysis results two categories emerged one about the lack of organization at the workplace bureaucracy and limitations to professional work in health environments and another about the facilitating aspects to exercise advocacy both individually and collectively conclusion when nurses provided with technical scientifi c and relational knowledge are empowered to make decisions they are not only supported by other professionals at work but also develop actions of health advocacy to users thus qualifying the care delivered

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introduction the who global commission on the social determinants of health concluded that social injustice is killing on a grand scale specifically the commission identified inequities in the conditions in which people are born live work and age driven by inequities in power money and resources driving inequities in health 1 as of 2015 average life expectancy in japan was 837 years and in sierra leone just 501 years 2 there clearly remains a rationale for action to improve the lives of those living in poorer countries such as chad however as has been well documented inequalities are also evident within countries towns and cities for example there is a 20year gap in male life expectancy between the richest and poorest areas in glasgow the average life expectancy for men in india was 62 at the same time that it was 54 for men living in the poorest area of glasgowcalton 3 similarly in baltimore and washington dc those living in the poor part of the city have a life expectancy 20 years shorter than those in a rich part 3 while there are competing views as to the scale of the influence of the social determinants of health figure 1 complied by the kings fund demonstrates that social and environmental influences are highly significant contributing to between 45 and 60 of the variation in health status providing universal access to good healthcare is therefore necessary but insufficient to optimise the health of populations and reduce inequities in health in england for example there is free universal health coverage but widespread large and persistent inequalities in health between social groups this is largely because for many communicable and noncommunicable diseases acting global action on the social determinants of health what are the new findings ► the paper provides a useful highlevel insight into action across the world ► it is clear that there has been sustained expansion of action on the social determinants of health and an increase in higher level restructuring to enable real action with for instance an increase in health in all policies approaches within governments recommendations for policy ► the report will be helpful to those trying to make a case for change in their territories ► it provides a useful summary of action that can then be further investigated if of interest ► further work is needed to determine the degree to which commitments in strategies are followed through and measurement of change should be considered an important step in that process bmj global health figure 1 estimates of the contribution of the main drivers of health status at the point at which someone presents with a health problem can be too late to improve health reduce health inequalities and reduce costs on healthcare budgets we need to improve the conditions in which people are born live work and age given persistent inequalities within and between countries and recognising the human and economic cost of inaction the lancetuniversity of oslo commission of global governance for health called for global political solutions that go beyond the health sector alone and beyond technical solutions and unilateral national action 4 in this paper we develop and update our previous reporting of progress across the world in 2010 5 and 2014 6 global action towards health in all policies following the who commission on social determinants of health the rio political declaration on social determinants of health 7 was adopted by 125 member states during the who world conference on sdh on 21 october 2011 the declaration expresses global political commitment for the implementation of a sdh approach to reduce health inequities and to achieve other global priorities the rationale was that it would help to build momentum within countries for the development of dedicated national action plans and strategies 8 in 2011 the united nations general assembly also adopted the political declaration on the prevention and control of noncommunicable diseases 9 calling for the development of multisectoral approaches to health at all government levels and to address the underlying determinants of health in may 2012 the 65thworld health association then endorsed the rio declaration and its recommendations it approved measures to support the five priority actions recommended in the declaration to address social determinants of health 10 this was followed by a un resolution on global health and foreign policy in december 2012 calling on member states and the un to accelerate universal health coverage and implement broad public health measures addressing the sdh through crosssectoral policies 11 the 2010 who adelaide statement on health in all policies paved the way for global recognition of the need for crosssectoral action as well as considering health in wider policies in order to improve health outcomes and equity hiap is a policy strategy which targets the key social determinants of health through integrated policy response across relevant policy areas with the ultimate goal of supporting health equity hiap is thus closely related to concepts such as intersectoral action for health healthy public policy and wholeofgovernment approach the hiap approach is being advocated in several countries and in june 2013 the who eighth global conference on health promotion was dedicated to hiap 12 building momentum for its implementation and highlighting the need to strengthen skill and political capacity to address the sdh there have also been a number of recent and significant supporting global developments with perhaps the most significant recent social policy development being the adoption of the sustainable development goals by the un 13 there is a high level of commonality between the sdgs and the improvement of the sdh 14 another important development is the declaration of oslo 2015 passed by the general medical assembly in moscow it sets out the importance of social determinants of health and principles of action for world medical association national medical associations and individual doctors 28 this declaration explicitly sets out a role for the wma in advising doctors and other health professions of good and innovative examples that will have a positive impact on the social determinants of health in doing so it importantly sets out an advocacy and leadership role for doctors and health professionals to improve peoples lives through action initiated outside the health sector europe buys in but economic policies could be more supportive health 2020 is the european health policy framework adopted by the 53 member states of the who european region in september 2012 it aims to support action across government and society to significantly improve bmj global health the health and wellbeing of populations reduce health inequalities strengthen public health and ensure peoplecentred health systems that are universal equitable sustainable and of high quality in october 2010 who european office launched a review of social determinants and the health divide in the region 15 to support the health 2020 strategy in 2015 the 53 member states of the region signed the minsk agreement committing to the adoption of the lifecourse approach across the whole of government that would improve health and wellbeing promote social justice and contribute to sustainable development and inclusive growth and wealth in all countries the european commission also administers the eu health programme fund which is the main instrument the ec uses to implement the eu health strategy this has provided an important strand in the eu contribution to reduce health inequalities in europe by cofunding projects and actions through successive health programmes since 2003 to date a total of 64 actions involving nearly 700 organisations and institutions from all eu european free trade association and european economic area countries and some candidate countries have been funded with ec cofunding amounting to €40 million the current third health programme 201420 is geared towards contributing to the objectives of the europe 2020 strategy and continues to address health inequalities as a priority 16 the european parliament has recently allocated funds to develop pilot projects designed to test the feasibility and usefulness of action in the area of health inequalities 17 the european pact for mental health and wellbeing is another related eu policy initiated in 2008 it recognises that considerable inequalities in mental health status exist and seeks to address these the united nations development programme has also been working with national partners to forward action on social economic and environmental determinants of health in the context of sustainable human development 18 national activities in a number of countries have followed the publication of health 2020 with lithuania producing a new national health plan and serbia running an appraisal of crosssectoral governance systems and capacity to address social inequalities in 2013 france launched a national health strategy this included a social contract under which every government department would be accountable for the impact of their policies on public health and health inequalities with the aim of ensuring a strong focus on the social determinants of health inequalities 19 eight member states requested support from who to integrate equity in the policy process and a further sixmember states are working with who regional office for europe to develop strategies to address the sdh and health equity with a particular focus on the roma population sweden have recently appointed a commission on health inequalities to further inform their strategy and norway hungary and poland have produced analytical reports 6 however while many health departments have embraced the sdh rationale they do not hold key levers for change social policy is often aligned with the sdh however economic policies to promote growth may have done so at the expense of quality of work and security austerity programmes have resulted in reduced services and cuts to the real value of social protection more needs to be done to incentivise or require other sectors to consider health outcomes the eu treaty obliges all eu policies to adhere to the hiap approach although not all countries have yet integrated this into legislation given the current policy environment integrating the hiap approach with the requirement to adhere to the sdgs makes much sense for example in april 2016 the welsh the wellbeing of future generations act came into effect the act requires that there is a commissioner guidance and training material for a wide range of public bodies who will have legal obligation in a number of areas that codify the sdgs including prevention the overarching goals are to ensure wales is prosperous resilient equal cohesive healthy culturally sensitive and globally responsive north americacanada has led the way the usa was switching focus to prevention under obama canada has been at the forefront of research into the sdh and this continues to be the case with academics and practitioners advocating an sdh approach to public health and influencing policies social determinants of health are now firmly on the agenda in canada there is a great deal of activity both at national and provincial level the federal minister of health has declared publicly that sdh is a priority for the government supporting the federal ministry the public health agency of canada has a sdh team several provinces have social determinants of health as central to their plans the canadian medical association has declared their commitment to action on sdh in pursuing this goal they held town hall meetings across the nation to engage public opinion 20 21 policy initiatives in the usa created by various provisions of the 2010 patient protection and affordable care act healthy people 2020 and the national partnership for action created an environment for the usa to address social determinants of health and health equity the patient protection and affordable care act established the nations first national prevention council with heads of 17 federal agencies representing multiple sectors that impact health the national prevention council developed the national prevention strategy which seeks to improve health outcomes by moving the nation from a focus on sickness and disease to one based on prevention and wellness in addition there are a number of delivery and payment reform initiatives within medicaid to address the diverse needs of the population served through an increased focus on social determinants of health for example bmj global health through the state innovation models initiative a number of states are engaged in multipayer delivery and payment reforms that include a focus on population health and recognise the role of social determinants for example connecticuts sim plan seeks to promote an advanced medical home model that will address the wide array of individuals needs including environmental and socioeconomic factors that contribute to their ongoing health its plan also includes community health improvement efforts that will coordinate efforts across community organisations providers employers consumers and local public health entities 22 also in 2010 the healthy people initiative coordinated by the us department of health and human services added social determinants of health topic area this national initiative involves a network of governmental private nonprofit and academic partners who work together to set priorities for national public health improvements 23 in 2011 the national partnership for actionthe nations first roadmap for reducing racial and ethnic health disparitieswas released by the us department of health and human services a dual approach of public health policy and research actions directed by federal agencies to reduce health disparities coupled with broad local and regional engagement in the implementation of public health strategies to reduce disparities is underway across the usa this article is being submitted in july 2017 the repeal of the affordable healthcare act is ongoing with current estimates suggesting that the present format would result in 22 million losing health cover there is understandably concern regarding the impacts that this could have on health inequalities south americastrategies to address health inequity becoming more common but widespread poverty still persists the countries in this region are at different points along the epidemiological transition with certain countries facing a disproportionate burden of infectious disease and maternal mortality while others are progressively facing higher rates of ncds strategies to address health inequity and inequality are increasingly at the centre of global and regional action in the americas in south america the union of south american nations council of ministers of health identified sdh as one of the five priorities in its 20102015 plan of action mercosur created an intergovernmental commission on health promotion and social determinants of health and pan american health organisation strategic plan ensured that sdh is an integral part of the organisations 5year plan 24 in 2016 paho commissioned a 2year independent review to describe and analyse major drivers of health inequalities across the whole region with particular focus on 14 partner countries the commission will make recommendations for action to improve equity and inequalities in health for international national and local organisations the recommendations and analyses will focus on social determinants ethnicity gender and human rights and will align with the sdgs many countries in the region do already have a longstanding and strong focus on social medicine health equity and human rights and hiap in 2006 brazil undertook a national commission on social determinants of health 25 and in argentina and chile policies and governance arrangements were created to promote social determinants in the ministries of health and at high levels of national government the sdgs are an important mechanism through which to take action on social determinants north africa and the middle eastmember states have agreed to action on the sdh the who regional office for the eastern mediterranean region initiated a regional strategic direction to implement the rio political declaration which was agreed by representatives of member states at a regional workshop in cairo in september 2012 the regional office also supported the creation of a national database for health equity in iran and capacity building in afghanistan iraq and oman for collecting and analysing disaggregated equity data the report identified a number of key themes specifically relevant to the region which interact with and impact on the sdh in particular issues of gender equity the status and employment conditions of migrants fast urbanisation and conflict all tend to hinder development improvement of the sdh and equity since the commission on the sdh 20052008 a number of initiatives have taken place to improve the knowledge base in the region and to engage member countries in debate on the sdh in particular knowledge sharing between academic institutions and nonprofit organisations and the production of countrylevel studies is seen as the basis for advocacy and the engagement of governments in the issue provision of primary healthcare is also seen as an entry point to raise awareness of the sdh in political debate emro therefore initiated a consultation with member states on focusing community and primary care on the sdh as well as running a pilot programme of intersectoral action aimed at tackling health inequalities in a number of countries it also runs programmes covering literacy training and income in 12 of the 22 member states in the region consideration is being given to ways of implementing programmes evaluated in other countriessuch as conditional cash transfers to women in latin americain the context of different gender relations in the region communitybased initiatives run by emro cover a population of around 37 million across all countries in the region and cover basic development bmj global health needs healthy cities and healthy villages and womens development at the 61 st session of the eastern mediterranean regional committee 2015 member states agreed a plan to hold a regional consultation on reducing health inequities in emr through actions on the social determinants twentytwo member states agreed to implement the components of a proposed framework on sdh and related actions with technical support from who subsaharan africaaction on sdh a who strategic priority for this region but more to be done to address widening health inequities within and between countries in the who african region accelerating response to the determinants of health was identified as one of the six who strategic directions for achieving sustainable health development in the african region between 2010 and 2015 the strategy presents several priority interventions for reducing inequities through action on social determinants of health aligned to the key recommendations of the csdh in may 2013 the who regional office for africa gathered stakeholders from 12 eastern and southern african countries to discuss how hiap can be implemented at the national level in order to achieve health equity afro is also supporting the documentation of intersectoral case studies in angola congo and mozambique the whos equity health health policy and human development programme works with afro to support member states implementing programmes addressing the sdh through the development of policies enhancing health equity gender equity human rights and poverty reduction it also aims to support regions and member states to achieve greater synergy between trade and health policy to maximise benefits for poor and vulnerable populations at the recent world medical association council meeting in livingstone there was a real commitment to setting up collaborative groupsand to sharing experience between countries the president of zambia has set up a ministry responsible for sdh and countries for example zimbabwe kenya nigeria and south africa are also keen to forward work in this area asiastrategic buy in through action on non communicable diseases some good examples of action but patchy progress the who regional office for south east asia have conducted reviews to assess the experience of intersectoral policies and actions to inform the development of further initiatives a number of countries within the region have demonstrated promising results to improving health and addressing health equity a review of action to address the social and environmental determinants of health inequity in asia pacific was undertaken by asia pacific healthgaen and published in 2011 this identified a number of examples of action across the asia pacific region 26 there are a number of more recent examples thailand has been one of the most successful countries in reducing child mortality alongside improvements in equitable access to healthcare thailand holds a particularly democratic national health assembly open to the public each year with regional representatives participating in health policy development bangladesh has also seen large improvements in health outcomes latest data for 2013 show that life expectancy at birth was 71 compared with india at 66 this success has been attributed to poverty reduction an increase in health resources and effective communitybased interventions the contribution of the bangladesh rehabilitation assistance committee to this success has been recognised specifically in terms of coordinating the activity of nongovernmental organisations the who regional office for the western pacific region aphealthgaen and the social inequity reduction network in thailand advocated for addressing determinants of health beyond health sectors and strengthening capacities for health equity analysis and health impact assessment wpro is also in the process of identifying suitable cases studies for the assessment of experiences of intersectoral policies and has supported cambodia laos papua new guinea and the philippines to undertake work on addressing aspects of sdh including equity analysis gender working with specific populations and intersectoral action every year pacific island ministerial meetings are run including health ministries recently they declared a non communicable diseases crisis and are developing approaches to tackle the issue in 2013 they adopted an sdh approach within the healthy islands framework which has political leverage as does the urban health equity assessment and response tool framework for the area which was developed by the who centre for health development in kobe japan adapted to an island setting and piloted in fiji in 2012 most countries in both the western pacific as well as south east asia country have ncds strategies and recently who focused its attention on supporting countries with sdh strategies and universal health systems ucl ihe have recently completed a review of health inequalities and the sdh for taiwan which was launched by president ma in november 2015 in china healthy china 2030 puts health at the centre of the countrys entire policymaking machinery making the need to include health in all policies an official government policy multisectoral collaboration and innovation play a key role in healthy china with over 20 departments drafting the 2030 plan a vision has been set for a significantly expanded health industry which would become a mainstay of the national economy and will be tasked with improving the quality and level of health service delivered across the country a key component bmj global health of healthy china is the promotion of healthy lifestyles and physical fitness including through the development of healthy cities to ensure a greater focus on prevention rather than treatment through greater technological advances and improvements to the health insurance system and prevention china is aiming to achieve health equity by 2030 27 australiaregional progress in some areas despite lack of national policy australia has been prioritising health inequities for a number of years with a particular focus on aboriginal populations a commonwealth government senate committee conducted an inquiry into australias response to the csdh however the change of government in 2013 has meant that health inequities in particular the sdh approach has come off the political agenda while major financial cuts to public sector spending have been implemented across the board however despite the lack of engagement by the current national government the federal system allows the states and territories to implement their own initiatives and a number of policies and programmes are ongoing while crosssectoral policies are being developed in various states for example in south australia hiap approach has been adopted in response to escalating healthcare costs driven by an ageing population and increasing incidence of chronic disease ilona kickbusch proposed that south australia adopt a hiap approach and that this approach be applied to targets contained within south australias strategic plan the governments overarching vision for its state the unique advantage of this proposal was the significant and strategic importance of sasp to all south australian government agencies sasp contains 98 targets under six objectives and there is strong alignment between the sasp objectives and the social determinants of health oversight for hiap was placed under the auspices of the highlevel committee responsible for overseeing the implementation of sasp reflecting the strategic importance of the work 29 conclusion this paper demonstrates with examples from regions that across the world there is commitment and action at national and local level to improve the social determinants of health we have also probably just touched the surface it is impossible to document all action and commitment in one paper and so readers should be aware that if an area or country is not mentioned this does not mean that there is no action the paper has not investigated progress on improving the social determinants of health or reducing health inequalities further work is needed to ensure that these commitments are carried through and that policies from a number of sectors align to ensure that power money and resources are sufficiently distributed to support the health of all this paper has not tracked progress on measurement of the sdh across the continents who are progressing a set of indicators that capture the sdh and align with the sdgs some countries have sophisticated monitoring systems while others are yet to register births and therefore do not have meaningful denominators by which to calculate rates measuring progress on the sdh globally will be key to future development of successful policies and implementation plans enabling the identification and sharing of best practice a health in all policies approach has been followed in some countries and more should be done to encourage remaining countries to take a holistic crossgovernment approach to improve health contributors the authors have all made a substantive contribution to this draft and have edited and viewed the final version disclaimer the author is staff member of the world health organization the author alone is responsible for the views expressed in this publication and they do not necessarily represent the views decisions or policies of the world health organization competing interests none declared provenance and peer review commissioned externally peer reviewed

action on the social determinants of health sdh is required to reduce inequities in health this article summarises global progress largely in terms of commitments and strategies it is clear that there is widespread support for a sdh approach across the world from global political commitment to within country action inequities in the conditions in which people are born live work and age are however driven by inequities in power money and resources political economic and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to a focus solely on increasing productivity a health in all policies approach can go some way to ensure this consideration and we present evidence that some countries are taking this approach however given entrenched inequalities there is some way to go measuring progress on the sdh globally will be key to future development of successful policies and implementation plans enabling the identification and sharing of best practice who work to align measures with the sustainable development goals will help to forward progress measurement

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introduction love is looking at a woman who is genuinely passionate about her work says alina levda an instagram fitness superstar with 76 million followers in russia love is not looking into the eyes of a man in order to find in them something that will praise you instead love is looking into your own eyes in the mirror seeing there your amazing inner world and smile realizing that you are living your best and unique life1 levda continues she is one of the countless influencers and microcelebrities who advise their followers to reach avenues of empowerment and accomplishment a sensibility that enjoys remarkable popularity with the proliferation of digital platforms in which finding your amazing inner world requires spiritual guidance and training in this article we look at levda and other top russian influencers that promote emotional tonalities of inspiration selfhelp and individual achievement on instagram namely elena blinovskaya with 51 million subscribers yana leventseva with 13 million subscribers and oxana samoylova with 155 million subscribers drawing on material from the accounts of these influencers which we regard as a local manifestation of a global influencer discourse we explore the ways that platformbased spiritualities are embedded in the neoliberal and depoliticized economies of selfpresentation microcelebrity and branding in russia and beyond in the essay the stars came down to earth theodor adorno looked at a weekly astrology column published in the los angeles times as an example of what he thought was a worrying tendency in modern mass societies a tendency towards irrationality such as the belief that ones life can be read in the stars and abstract authorities such as the astrology expert who is legitimized through the column to publicize unverified advice for adorno superstition occultism and selfhelp which are part of this tendency existed before the formation of mass societies in varying geographies and degrees yet it is in mass societies that their institutionalization has reached by means of mass production a quantity which is likely to result in a new quality of attitudes and behavior for adorno the institutionalization of spirituality happening not only against but also from within modern reason via mass means of communication like newspapers radio and tv was indicative of the cultures of capitalist societies in other words the model of marketbased media production allowed these abstract authorities to shape irrational attitudes and behaviours accordingly with the term platform spiritualities we want to highlight a likewise expansive and multidirectional logic addressing matters around the spirit in the age of social media platforms by means of the affordances of the latter there is a dazzling worldwide proliferation of industries subcultures discourses practices communities and abstract authorities around spirituality that mediates public discourse we understand spirituality as a broader figure encompassing both external beliefs in the divine such as in magic spirits and forces that lie beyond human understanding as well as internal beliefs in spiritual tropes for reaching selfdevelopment including exercise mindfulness and life coaching among others both external and internal spiritualities suggest ways of escaping the complexity of the social world by postulating abstract authorities eg the coach the guru the shaman or the self who possess a certain wiser higher truth in the age of social media platforms and the shift from representational to presentational media that assembles a widening dimension of the public self these abstract authorities multiply and have the ability to control their own profiles independently of the authority of the editor we start this paper by looking at the dependencies between content creators and platform infrastructures and move on to explore the entrepreneurial spiritualities that influencer discourses endorse after presenting the method and material we explore the particularities of the russian context and discuss some of the most prevalent themes appearing across the platform interactions of these influencers namely the trope of the perfect dream the injunction to develop a certain mindset to achieve this dream and the constant circulation of upbeat content we conclude by arguing that rather than simply being progressive vehicles for democratic publics and participatory cultures social media platforms and instagram in particular are key to intensifying an entrepreneurial selfhood that relies on magical thinking and spiritual guidance from abstract authorities in repressive political contexts platforms cultures and authorities the concept of platform is an umbrella term that refers to digital infrastructures mainly privately owned and profitoriented that facilitate connectivities authorize and curate content and invite users to varying degrees of interaction on their space while the main global platforms typically referred to as the socalled gafam initials that correspond to the corporations google amazon facebook apple and microsoft control the lions share of the global internet the platform ecosystem is fragmented into countless overlapping platform segments ranging from search engines to dating apps performing diverse functions indicatively the concept has been varyingly used to describe audiovisual streaming platforms such as netflix and amazon prime music streaming platforms such as spotify and apple music search engines like google app stores like google play and apples app store and social media platforms such as facebook youtube tiktok and instagram among others to a large extent the business model of the platform relies on extracting rent or subscription revenues from the creation of multisited markets that connect producers consumers advertisers and endusers into a single space of interaction as well as from the extraction and processing of user data which can then be sold to advertisers used to train algorithms build recommendation systems improve platform services and generally help the platform grow economically platforms are generally dependent on user participation that is on users voluntarily spending time resources and attention in their space either as creators or as audiences so that the value of the platform increases in the less commercialized days of the internet of the 2000s user participation was seen as a potentially positive step for the creation of more democratic selfreflexive and participatory societies the post2010 dominance of the digital platform however entails a commercialization of the online space that encourages the generation of narcissistic and selfabsorbed cultures rather than participatory in the civic sense of the term the figure of the internet celebrity or influencer is paradigmatic in this regard as what sophie bishop calls the influencer creep whose key tenets include selfbranding optimisation and a performance of authenticity permeates various online industries and cultures such as the artworld while influencers similar to traditional celebrities can advocate for social issues that contribute to progressive change their activity is calculated to be as safe and riskfree as possible becoming controversial can lead to public image ruination and therefore loss of income internet celebrities therefore tend to selfbrand via safer narratives that primarily revolve around the self and its feats that is to say the core narratives of a global neoliberal ideology as a case in point bishop notes how the influencer management tools that is algorithmic tools helping advertisers understand the appropriate influencers to promote their products tend to privilege the creation of safe frictionless content therefore advertisers generally desire to influence content and reward production that is noncontroversial light and nonpolitical as this sustains a buying mood that is a smooth flow of content that sustains a positive brand ambience with the threat of cancelling looming over content producers influencers are forced to curate their profiles so as to appeal to audience desires the preoccupation with spiritual tropes including wellbeing success empowerment and the therapeutic is indeed one of the safest choices for influencer content since in principle it boosts the influencer image of a trained spiritual accomplisher without in any way threatening their publicity spirituality and entrepreneurialism the umbrella term spirituality is useful for thinking through a distributed sensibility among social media usage that is manifested in the public performances of influencers microcelebrities and everyday users alike spirituality pertains to matters of the spirit a term that engulfs transcendental values and worldviews including the idea that there are impenetrable essences above beyond and around the interactions of physical matter rather than via strict logic and reason these essences can be accessed through intuitive understanding belief in the self or external entities and training of the soul spirituality makes an appeal to the transcendental and the metaphysical as forces that can regulate not only the natural world expressed for instance in common injunctions like nature has its own secrets and nature is magical but often the social world spirituality then refers to a system of thought that poses the transcendental and the metaphysical as foundational modalities of reasoning and understanding the world and its phenomena furthermore the word refers to the values and meanings of a person as well as to the ideal of the human spirit and its attempts to reach full potential todays understanding of spirituality is closely linked to the idea of the inner self which is exemplary of the massive subjective turn of modern culture as charles taylor puts it resulting in a new form of inwardness in which we come to think of ourselves as beings with inner depth building upon this idea heelas and woodhead suggest that the sacred domain of the western world undergoes a spiritual revolution according to heelas and woodhead this spiritual revolution entails on the one hand the decline of religion which relates to lifeas forms of the sacred that is a life lived in terms of external or objective roles duties and obligations and on the other hand the rise of spirituality relating to subjectivelife forms of the sacred and referring to a life lived by reference to ones own subjective experiences dominika motak develops the idea of the subjective turn in contemporary religiosity by offering the notion of postmodern spirituality and its links to the culture of individualism motak highlights the tight bond between the modern individualistic account of spirituality and the consumer society the spirituality of an individuum develops in the onesizefitsall consumerist culture in turn jeremy carrette and richard king provide a comprehensive analysis of how this focus on selfrealization in todays spirituality fits in with neoliberal capitalism and the idea of what they call capitalist spiritualities which go beyond the embracement of an individual self and towards a concern with making the individual employeeconsumer function as effectively as possible for the benefit of corporate organisations and the global economy according to carrette and king in the age of global finance capitalism spirituality becomes a way of developing incentives that are conducive to the corporate objectives of the employer the tendencies that carrette and king observed in 2004 bourgeoned as platforms became a significant part of todays global culture recent studies show that posts covering the topics of witchcraft and wicca religion reach millions of followers globally lionel obadia points out that the internet has become a fertile ground for a redeployment of magic in culture and society in his recent work chris miller proposes a complex review of the witchtok subsection on tiktok with a specific focus on how materiality and magic are conceptualized and how modern social media witchcraft intersects with consumer capitalism moreover these spiritually related topics are exploited not only by practitioners but also by companies with no relation to religion like sephora cosmopolitan or walt disney however it would be a mistake to limit todays spirituality on social media to a direct citation of wiccan traditions or the performance of witchy aesthetics the key element of spirituality today is the focus on the individual self and the idea that its potential can be reached to its fullest which connects it to the popular practices of wellbeing mindfulness and selfdevelopment these practices being an intrinsic part of a neoliberal culture can harbour manifestations of sociopolitical discourses for example charlotte ward and david voas highlight how new age beliefs in a supposed paradigm shift in consciousness and the spiritual awakening of humanity at the dawn of the 21 st century merge with conspiracy theories thus forming a unique hybrid that they call conspirituality stemming from the web cultures of the mid1990s conspirituality was formed as a seemingly contradictory synthesis of maledriven politically charged conservative and pessimistic conspiratorial thinking with femaledriven selforiented optimistic new age spirituality in this union political cynicism is tempered with spiritual optimism ward and voas emphasize that the ideas of conspirituality penetrate the mainstream through the web and that conspirituality in general is an online movement developing the notion stephanie alice baker argues that conspiracy thinking interweaves with current lifestyle selfcare and wellness cultures in denial of covid19 and circulating misleading medical advice according to baker wellness influencers were spreading misinformation and conspiracy theories during the covid19 pandemic using the same techniques they employed to achieve their microcelebrity status the platformbased spirituality that we discuss here can be seen along the lines of capitalist spirituality which is based on the culture of individualism and the mobilization of transcendental and metaphysical reasoning for commercial purposes with influencers becoming newage gurus possessing a deeper knowledge this involves the spiritual framing and interpreting of exceptional moments that refer to instances of selfmaking success and status and emphasizes the power of individual will and determination rather than say luck or circumstances in interpreting various events take for instance the following example today in honor of the holiday…in our wishes we will make a wish for an apartment says elena blinovskaya a life coaching superstar in russia who runs a series of marathons assisting people to make their dreams true this most powerful egregore 2 of your desires … think about it for now … what kind of apartment do you need and most importantly how much does it cost perhaps you need the apartment as an investment or an inheritance for a child everyone may have a different need … today we will twist this reality3 blinovskaya mobilizes this unaccountable spirit will and intuition not only as a framing device to speak about her own selfmaking and success but as a means of convincing her audiences that the power of thought can be used to acquire material possessions such as an apartment platform spirituality harbors an entrepreneurial sensibility which is in turn evocative of the digital expansion of what nikolas rose has previously called the psydisciplines including psychology psychoanalysis selfhelp life coaching and advice literature eva illouz uses the broader concept of the therapeutic to likewise refer to neoliberal cultures encouraging selfentrepreneurialism and a focus on individual responsibility for instance rimke argues that n eoliberal subjects are encouraged to almost exclusively view and understand themselves according to the truths practices and techniques promoted by therapeutic industries as m odern life is colonised by therapeutic cultures of the global medical industrial complex … that mask and distort the inherent problems of neoliberal societies the entrepreneurial aspect of platform spiritualities as we shall see below promotes particular conceptions of gender including in our case the idea that femininity is a project that needs to be managed through emotional selflabor for reaching middle class aspirations in love career and personal life postfeminist sensibilities and platforms in russia as noted above there is a constitutive relationship between platforms and influencer content with instagram being one of the central online spaces where careers and reputations are built in russia and beyond this relationship which is essentially a relationship that can guarantee symbolic and economic value was not broken in russia even after the government prohibited access to instagram at the beginning of the russian invasion of ukraine in february 2022 meta platforms was recognized as extremist by the tverskoy court of moscow and some of its products facebook and instagram became accessible on the territory of russia only through vpn in the fog of uncertainty following the courts decision bloggers who built their media persona and business on instagram started to bid farewell to their audience its hard to believe but its the same with the events of each day… at first cant believe it i support i find words in telegram elena blinovskaya writes on march 11th promising to switch to telegram and vkontakte social media platforms that became an alternative for russian bloggers who lost their audience due to the ban this era which made me who i am … me and the desert … symbolic however what will i build here which values will i take with me which ones will i create 4 she writes in her reflection on the possibility of leaving the platform that created her brand and persona yet more than a year after the russian invasion and metas ban from russia instagram continues to be a significant social media platform for the russian audience and blinovskaya continued to regularly post and launch her dreams marathons until the end of april 2023 when she was arrested for tax evasion and banned from using the internet 5apart from banning meta products that were widely used in russia russian influencers and online content producers faced more challenges as the government became openly authoritarian after 2022 which greatly increased censorship at several levels of society this involved an effort to conceive russia as a geopolitical brand that is to symbolically differentiate and conceptualize russia as a distinct civilization a presumed russian world with its own history rituals and norms that defends traditional and family valueswhat critical theorist ilya budraitskis critically refers to as russias special path this geopolitical branding conceptualized russia and its spirit as different from western liberalism which in governmental discourse is related to a negativelyperceived unfettered freedom moral decadence and a focus on the individual rather than the communal the acceleration of this hegemonic conservative agenda after 2022 posed increased difficulties for content producers especially the more politicallyoriented ones for instance the passing of a law against propaganda of nontraditional values led to a general climate of selfcensorship towards lgbt topics in platform cultures and beyond in this sense the influencers we present here adhere to typical neoliberal and postfeminist cultures of success accomplishment narcissism individualism and personal fun which are however enabled within an increasingly conservative political and social context the russian influencers we explore express a postfeminist sensibility a term coined by the feminist scholar rosalind gill to account for the mainstreaming of feminism in western societies that replaces traditional feminist demands for radical social change according to gill postfeminism should not be seen periodically that is as a chronological era where feminism is substituted by something else but as a sensibility or diffusing constellation of affects and discourses permeating popular culture characterized by and expressing a set of characteristics and beliefs femininity is a bodily property a shift from objectification to subjectification the emphasis upon selfsurveillance monitoring and discipline a focus upon individualism choice and empowerment the dominance of a makeover paradigm a resurgence in ideas of natural sexual difference a marked sexualization of culture and an emphasis upon consumerism and the commodification of difference in the age of platforms this postfeminist sensibility is a globalized digital feeling as adrienne evans puts it found in an array of settings such as russia that we here discuss postfeminist platform cultures further promote selflabour as a means to perform a successful womanhood turning the mandate of working with yourself into a socially diffused injunction looking at selfhelp literature in russia suvi salmenniemi and maria adamson likewise argue that one of the main modalities through which postfeminist sensibility is domesticated is labor that is the labour of personality the labour of femininity and the labour of sexuality this aesthetic labour which has to be constant and continuous rather than oneoff promises to turn women into desirable and valuable subjects ekaterina kolpinets explores how internet celebrities employ affective and emotional labor and construct affective labor strategies in creating bonds with the audience one of the recent studies on the russian speaking instagram influencers identified four leading role models for women ideal mother successful businesswoman standard of woman and daring woman the unifying features of these models are the unspoken need to conform to traditional standards of female behavior which are based in one way or another on the demonstration of marital and maternal relationships in the blog and exploitation of the selflove theme interpreted as taking care of external attractiveness kolpinets and kozharinova then argue that russian instagram culture is extremely patriarchal and demanding of women and female bloggers represent themselves not as subjects but as objects and especially as objects of male attention in what follows we look at the content produced by top russian influencers so as to get a glimpse into their worldview and values from within their discourse we understand the discourse of russian influencers as a localized manifestation of a global phenomenon if we think of the figure of the influencer as a transnational or global form then the figure of the russian influencer is a localized adaptation of this form that is specific to some of the dominant values pertaining to the russian internet space and its publics including increased constraints in celebrating alternative sexualities and alternative gender roles avoiding touching upon risky geopolitical themes and conforming to heterosexual family norms this is so because as mentioned above the influencer economy nurtures riskless cultural forms so as to avoid friction and potential cancellation by both the government and the public also while all the blogs that we examine in the article are owned by women some of the tendencies that we observe can be witnessed in male blogs however we limit the scope to female bloggers due to our understanding of blogging as affective labor which as ekaterina kolpinets discusses in her work has been theorized in feminist critique as gendered specifically female labor while platform spiritualities constitute a distributed sensibility across social media cultures rather than being confined to the selfpresentation strategies of influencers we examine influencers since their public performances not only get widely diffused but are more meticulously curated and thus these sensibilities become more legible and apparent we identify the spiritual tropes employed by russian influencers on instagram in their struggle for the audiences attention focusing on the themes that they regularly discuss in developing a model of individualistic spirituality in the context of platform capitalism and postfeminist sensibility our goal is to show how capitalist spirituality which treats the individual as a means to achieving financial growth manifests itself in the lifestyle content of tremendously popular personas who became role models for millions of women seeking happiness methods and material we thus explore the content that is produced by popular russianspeaking bloggers that aim at a russian audience elena blinovskaya alina levda yana leventseva and oxana samoylova our choice of these four bloggers was based on a combination of popularity and the common themes they post each blogger in one way or another frames topics such as family selfdevelopment wealth and luxury travel through spiritual tropes as understood above despite often engaging with the same topics each blogger has quite diverse content strategies and personal backgrounds however all of them are united in the presentation of a specific project of spirituality that constructs a system of what we can call instagram ideology which at least in russia assembles itself on the foundations of individualism luxury aesthetics and conservative family values most of the bloggers rely on the more general discourse of capitalist spirituality developed within platform economies and cultures the initial corpus of texts consisted of posts published between january 1 2021 and july 13 2023 amounting to a total of 1702 posts to ensure the broadness of the topics included in the analysis we have not selected the posts based on metrics and as a first step we used open coding to analyze the sample during the first cycle of coding we identified several recurring topics in the content under analysis and assigned labels infoproduct business advertisement body travel romantic relationship wealth money items of luxury family children marriage during the second cycle of coding we also identified instances of esoteric language as well as conservative and patriotic ideas additionally we have also looked at the information products that these bloggers offer to their audiences which mostly consist of online courses and webinars this allowed us to examine both the goods and services they sell and the narrative that supports these business enterprises in personal and spiritual development we are focusing on bloggers with different specializations and varying accents on spirituality for example elena blinovskaya is probably the most spiritual of all and explicit in her transcendental leanings focusing on wish fulfillment and producing reality framing her spiritual approach as psychological work alina levda shows her subscribers the way to the dream body and sells weight loss courses training programs and a menu with the straightforward name eat and lose weight yana leventseva presents herself as a top travel blogger of russia and an instagram expert she teaches how to shoot instagram stories how to pose and how to edit photos in lightroom finally oxana samoylova in her instagram activity primarily focuses on her children and family visuals and her account description features a link to the website of samoylovas cosmetics brand after the stage of coding we proceeded to thematically analyze both social media posts and the information products offered by influencers building upon the set of initially generated codes we have identified the themes that are recurrent in the materials to establish the core values of the platformbased spirituality that the influencers endorse with their content we have identified three themes that contribute to the construction of influencer spiritualities perfection as the ultimate goal a certain mindset as the path to perfection and positivity as a way of obscuring disturbing political events and adhering to a depoliticized self even when living in times of a major crisis such as the war in ukraine findings dreams of perfection in all the influencers we looked at the question of how to reach personal improvement as well as accomplish ones dreams is constant the imagebased nature of the medium is key as visuals create more direct representations than the written text providing pictorial evidence of how these dreams and perfect lives look like ekaterina kolpinets in her book the formula of dreams writes about a set of visual clichés that dominate the platform dream body and face dream home dream trip dream relationship and dream job according to kolpinets the clichés that define the visuals and fashion of instagram are a way to embody the life that no one really lives but that everyone dreams of and a life worth dreaming about this is apparent in the case of blinovskaya who is best known as a creator of the socalled marathon of dreams an online course that promises to help to learn to dream realize everything that really matters to you discard all unnecessary things fears doubts expectations of others and start the path to the life of your dreams6 blinovskayas personal website features several other online info products for example the financial marathon new dimension promises to open a personal portal to abundance and opportunities the marathon relationship is presented as a chance to find yourself in your most harmonious relationship with everyone around you with a partner children parents friends and any other people and a date with the body promises that participants will say goodbye to all complexes and solve health problems in the description of the semimarathon husband on couch muzh na divane blinovskaya laments that women in the 21st century have received so many rights and freedoms that they do not know how to dispose of them and promises that thanks to her webinar they will remember the main thing and will be able to make your king carry you in his arms other courses and webinars are dedicated to such topics as pride envy and jealousy friendship purpose astrology sex and motherhood while the concept of dreams is a foundation for her business and content dreams are featured regularly in her posts and in her accounts description blinovskaya describes herself as a fairy and assures that dreams have brought you here blinovskayas persona is based on two things on the one hand she performs the dream life based on dominant ideas of how success looks like on the other hand she reaches out to her audience the dream life that you see in my account is accessible to you too you just need to want it blinovskayas conservatism and metaphysical thinking mirrors and exacerbates the mainstreamdominant attitudes in the russian social and political environment as discussed above presented here under the aura of empowerment confidence and selfassertion if instagram as kolpinets writes is a wishmaking machine then blinovskaya with her performer of desires brand is an ideal instagram entrepreneur her courses promise to give audiences the life of their dream perfect relationship perfect body perfect trip and perfect job as popular instagram reels courses promise to teach subscribers how to imitate the instagram perfect life and reproduce the visual clichés that signify it blinovskayas courses promise to make the instagram perfect life a reality yet to be a perfect woman realizing her dreams demands intense laboring a performance characterized by relentless individualism that calls forth endless work on the self and which centres notions of agency empowerment and choice while enrolling women in ever more intense regimes of the perfect what is needed for these perfect dreams to be able to come true is the cultivation of a right way of thinking the right mindset that once acquired can automatically lead to riches and abundance mindsets of empowerment happiness and family the concept of mindset denotes the attitudes beliefs and values a person holds about the world and the phenomena around it the influencers we examined either explicitly or implicitly emphasize to their followers the need to develop a particular mindset a winner mindset which can raise their social position and bring happiness the idea that certain mindsets are problematic while others are desirable is extremely widespread in life coaching cultures with the former being characterized by victimization and fixedness and the latter by empowerment adaptability and resilience the russian influencers follow these global trends and offer normative advice and instructions to reach the desirable mindsets and avoid the problematic ones this advice addressed here primarily to women is usually awash with the selfobjectifying clichés that recollect gills idea of postfeminist sensibility for instance alina levda explains what is the right mindset for a woman who wants to be attractive to men …but a man does not need a mysterious quiet girl or an arrogant iron lady something completely different attracts as a magnet a man falls for special features … when he sees the real manifestation without fear of seeming too light or somewhat infantile what attracts is the essence which is in harmony with the external appearance so for me it is enough just to be myself and to come into this world without limiting judgments that the depth of dignity is an imposed framework of social behavior not at all to be yourself to love yourself and not to be afraid to shine into this world illuminating it with warmth creating energy inside taking care of yourself and as a result taking care of others yes7 reaching the right mindset then requires cultivating a particular way of thinking and behaving such as that women have to be themselves and love themselves yet the idea that a woman has to be herself in order to reach happiness operates as a regulating device a means of discipline that requires presenttime sacrifices including monetary ones for reaching a future promise to illustrate her own reward from possessing this elevated mindset the influencer shares an idyllic series of pictures in which she enjoys time with her husband who cheers for her success throughout the feed the husband serves as a prop which along with the propchildren perform the idea of the perfect family as the influencer maintains a delicate balance between personal development fun and commitment to something bigger than the self the family is another accomplishment in a series of accomplishments a payoff coming from levdas tireless labor with herself a similar regulatory role has the mindset of compulsory selflove that should happen anywhere and anytime indicatively oxana samoylova tags herself for her birthday in dubai a place where many richer russians moved after february 2022 and confesses …i become more and more confident every year more whole and stronger and this is an absolutely amazing feeling i live my life to the fullest i live every day in happiness and gratitude i use every opportunity given to me by god i fulfill all my dreams i gave life to 4 beautiful children i evolve and never stop there is so much more interesting and inspiring ahead i love you life ps and today tomorrow and the day after tomorrow in honor of my holiday i will delight you too moreover like never before to the fullest just go to my stories 8 here the right mindset entails embracing an attitude in which the regulatory ideas of loving life and living it to the fullest are a precondition for happiness in this neverending journey towards selffulfillment god is the provider of opportunities and samoylovas children are the fruits of her long personal quest to reach joy similar to levda the husband and the four children are employed in samoylovas feed as theatrical props performing a script of a perfect life besides as gernot böhme notes the employment of theatricality in the contemporary creative industries aims to create particular potentially monetizable atmospheres by curating the moods which are in the air and the emotional tinge of a space these influencers curate atmospheres of right mindset aiming to inspire followers with recycled stereotypes that not only confirm the dominant values of russian political identities but remodel these values under an atmosphere of desirable luxury and individual empowerment that can reach wider parts of the population in turn yana leventseva a selfdescribed opinion leader who claims to have changed the mindset of 60000 people and equally uses her family to evoke the responsible and committed side of her identity suggests that the right mindset requires proactive individuals not only regarding career but also as concerns more social institutions like friendship think about it when was the last time you took the initiative when did you call your friends to go out somewhere have we forgotten how to be friends why does our brain have so many excuses not to call someone out for coffee right now instead of scrolling through the feed and stories start thinking in this direction and the world will unfold for you and your request9 here the right mindset for leventseva consists of rebelling against the platforms raison dêtre as she encourages followers to go out and meet people instead of scrolling through the feed and stories this symbolic revolt against the infrastructure that contains her influencer persona registers a rebellious spirit that goes against the mainstream eg incessant scrolling that is a spirit that operates outside of the box the brain should change and break with social media addiction leventseva suggests otherwise friendships will end and people will forget what real relations mean 10 in another celebration of the magical powers of the brain leventseva writes our brain always confirms what we believe in and finds what we are looking for for many years now all the pictures from my head have become reality im going to buy a gray gelik 11 i see them everywhere want to go to the maldives immediately there is a partner in crime who agrees to your adventure ill tell you a cool exercise that i give when training called 100 pleasures try to write out 100 desires not material but sensations for example i do it before each trip to wake up with the rays of dawn in the maldives that fall on the bed and to feel their warmth to take a slow hot shower with aroma gel and to feel the hot drops flowing down your body to get under the cool rain that will wet me through and feel the contrast of warm air and cold drops to inhale the aroma of coffee and look at the azure water to walk along the pier in a silk dress and to feel how silk caresses smooth skin to bury your feet in the sand and feel the coolness layer by layer and so on and you will notice how your life will begin to change right from following this list and then you can go into the material what would you like to feel right now 12 this typical metaphysical thinking presents the brain as having the capacity to actualize desires only by thinking about them the desires that are given as examples are fixes to instant gratification operating in the overall context of experience economy where the experience of as many and as diverse sensations and feelings as possible become part of ones identity and vision the audience is here prompted to escape social complexity by means of inspirational magical thinking figure 2 leventseva using her son as a prop source 10 yet addiction is not exactly an individual anomaly in social media usage platforms are act ively creating the conditions for addictive usage so as to exploit attention data visibility and so on 11 gelik is a russian jargon word for gelendvagen a symbol of success and prosperity 12 positivity and depoliticized selfhood similar to the dominant platform cultures around the world the russian influencer scene promotes positivity as a key attitude to overcome obstacles and be happy drawing on the spread of popular psychology positivity is a compulsory injunction an imperative of neoliberal cultures in influencer content positivity translates into inspirational and aspirational injunctions affirmations and gratitude mantras that oversimplify phenomena and cultivate a selfabsorbed and even infantilizing outlook among their publics for instance after a trip in africa samoylova writes the simplest iphone photos just like before and our africa we want to come back here again and again every time is like the first time every safari is like a kinder surprise with emotions and impressions you know those trips that you remember all your life and carefully keep in your heart africa cannot be described or conveyed with photos and videos the only option is to feel it so i just wish each of you to see this untouched wild world with your own eyes 13 here africa is a place that can only be felt it possesses a spirit that eludes rational capture the name of the african country where the influencer was on holiday seems irrelevant as the enigmatic signifier africa is caught in an unproblematic vortex of positivity marked by touristic stereotypes such as safaris and untouched wilderness in this mystification of africa as a raw site of eternal and organic spirituality there is no room for thinking through negativity such as poverty colonialism and structural injustice while the africans themselves are absent from the picture the generation of upbeat content is not accidental to these russian influencer cultures but derives from instagram audiencing itself as scrolling audiences tend to turn their attention to digestible and uncritical messages that are funny creative and inspirational14 for instance it is indicative that none of these russian influencers has posted a negative post to refer to the war in ukraine a devastating event that dominated local and international discussions this absence is as telling as it is expected the influencers not only know that they may be cancelled or attract unwanted publicity if they touch upon sensitive issues which can lead to them being tagged as a risky investment from the advertisers but also that negative content can alienate their audiences instead the surrounding negativity becomes the ambience against which individual pleasure fixes or longer strategies of the self can evolve as the first months of the war were a period of intense uncertainty for russian audiences the influencers often treated this uncertainty as a raw material a background for further spreading positive messages for instance levda in april 2022 starts a post by saying if there is no point in planning your life much ahead yet maybe allow yourself to live the way you want now15 and goes on to explain how we should do whatever we want and feel without depending on the circumstances that always change in early march 2022 blinovskaya writes the world is changing and so am i ☺️😉 but everything is for the better no matter how difficult it may be to believe now the best investments are investments in yourself the best thing we can do is get to know and improve ourselves and our skills it will definitely pay off16 here the surrounding negative context is repurposed for engaging with an even more intense preoccupation with the self turning a disturbing political situation into a backdrop where selfdevelopment should occur no matter what this is a structural effect of influencer economies in which as we discussed above the less confrontational an influencer appears to the beliefs of their audiences and stakeholders the more potential they have for maintaining and expanding their clout the presentations of the self around regimes of happiness positivity selfgrowth and unfettered joy amidst surrounding negativity curate a depoliticized selfhood that is one that is constantly mobilized into looking at personal solutions instead of collective ones this depoliticization infantilizes audiences as africa turns into a mystical escape route for middleclass fun and adventures and the war becomes an opportunity for opening new personal avenues conclusion to recap platform spirituality inhabits the combination of metaphysical and entrepreneurial sensibilities and spreads them through the use of social media including instagram and also other popular platforms like youtube and tiktok while religious spirituality inhabits more collective and selfnegating modalities the design architecture of platforms encourages modalities of individuation eg profiles payment systems algorithmic recommendations and modes of socialization that correspond to named individuals following platforms encourage a selfabsorbed understanding of the right spirit or often the right mindset as a resource whose possession can lead to success happiness and abundance they espouse the metaphysical tradition but also rely on the authority of popular science for instance in the form of short quotations by popular psychologists that are authoritatively used to prove ones claim platform spirituality is based on the wider subjective turn of contemporary religiosity that gives path to capitalist spirituality in the context of a global neoliberal market system at the level of the individual this shift manifests in a desire to connect with an inner self through practices of wellbeing and mindfulness that according to this worldview lead to prosperity the ultimate goal in parallel with platforms that seek to capture audience attention platform spiritualities connect the language of mindfulness with profitoriented content creation in the case of russian female bloggers this profitoriented spirituality is accompanied with the postfeminist injunction for women to construct and selfregulate their own human capital in all spheres of life that is focus on their selves travel dressup dream about wealthy husbands and exotic sensations and prioritize their own wellbeing and empowerment over anything else in an increasingly conservative political and social context through the thematic analysis of the instagram posts that were created by four top russian instagram influencers we have encountered three key elements that contribute to the construction of the individualistic spiritual narrative perfection as the goal mindset as the way to achieve it and positivity as a tool to avoid obstacles such as political and social crises the spirituality that we are looking at is an evasive concept sometimes it can be more pronounced such as with elena blinovskaya who openly employs esoteric language such as egregore in other cases it can manifest itself in general injunctions to reach your inner self or simply think positively as a path to happiness and success ethics this research was conducted in line with the aoir guidelines 2019 this study has not intervened with any personalsensitive information of the subjects the research was conducted on the basis of open social media accounts that are accessible to the general public and content cited according to the needs of transparent analysis with reference to the content producers

in this article we look at how preeminent russianspeaking influencers spread sensibilities of entrepreneurialism and postfeminism on social media platforms and specifically instagram drawing on platform studies critical theory and material from influencer accounts we explore the ways that platformbased spiritualities are embedded in the neoliberal economies of selfpresentation microcelebrity and branding in russia and beyond we understand spirituality as a broader figure encompassing both external beliefs in the divine such as in magic spirits and forces that lie beyond human understanding as well as internal beliefs in spiritual tropes for reaching selfdevelopment including exercise mindfulness and life coaching among others by amplifying presentations of the self around regimes of happiness positivity selfgrowth and unfettered joy platform spiritualities nullify critical thought and normalize a depoliticized conception of selfhood in the russian public space influencers encourage women to focus on themselves travel dress up dream about wealthy husbands and exotic sensations and prioritize their own wellbeing and empowerment over social or collective concerns the depoliticized discourse of these influencers is largely an outcome of the social media imperative to produce safe and riskless content under the fear of cancellation which can lead to a loss of advertising and other forms of revenue we argue that rather than being simply progressive vehicles for democratic publics and participatory cultures social media platforms and instagram in particular are key to intensifying an entrepreneurial selfhood that relies on magical thinking and spiritual guidance from abstract authorities in repressive political contexts

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introduction the aging process is very complicated with obvious changes both physically and psychologically as people get older the risk of having multiple coexisting chronic diseases increases recently 92 diseases have been identified as age related accounting for 513 of all global burden among adults in 2017 1 however physical degradation chronic diseases and disability associated with aging may cause psychological pressure negative emotional feelings and even depression 2 this is a phenomenon that requires attention in an aging society 2 the world health organization reported that the incidence of unipolar depression is 7 in the elderly and accounts for 57 of years lived with disability for those over 60 years old 3 depression can cause great pain and adversely affect the activities of daily living even more so than other chronic diseases often associated with a profound impact on ability in a systematic review on the morbidity rate of depression in older adults 74 studies involving a total of 487275 people aged 60 years and above were included the morbidity rate of depression was determined to be 47160 with a median morbidity rate of 103 4 depression is associated with physical and psychological problems soysal et al 5 found that among 2167 older patients with depression the prevalence of frailty was 4040 moreover depression may lead to suicide the taiwan ministry of health and welfare reports 6 indicate that the suicide rate among middleaged and older people was the highest among all age groups and depression was an important factor of this 7 reviews of published literature indicate that many factors are associated with depression social support is one such factor found to be associated with depression 8 moreover high rates of low health literacy among older adults along with a high prevalence of chronic conditions may lead to increased levels of depression symptoms 910 however the relationship between the level of health literacy social support with exchange and depression remains largely unknown and unexplored thus the present study investigates the mediation effect of health literacy on the relationship between social support with exchange and depression social support with exchange and depression social support is a mechanism that relieves life pressure and promotes health at the same time thereby contributing to positive psychological effects middleaged and older people with less social support have a higher incidence of depression 89 11 12 13 14 15 16 a systematic review of 24 studies found that good social support is associated with the reduction in depression 17 however relying on the support of others may lead to guilt and anxiety 18 in contrast if older adults are provided with instrumental assistance it can help prevent a decline in their daily living activities 1920 brown et al 21 also identified that older adults who were provided tools by friends relatives and neighbors exhibited significantly reduced mortality there is accruing evidence that providing social support may be more beneficial than obtaining social support 2122 thus our first hypothesis is that social support and exchange affects depression the nature of such effect forms one of the questions addressed in the present study social support with exchange and health literacy health literacy is an important factor in determining public and personal health and is regarded as the core of patientcentered care 23 nutbeam 24 defined health literacy as a personal cognitive and social skill that determines the individuals ability to obtain understand and use information to promote and maintain good health poor health literacy is a silent epidemic across the globe affecting every aspect of health 25 in several reports a lack of health literacy has been associated with higher mortality poor selfmanagement skills lower satisfaction with medical communication poor awareness of diseases higher hospitalization and emergency medicaluse rates incorrect use of medication low utilization of preventive healthcare services high prevalence of chronic diseases and high healthcare costs 2627 there are suggested associations between health literacy and social support this includes reports by liu et al 28 showing that health literacy was positively correlated with social support but negatively correlated with depression in 637 adults aged ≥65 years with hypertension and diabetes living in the community this indicates that older people with higher health literacy tend to have better social support and relatively lower levels of depression on this premise we next hypothesized that the interaction of social support with exchange is affected by health literacy and investigated the nature of the probable effect of health literacy on social support health literacy and depression many studies have shown that poor health literacy is significantly associated with increased incidences of depression 91015 29 30 31 32 including middleaged and older adults a study of 3260 older people showed that compared with persons with sufficient health literacy skills those with insufficient health literacy were 12 times more likely to be depressed however this was mostly explained by the bidirectional relationship between health literacy and depression which may be mediated by health status 9 hsu et al found that improving the health literacy of diabetic women elicited reduced psychological distress in those with depression as shown by the negative correlation between health literacy and depressive tendencies 10 in fact for each 1point rise in the chinese health literacy scale for diabetes score the center for epidemiologic studies depression scale score decreased by 017 points 10 thus extrapolating from the general population to a more specific age group the present study evaluated the relationship between health literacy and depression in middleaged and older adults with the working hypothesis that health literacy is inversely associated with depression health literacy as a mediator between social support and depression this present study investigates the relationship between health literacy social support with exchange and depression liu et al 28 described health literacy as a predictor of social support and depression zhang et al 32 concluded that physical comorbidity and health literacy mediate the relationship between social support and depression among patients with hypertension in their study of 549 hypertensive adults however little is known about the protective effect of health literacy on middleaged and older people against this background we further hypothesized that health literacy has a mediation effect on the relationship between social support with exchange and depression to further clarify the mediation effect of health literacy on the relationship between social support with exchange and depression this study also adjusted other related factors as far as we know this is the first study to investigate the mediation effect of health literacy on social support with exchange and depression in middleaged and older people in taiwan theoretical framework according to sørensen et al 33 health literacy is linked to literacy and entails peoples knowledge motivation and competency to access understand appraise and apply health information towards making judgments and decisions in everyday life concerning healthcare disease prevention and health promotion to maintain or improve quality of life during ones life course sørensen et al 33 proposed an integrated model of health literacy which combines the qualities of a conceptual model outlining the main dimensions of health literacy and those of a logical model showing the proximal and distal factors which impact health literacy as well as the pathways linking health literacy to health outcomes the core of the model is the ability to acquire understand evaluate and apply healthrelated information across the three dimensions of health literacy namely health care health promotion and disease prevention in addition to the components of health literacy the model also shows the main antecedents and consequences the antecedents are personal determinants and situational determinants moreover health literacy could affect health service use health costs heath behavior and health outcomes at the individual level and participation empowerment equity and sustainability at the population level we used this model as the framework of this study in summary the path model of this study aimed to confirm the mediation effects of health literacy on the relationship between a situational determinant namely social exchange with emotional support and a health outcome depression with the personal determinants of middleaged and older people as control variables methods study design and data collection since 1987 taiwan has been conducting surveys and studies collectively known as the taiwan longitudinal study on aging in order to understand the health and living conditions of middleaged and older people over the age of 50 eight research sessions were completed between 1989 and 2015 34 the tlsa survey adopts stratified random sampling allowing the collected data to fully reflect the physical psychological and social aspects of the participants data and results from the tlsa project can also serve as empirical basis for the formulation of social and healthcare policies for older adults this study used data from a component of the tlsa termed the longterm tracking survey of the physical and mental and social life of the middleaged and older people in taiwan in 2015 measures 231 demographic characteristics the demographic characteristics evaluated included gender age and education level consistent with lin et al 35 according to their age participants were divided into two groups 50 to 64 years and 65 to 85 years similar to the levels of education used by xu et al 36 the study cohort was also divided into two strata junior high school or lower and senior high school or above social support with exchange scale this 7item scale consisted of two subscales social exchange and emotional support the three questions on social exchange were scored on a scale of no occasionally and often the total score range of the three items was 06 a higher total score indicated a greater frequency of social exchange which in turn implied better social support there were four questions on emotional support the scoring method was divided into very supported supported normal not supported very unsupported the total score range of the four items was 420 a lower total score indicated better emotional support of the respondent in this study the cronbachs α of the scale was 070 the social support with exchange scale facilitated the understanding of the social status of the middleaged and elderly in taiwan such as the participants family structure living arrangements social support leisure activity socioeconomic status life satisfaction occupation and retirement and awareness and utilization of services provided by the government 37 health literacy scale the scale contained three dimensions health care health promotion and disease prevention there were a total of 9 items which were scored on a 5point likerttype scale the total score range was 945 a score of 20 points or less was considered to indicate good health literacy in this study the cronbachs α of the scale was 086 the tlsa health literacy scale is a reliable and valid instrument for measuring health literacy in middleaged and older people 38 as alluded to already the health literacy scale allows the comparison of the differences in health and social status among subgroups of people characterized by their socioeconomic background 37 center for epidemiological studies depression scale the abbreviated version of the center for epidemiological studies depression scale was used to measure depression during the survey the scale was composed of 11 questions out of the original 20 questions on the cesd developed by radloff 39 the short version of the cesd scale included three factors physical symptoms depressive emotions and positive emotions each of these 11 items was scored on a 4point likerttype scale of rarely 0 to frequently or consistently 3 the total score range was 033 a higher score indicated a higher frequency of depression whereas a score of 8 or higher indicated obvious symptoms of depression the cronbachs α ranged from 076 to 081 indicating that the tlsa short version of the cesd scale which was based on the iowa epese had good internal consistency reliability 40 in this study the cronbachs α of the scale was 071 statistical analysis in this study the chinese version of spss 220 was used for data analysis all variables adopted descriptive statistics variable correlation analysis and univariate linear regression were used to examine the association between social support with exchange health literacy covariance and depression scales the process procedure for spss version 352 statistical software model 4 41 was used to analyze the mediation effect of health literacy on social support with exchange and depression in middleaged and older adults the bootstrap participants numbered 5000 and a 95 confidence interval was set to achieve sufficient statistical analysis power since the gender age education level and key variables were all related we used these three as covariates in the mediation regression model results descriptive statistics the descriptive statistics of the participants are listed in table 1 our total participants consisted of 3917 females and 3719 males the largest groups were those 6585 years old and above and those with a primary or junior high school level education the average depression score was 43 ± 53 the depression group was older and mostly female and had a low education level social support with exchangesocial exchange was low social support with exchangeemotional support was poor and health literacy was also low in addition the average scores of social support with exchangesocial exchange social support with exchangeemotional support and health literacy were 203 ± 001 733 ± 255 and 1512 ± 592 respectively most of the participants had sufficient health literacy the correlation of health literacy and social support with depression the correlations between the key variables are listed in table 2 health literacy was positively correlated with depression indicating that better health literacy was related to lower depression social support with exchangesocial exchange was negatively correlated with depression indicating that better social exchange was associated with a lower degree of depression social support with exchangeemotional support was positively correlated with depression suggesting an association between worse emotional support and a higher degree of depression the mediation effect of health literacy based on baron and kenny 42 this study proposes the conditions and tests of the intermediary variables the results of the model are shown in figure 1 paths a b and c represent standardized regression coefficients between paths path c presents the association between social support with exchange and depression path a shows the association between social support with exchange and health literacy path b shows the association between health literacy and depression and path c presents the mediation effect of health literacy on social support with exchange and depression the direct indirect and total effects of the key research variables are presented in table 3 the indirect effect was defined as the product of coefficients a and b 43 if the 95 bootstrap ci did not contain zero the indirect effect was considered to be significant indicating that there was a mediation effect health literacy had a mediation effect on social support with exchange and depression discussion this section will discuss the hypothesis proposed in this research and report the related limitations health literacy status positively correlates with social support with exchange but is inversely associated with depression in this nationally representative study with middleaged and elderly communityresident participants we found that the prevalence of depression in middleaged and older people was 194 which was lower than the prevalence reported in the previous study 44 and lower than those in india and south asian countries 45 however it was higher than the worlds median of depression in an older population of 103 4 which in turn was higher than the 13 rate in the united states 46 139 in sri lanka 13 and 185 in thailand 47 therefore surveys of depression in older adults are easily affected by the differences in customs and cultural backgrounds of various countries the total effects of social support with exchangesocial exchange and emotional support on depression in middleaged and older people were significant which supported hypothesis 1 the effects of social support with exchangesocial exchange and emotional support on the health literacy of middleaged and older people respectively were significant thus supporting hypothesis 2 the effect of health literacy on depression was which supported hypothesis 3 when health literacy was incorporated into the regression the effect of social support with exchangesocial exchange on depression became nonsignificant indicating that health literacy could completely mediate depression in social support with exchangesocial exchange figure 2 shows that after adjustments for gender age and education level health literacy still had a complete mediation effect on the relationship between social support with exchangesocial exchange and depression in addition the influence of social support with exchangeemotional support on depression was significant indicating that health literacy could have a partial mediation effect on depression between social support with exchangeemotional support accounting for 1646 of the total effect these results supported hypothesis 4 discussion this section will discuss the hypothesis proposed in this research and report the related limitations health literacy status positively correlates with social support with exchange but is inversely associated with depression in this nationally representative study with middleaged and elderly communityresident participants we found that the prevalence of depression in middleaged and older people was 194 which was lower than the prevalence reported in the previous study 44 and lower than those in india and south asian countries 45 however it was higher than the worlds median of depression in an older population of 103 4 which in turn was higher than the 13 rate in the united states 46 139 in sri lanka 13 and 185 in thailand 47 therefore surveys of depression in older adults are easily affected by the differences in customs and cultural backgrounds of various countries discussion this section will discuss the hypothesis proposed in this research and report the related limitations health literacy status positively correlates with social support with exchange but is inversely associated with depression in this nationally representative study with middleaged and elderly communityresident participants we found that the prevalence of depression in middleaged and older people was 194 which was lower than the prevalence reported in the previous study 44 and lower than those in india and south asian countries 45 however it was higher than the worlds median of depression in an older population of 103 4 which in turn was higher than the 13 rate in the united states 46 139 in sri lanka 13 and 185 in thailand 47 therefore surveys of depression in older adults are easily affected by the differences in customs and cultural backgrounds of various countries this study found that in terms of gender differences middleaged and older females were more likely than their male counterparts to have depression this finding was consistent with those in previous studies that the female gender is a risk factor of depression in old age 213 44 45 46 47 48 49 50 51 52 moreover age is positively correlated with depression as age is an important determinant of mental health due to the normal aging of the brain the deterioration of physical health and brain diseases the overall prevalence of mental and behavioral disorders has been shown to increase with age 245 we demonstrated that the severity of depression increases with age as was consistent with the findings of previous studies 2454849 furthermore we found that a low educational level was significantly associated with a higher risk of depression corroborating the findings of portellanoortiz et al 50 and ylli et al 52 in a crosssectional study a total of 93590 people over 55 years of age in 18 countries completed questions related to depressive symptoms using the shortened cesd or eurod scale the study indicated depression prevalence was generally highest among women individuals aged 75 years or older those who were divorced widowed or single and those who did not attain a secondary education 53 which is similar to our research results our data showed that 792 of the middleaged and elderly people had sufficient health literacy similar to the results of a finnish study which found that 514 had sufficient literacy and 123 had excellent health literacy 54 however this is higher than the figures reported in studies from the united kingdom the united states taiwan and germany with 495 51 537 and 6680 of persons older than 65 years having poor or limited health literacy respectively 55 56 57 58 or worse still in turkey where 851 of the elderly are considered to have problematic or insufficient health literacy 59 components of social support with exchange differentially affect depression social support elicits better mental health the results of this study indicate a negative correlation between social support with exchangesocial exchange and depression a higher score for social exchange indicated that better social exchange was associated with lower levels of depression this may be related to the traditional concept in chinese culture that it is more blessed to give than to receive in chinese society providing support to others increases happiness in older people 60 brown et al 21 pointed out that giving support may be an important part of interpersonal relationships and has considerable value for health and wellbeing chen et al 61 stated that encouraging individuals to provide appropriate support such as helping others and being willing to accept support may be beneficial for wellbeing and longevity conversely social support with exchangeemotional support was positively correlated with depression implying that a higher score on emotional support indicated worse emotional support and thus a stronger likelihood to depression this impact of social support on depression is consistent with findings from other studies 9136263 gyasi et al 64 found meaningful social support to be a key element of life in older people by strengthening opportunities to establish closer interpersonal relationships with others older adults could improve their mental health independence and quality of life therefore social support with exchange helps people release negative psychological pressure during the aging process social support with exchange reflects health literacy status social support with exchangesocial exchange was negatively correlated with the health literacy of middleaged and older people which means that better social exchange was associated with higher health literacy consistent with the conclusions of previous studies 2858 65 66 67 we found emotional support was positively correlated with health literacy suggesting that if the degree of support was poor the level of health literacy was also low thus the rationality of de wit et als proposed practice of collaborative learning and social support to improve the health literacy of older people 68 moreover social support could help alleviate the negative effects of low health literacy 65 inadequate health literacy is implicated in mental health deterioration and depression this study found that health literacy was positively correlated with depression inadequate health literacy in middleaged and older people was associated with the deterioration of physical and mental health including increased depression this finding aligns with those previously reported 9103154 and therefore it can be stated that insufficient health literacy is strongly related to depression gazmararians team in their seminal study of 3260 elderly people found that individuals with inadequate health literacy were 27 times more likely to be depressed compared with individuals with adequate health literacy 9 in addition do et al 69 in their study of 928 adults aged 6085 reported that every onepoint increase in health literacy decreased the likelihood of depression by 9 concurring with parikh et al 70 we found that people with low health literacy often feel shame and embarrassment which can cause social isolation and constitute a serious psychological barrier to seeking help this in part explained the observed higher odds of depression among people with lower health literacy than their peers with higher health literacy thus we posit that improving health literacy has a health protective effect for older people and is a protective factor against depression for contextualization the current covid19 pandemic is associated with increased anxiety and mental health problems in the public 71 72 73 and as established by robb et al 13 of the elderly feel worse in terms of depression 51 however a 45 reduction in the likelihood of depression was reported for each unit increase in health literacy score further highlighting the protective effect of health literacy against depression during the pandemic 74 health literacy significantly mediates the relationship between social support with exchange and depression to the best of our knowledge this study is the first to analyze the relationships between social support with exchange health literacy and depression among the elderly in the community our results showed that the health literacy status of middleaged and older people has a mediation effect on the relationship between social support with exchange and depression when social support with exchange and health literacy were input into the final mediation model the association between social exchange and depression was eliminated and the relationship between emotional support and depression was reduced accounting for 1646 of the total effect size the reason for this may be that the need for listening and caring is extremely important in chinese culture and society 63 our findings on the mediation effect of health literacy is consistent with those by zhang et al 32 and zou et al 15 validating the working hypothesis of the present study health literacy mediates the impact of social support with exchange on depression among the elderly in the community therefore the improvement of health literacy and intervention measures require due attention duong et al noted that entertainment series and educational tv programs on health promotion and healthrelated community activities help increase health knowledge and health behaviors thereby improving health literacy 75 as rightly opined by nutbeam 24 findings in the presented study do suggest that the improvement of health literacy should emphasize more personal communication communitybased education outreach and health education content with a focus on suitable equipment to overcome structural barriers to peoples health therefore we recommend that coping strategies and support resources be provided to help middleaged and older people improve their health literacy and mitigate or prevent depression herein our results echo the health literacy integration model proposed by sørensen et al 33 this study confirmed the mediation effects of health literacy on the relationship between situational determinants personal determinants and the health outcomes of middleaged and older people herein our results echo the health literacy integration model proposed by sørensen et al 33 this study confirmed the mediation effects of health literacy on the relationship between situational determinants personal determinants and the health outcomes of middleaged and older people limitations of this study this study has some limitations first the individuals in this study were middleaged and older people living in the community compared with individuals living in institutions they may have relatively better mental health social support with exchange and health literacy second because the health literacy assessment was a component of the first survey in 2015 continuous data analysis could not be done third unlike analytic devices used for clinical diagnosis the cesd indexes only selfreport current symptoms therefore depression symptoms may be overestimated finally the inclusion of other age groups in the study participants may also be necessary in extending the limitations of this study this study has some limitations first the individuals in this study were middleaged and older people living in the community compared with individuals living in institutions they may have relatively better mental health social support with exchange and health literacy second because the health literacy assessment was a component of the first survey in 2015 continuous data analysis could not be done third unlike analytic devices used for clinical diagnosis the cesd indexes only selfreport current symptoms therefore depression symptoms may be overestimated finally the inclusion of other age groups in the study participants may also be necessary in extending the conclusions to a larger population conclusions in middleaged and older people social support with exchange differentially affects depression and this association is mediated by health literacy status improving health literacy offsets the adverse effects of social support with exchange on depression in view of these results multidisciplinary intervention measures should be formulated to increase the social exchange component of social support with exchange and improve health literacy so as to reduce the likelihood and incidence of depression in addition the results of this study echo sørensens health literacy integration model which extends the need to improve health literacy and patientfamily engagement empower people to take charge of their health and better prepare them to deal with health crises rather than becoming passive recipients of services this is an integrated peopleoriented health service the results reported herein may serve as an evidencebased reference for evaluating andor mitigating depression in middleaged and older people in taiwan data availability statement the data that support the findings of this study are available from health data science center taiwan but restrictions apply to the availability of these data which were used under license for the current study and so are not publicly available data are however available from the corresponding author upon reasonable request and with permission of the taiwan ministry of health and welfare funding this study was not funded by any institution or manufacturer institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by fu jen catholic university institutional review board informed consent statement informed consent was obtained from all subjects involved in the study

the proportion of the worlds population that are over 60 years old is increasing rapidly the physical and mental health of older people is affected by depression health literacy is a major determinant of health and healthcare for the aging middleaged and older people with high health literacy are more likely to maintain a healthy lifestyle and control or manage their chronic diseases therefore this study explored the relationship between health literacy social support with exchange and depression in middleaged and older adults in the community using data from the 2015 taiwan longitudinal study on aging tlsa database of the 7636 participants 1481 194 were middleaged or older persons with depression symptoms we found age gender and education level to be significantly related to health literacy status social support with exchange and depression health literacy was positively correlated with depression and social exchange in social support with exchange whereas the emotional support component of social support with exchange was negatively correlated with depression regressionbased process analysis was used to verify the mediation effect of health literacy our results indicated that when health literacy was entered into the regression model a × b path the effect of social exchange on depression was insignificant c 001 p 084 indicating a complete mediation effect these findings suggest that improving health literacy may offset the impact of social support with exchange on depression and lead to the mitigation of depression in middleaged and older people in taiwanese communities

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introduction patterns of traveler behaviors have increasingly changed in recent years and industry leaders and professionals are working diligently to change along with them one of the most recent changes regarding patterns of airline passenger behavior is an astronomical increase in air rage incidents although air rage is not a new phenomenon it has become newly relevant because of the recent escalation in frequency and intensity it is well documented how significantly disruptive passenger behavior can threaten the safety and security of an aircraft passengers and crew for example recent attention from the international transport workers federation shows concerns and efforts regarding safety and defense for airline staff in the presence of unruly passengers therefore a statement of the problem is that over the past 2 years airline passengers are suddenly engaging in physical fights and extreme verbal confrontations on airplanes in record numbers therefore one of our research questions is what has changed in the airline industry during the last 2 years that has contributed to alarmingly high numbers of air rage incidents our initial research efforts answered this question fairly quickly the short answer is the biggest change in airline passenger behavior over the past 2 years was the introduction of wearing masks in public during the pandemic of the 5981 reported unruly passenger incidents in 2021 4290 were maskrelated incidents put simply masks and maskrelated issues have been the biggest recent change in the airline industry over the past 2 years that means masks and maskrelated issues are at the core of this social problem however more importantly we still do not fully understand why people are fighting on airplanes over masks and maskrelated issues therefore we asked a second research question what is it about masks that contribute to groups of people fighting on airplanes in record numbers our exploration into this topic will provide valuable sociological insight into this recent social problem as this exploratory study aims to investigate air rage using sociological perspectives our research may be beneficial to those interested in tourism and hospitality among other industries as well methodology we conducted a qualitative content analysis of online material related to air rage incidents posted between 2020 and 2022 we triangulated data from several online sources including news stories about air rage youtube videos of actual air rage incidents comments posted below youtube videos of air rage incidents as well as interviews with professionals and experts who spoke about this issue we decided to use a content analysis of online sources because it was the most strategic way to gather large amounts of qualitative data within the limited time we had along with the limited resources available to us researchers further it was not possible for us researchers to be present in real time to gather firsthand qualitative data during thousands of air rage incidents finally this approach also gave us incredible access to a variety of perspectives which included videos containing interviews and reports from industry professionals and experts whom we may not have been able to reach otherwise for example five lengthy interviews were included in our analysis of online video coverage concerning this topic with airline industry professionals experts and airline leaders which included the president of the association of flight attendantscwa aflcio a flight attendant assaulted in an air rage incident a university professor of international business and author of the book air rage crisis in the skies and the former ceo of spirit airlines under ideal circumstances we would have preferred to conduct personal interviews with previously mentioned experts and professionals as well as with airline staff and passengers however we were not able to conduct personal interviews or make firsthand observations due to time and resource limitations during phase one of our research process we collected data from dozens of website news articles written about this topic between the timeframe of 2020 and 2022 we analyzed articles and news stories on this topic that were relevant to our research during phase two of the research process we used the internet to collect and observe roughly on 117 min of recent youtube video footage captured and posted by bystanders of actual air rage incidents we exhaustively watched the footage as we gathered relevant data based on our observations during phase three we collected and analyzed the data from thousands of available comments posted below recent youtube videos of air rage incidents we gathered hundreds of comments that were relevant to our research we realistically could not include every available comment in this study therefore any comments we provide as examples later in this paper are representative of our overall discoveries for anonymity purposes we did not include actual names or usernames of peoples comments who we selected to use as examples we continued to gather data until we reached a point of data saturation during the next step in our research process we used an open coding approach as we developed categories based on patterns that emerged from our data we discovered the following categories which we will provide specific quotes and comments as examples later in this paper personal insults roll of technology physical and verbal altercations spatial factors the uncertainty over usefulness and effectiveness of masks politics ingroupoutgroup statuses and culture although interesting our discoveries listed above do not get to the root of this issue alone consequently it was vital to our research that we apply a sound theoretical framework to our analysis of the data to gain rich insight into this social phenomenon therefore our research is theoretically guided by collins idea of interaction ritual chains which he developed from durkheims work involving religion and rituals as well as the idea of interaction rituals which were offered by infamous sociologist irving goffman we found it useful to reference some of collins most recent work regarding ir according to collins …there are several ingredients or variables that go into a ritual that is successful in creating solidarity and these can be analyzed in any social encounter whether it has the formal qualities of explicitly recognized rituals or are informal rituallike activities in a durkheimiangoffmanian sense the ingredients necessary to create successful social encounters include copresence mutual focus of attention shared mood or emotion rhythmic entertainment social solidarity emotional energy collective symbols and moralities of right and wrong ultimately our research actualizes collins statement that interaction ritual is a term of tradition and convenience what is important is to see what affects whether solidarity will be high low or nonexistent in any particular situation therefore during the fourth phase of our research process we compared categories we developed with the ir framework discussed by collins to see what implications an ir framework may have on our research overall we found conflicts between what the ir framework suggests is needed for successful social encounters and what our data reveal is frequently taking place inside aircrafts today our discoveries provide sociological insight into why groups of people are fighting on airplanes over maskrelated issues which we discuss more in detail later in this paper first however in the following section we will provide a brief review of relevant literature regarding air rage literature review many changes have occurred in the airtravel industry over time including seat size technologies delays and cancelations and overcrowded airports most of which are known to contribute to unruly passenger behavior other causes of air rage have been suggested over the last 20 years as well with much research focusing on alcohol consumption being the leading cause of air rage our review of the literature on this topic will show several passenger stressors that are historically correlated with air rage incidents others identified disruptive passengers as a growing problem as early as the mid1990s mclinton et al extensively explored disruptive airline passenger behavior prior to the pandemic their metareview of the literature on this topic synthesized and summarized the overarching characteristics of 19 studies conducted on issues surrounding air rage their findings identified alcohol consumption as a primary cause of disruptive airline passenger behavior as previously mentioned their work was conducted prior to the onset of the pandemic therefore their research does not include maskrelated issues coyle et al also reviewed this topic from a historical approach ranging from 2000 to 2020 which included multiple factors such as year flight details age nationality of passengers involvement of flight crew stage of air journey flight diversions presence of intoxication psychiatric history and fear of flying others such as goldsmid et al also provide insight into this topic by researching service failure intoxication criminal and civil policies and risks of harm and consequences overall a significant amount of literature on this topic reveals more about how the declining quality of air travel continues to plague the airline industry today long gone are the days when passengers ate a complimentary hot meal using actual silverware the large luxurious seats of the 1950s slowly evolved into the highly cramped seats we see today also referred to as sardine seating arrangements seat width and pitch have narrowed quite a bit and vary tremendously among airlines and aircrafts it was reported that seat width the distance between armrests has shrunk up to 4 inches over the last 20 years from roughly 20 inches to 17 inches with a few airlines as little as 16 inches these have been compared to the average movie theater seat where the average width is 25 inches airline seat pitchthe distance from one row to the next has shrunk from 36 inches to 31 inches with a few airlines as little as 30 inches an adequate seat size and a comfortable seat promote proper rest general comfortability and sleep while some passengers involved in air rage incidents have blamed the shrinking seat size another subtle change in passenger behavior is that the elegance of passengerdress during the1950s has been replaced with more casual sometimes inappropriate attire such as oversized pajamapants and or sleepwear for some travelers the novelty of flight seems to have worn off as according to dahlberg modern airline passengers are no longer in awe of the technology of flight major aviation issues also include late arrivals canceled flights and lengthy tarmac times the term tarmac time refers to the amount of time sitting on an airplane stuck on a runway where the aircraft is not moving the stress from flight delays cancelations ontime performance and tarmac time does not promote health and wellbeing but instead contributes to a deterioration of comfort and overall satisfaction which are known to contribute to incidents of air rage hunter reported that in 2007 planeloads of passengers sat locked in planes on airport tarmacs for 612 h at a time sometimes with limited access to basic needs such as food water and other resources this is supported by goguen who wrote that in august 2009 47 passengers spent almost 6 hours sitting onboard a plane that was parked on the tarmac of rochester international airport in minnesota mpr news further elaborated that this was nearly an overnight tarmac stay this infamous case got the federal governments attention and tarmac rules changed the following year the unknown of sitting endlessly on the tarmac might trigger emotional insecurity and discomfort which can account for some incidents of air rage in many instances delays and cancelations are a common occurrence since the hubandspoke system in air travel was developed according to irving the idea of the hubandspoke system was to concentrate traffic to a given airport which is considered to be the major hub and the routes toandfrom the airports are referred to as the spokes similar to a wheellike process regarding the hubandspoke system time management stands out as a major issue and may be correlated with incidents of air rage the system relies on the arriving aircraft landing on time so that this same aircraft can also depart on time with a plane full of new passengers if one aircraft is delayed the entire hubandspoke system for that airline may be severely disrupted this failure contributes to increased tarmac times and delayed flights with decreasing ontime performances this system seems to make economic sense since it increases city market share although it does not come without drawbacks airlines do not seem to have an answer to this issue as passengers have become increasingly agitated by delayed and canceled flights this system along with many issues it presents is known to contribute to disruptive passenger behavior while some literature focused on the aircraft temporal issues andor flight patterns others have focused on the airport itself for example decelles et al conducted an indepth study of air traveler behaviors at gates before boarding their flights some of the stressors they found include flight delays physiological disruptors and overcrowding they concluded that not only is an airplane a stressful environment but so are airports in general moyle and muir identified several airport stressors that can be connected to flightrelated challenges mentioned previously another documented passenger stressor common to the airport experience is the role that technology plays during travel technostress is a term that refers to feelings of burnout and exhaustion primarily due to technological overuse and overconnectedness technostress is something that many people experience in everyday life as well as during modern travel experiences all too frequently for many travelers today intended relaxing holidays become full of exhausting and draining pressures often due to technological demands for example cohen et al showed how many travelers rely on and trust technology to search for information to buy products to share opinions and experiences and to search for information however as convenient and helpful as technologies can be opposing demands that technologies impose on health and wellbeing are plentiful for example ozdemir and goktas thoroughly discuss how the overuse of information and communication technologies is associated with various health issues ranging from anxiety and depression to addiction and loneliness in other words modern technologies have been shown to have harmful social and psychological side effects for example technologies can create demands even false demands including a sense of urgency to immediately reply to a nonurgent text message or social media post which can additionally add more stress to the already intense experience of navigating through an airport certain technologies can create more demands than necessary as people attempt to keep up with the latest uses and gratifications of technological gadgets while traveling rather than enjoying restorative and rejuvenated travel experiences many passengers find themselves bringing their work and personal baggage along with them on their travels via their technological devices while often feeling drained and sometimes trapped by them clearly the travel experience has drastically transformed in recent years our brief review of the literature provided above is twofold firstly it is intended to acknowledge that there are several documented passenger stressors which have been historically correlated with incidents of air rage and second this review shows that there is a gap in the literature regarding how masks and maskrelated issues are a new and significant factor in reports of air rage incidents as we were not able to find any scholarly articles about this issue at this time we do not claim that our current research discoveries somehow replace other known passenger stressors in terms of air rage rates of alcohol consumption delays cramped seating cancelations and uses of technologies are still important contributors to unruly passenger behaviors to this day our research in the sections below shows that there is a new contributing factor to unruly passenger behavior that is worthy of scholarly attention hence our research updates the literature on this topic and is intended to show how masks and maskrelated issues are now added to the increasingly long list of social factors associated with air rage incidents results and discoveries overview of the data masks in general are deeply symbolic objects loaded with various social meanings for example according to inglis masks are powerful objects in various ways including magical ones they are intimately associated with identity and transformations of identity masks play a role in citizenship as esthetic objects they impact policing they invoke culturally and geographically variant responses masks are deeply gendered they play significant roles in the symbolism of crime and social deviance masks are often profoundly political they are often involved in social disorder masks are ambiguous and they often represent issues of death and life in other words for a multitude of reasons varying meanings of masks cause a great deal of contention in society which is consistent with what we discovered throughout our research process after observing nearly 117 min of recent youtube footage of various air rage incidents as well as analyzing several hundred recent youtube comments about air rage videos online analyzing interviews with experts and professionals and analyzing dozens of website news stories concerning this issue we identified the following themescategories we did not include actual names or usernames of peoples comments for anonymity purposes it is also important to note that we decided to keep the original quotes intact regardless of punctuation and grammatical errors category 1 personal insults a mix of men and women were involved in the air rage incidents we observed however more than one woman was referred to as karen which is typically a pejorative term insult usually used toward a white woman who is perceived as entitled or demanding for example during a video where a woman was kicked off an airplane for unruly behavior a man yelled out bye karen as the woman exited the aircraft a youtube commenter wrote the guy who said bye karen was legendary… yet another wrote geez karens arguing over masks is sooooo 2020 as mentioned earlier the term karen refers to a stereotype about being the kind of person who is demanding belittles serviceindustry workers and carries out microaggressions toward others in a separate instance one youtube commenter referred to women as pavement princesses when he wrote air travel is the rare situation where pavement princesses step out of their suvs and take public transportation they dont take the bus or the train because in their eyes those things are for poor people and losers but they do get on planes theyre used to getting away with road rage so when they want to go on vacation they take it to the skies fatshaming homophobic and racial slurs were not uncommon as well according to sara nelson president of the association of flight attendantscwa aflcio 61percent of the reports they have seen were related to racial gender and homophobic slurs african american flight attendant teddy andrews stated that a passenger said to him after mr andrews asked the passenger to put on his mask nword i dont have to listen to a goddamn word you have to say this is a free country… such terrible racial comments came during particularly turbulent times as widespread news traveled regarding tragedies of the deaths of the likes of george floyd and breonna taylor which sparked the black lives matter movement category 2 roll of technology the roll of technology was obvious in varying ways for example all of the clips we gathered and analyzed were filmed and posted on the internet and thousands of comments were made in the comment section below the videos which is an interesting social phenomenon inandofitself there was also an awareness of being filmed on behalf of some air rage offenders several offenders stated that they did not care if the video of their outbursts went viral in some instances people even seemed to behave more aggressively because they knew they were being filmed category 3 physical and verbal altercations during our observations of video footage it was not uncommon to see multiple incidents of unruly passengers being restrained tackled screaming and yelling at others on the plane charging up and down the aisle swinging and punching each other and being pinned down by various people aboard aircrafts while their hands were being restrained sometimes with zipties shockingly one highly intoxicated passenger was physically ducttaped to his seat from headtotoe category 4 spatial factors lack of space is a common controversial issue on airplanes especially during the pandemic where people were told to social distance from one another which is nearly impossible to do on an aircraft full of passengers as the pandemic continued people became more aware that the risk of transmission of the covid19 virus is higher in poorly ventilated indoor spaces one commenter wrote the airline is full of it they dont even try to social distant every seat is occupied and full of passengers if theyre really concern over the cdc regulations… then theyll start with basic rule number one … six feet many people are agitated in general by the increasingly cramped spaces on airplanes for example another person wrote flying has become exceedingly awful experience even without any incidents the seats are getting smaller and smaller while the people are getting larger and larger overall the whole system is designed to aggravate passengers then we have the antimask idiotswhich is whole different problem all together feel sorry for the cabin crew another person commented its ridiculous that as seats are so cramped that they even have reclining seats all packed in like sardines so the airlines can make even more money i would never recline my seat knowing it was going to make the person behind journey even more uncomfortable category 5 uncertainty and disagreement over usefulness and effectiveness of masks many comments were made arguing backandforth about the efficacy of masks both sides presented seemingly valid points regardless of who is right or wrong about the effectiveness of masks the key theme to identify here is the uncertainty surrounding the efficacy of masks that leads to frustration which leads to aggression for some groups one person wrote masks work to contain respiratory droplets which may contain virus particles the virus itself needs a vehicle to spread about and most pathogens do this is why surgeons or anyone in an operating room wears a mask to keep their snotspit out of the patients open body if you ever have surgery just tell everyone not to worry about masking up you dont believe they work and they are welcome in spraying your insides with saliva coffee and whatever else they ate right before the procedure conversely another person wrote im antimask to the fullest they dont work i honestly hate them…but to risk youre flight over not wearing a mask is not worth the penalties that awaits you let alone embarrassment ill wear the damn thing for hours to avoid a fine and then being banned it aint worth it many citizens were told by experts during the pandemic that there was evidence to suggest that the virus could be spread by tiny particles suspended in the air on the other hand many professionals claimed that tiny particles fall to the ground due to gravity and they are not suspended in the air for lengthy periods of time others believed there was nothing you can do to avoid the virus at all one person wrote know what is stupid the idiotic idea that wearing a few pieces of thin paper over your nose and mouth actually protects you and your fellow passengers while all of you are stuck in a flying sardine can for hours opposingly another person replied perhaps not in your fantasy world but in the real world masks work well described and proven im sorry that you cant grasp the understanding of how and why they work they just do buddy hey…let me just explain it the way i had to for my daughter when she was 5…magic thankfully she now understands how masks work at the age of 8…im such a proud papa early information from the world health organization stated masks should only be worn by people who had symptoms such as coughing and sneezing relatively shortly after that information was released citizens were then told that many people who have the virus may not have symptoms but can still be contagious therefore officials stated that masks were able to stop infected people from passing the virus on to others in other words conflicting reports from experts at the time contributed to mass confusion regarding whether or not masks were effective in stopping the spread of the virus one person wrote whats the use of mandating masks if people take them off when eatingdrinking and take all the time of the world to so in order to not wear the mask for at least one hour information on this topic frequently changed during the course of the pandemic which made it difficult for people to agree upon the effectiveness of wearing a mask in public category 6 politics and masks masks became highly political during the pandemic as we found evidence to show that they reflect issues regarding constitutional rights for some groups in america the issue also reflects a classic american struggle between groups who feel as though they are defending public safety and those who believe equally as strong in personal liberty for example one youtube commenter wrote you know its been a long time since i read the constitution but i do not remember reading where wearing a mask for public health safety issues was unconstitutional in fact i dont remember reading about masks in the constitution at all so do tell me where do you get this nonsense from responding to a comment made likening mask mandates to nazis another youtube commenter wrote trying to compare a cloth masks to nazis only reinforces ops point you sound like you have been threw real hardship if your comparing a cloth masks to the nazis one person wrote honestly though the us is one of the last countries to not just roll over belly up im not even republican didnt vote for trump but i know what standing up for yourself is sure put up with inconvenience youll soon be putting up with the trampling of your rights that said just wear the damn mask its not even an inconvenience my point is god bless a country that can act that way and knows how to not just give up the dispute over masks embodies many political dynamics wearing a face mask in public can potentially signal ones political identity to others as well as convey loyaltydisloyalty to certain groups during the pandemic the general democratic position was supportive of the mask mandate while the general republican position on the mask mandate was not necessarily in favor some people stated that former us president donald trump was to blame for the mask mandate further many republicans identified with then president donald trump who was not initially in favor of a mask mandate some people stated that trump was to blame for the spread of the virus while others stated that trump didnt start the pandemic he was only forced to react to it in july 2020 nearly over 1 year into the pandemic president trump ultimately wore a mask in public for the first time during a visit to a military hospital regarding masks and the mask mandate a youtube chat exchange included the following comments one commenter wrote trump supporters while another commenter wrote bidens administration and another commenter wrote regarding the mask mandate what a political sham category 7 ingroupoutgroup statuses some groups may feel at odds with other groups who have a different outlook on an issue another youtube commenter wrote so funny how these i love law enforcement types love law and order until it applies to them then they have no problem assaulting law enforcement the divide between maskers and the antimaskers as they have been frequently called is significantly large a youtube commenter stated absolutely the most entitled travelers i have seen in my years of international travel they always seem to place their rights above common sense and personal responsibility while another youtube commenter wrote next time you contemplate flying do the world a favor and go grayhound or amtrak opposing sides defended their position for wearing a mask in public while others argued against wearing masks in public for example a youtube commenter wrote hhaha you covidians and your seat belt analogies… youll do anything to fit in wont you one person commented im so tired of these the rules apply to everyone but me people just get off the plane and go many people were deeply mistrustful of others and blamed the other side for contributing to the public health crises one youtube commenter stated this is what happens when peasants can afford plane tickets another commenter wrote why not fine air rage thugs the round sum of 100000 and a lifetime ban on airlines do something another youtube commenter wrote second rank citizenship one youtube commenter wrote ban them from all airlines permanently comments provided above are evidence of ingroupoutgroup mentalities of either being in with wearing masks or out with not wearing masks or vice versa with a clear division between opposing sides category 8 culture we discovered that culture played a significant role regarding this topic according to borer one way culture can be understood is the way people make sense of their world and the symbolic and material products that express that way of life masks are not only highly symbolic material products but for some wearing a mask in public is a way of life in the postpandemic world we live in today and may continue to be for the foreseeable future further the adoption to wear them or not had some relation to cultural norms and expectations for example groups from other countries like italy may have adopted mask wearing more readily as they were hit sooner and harder by the virus more than those in the united states further people from countries other than the united states that had previously experienced the sars pandemic in 2003 or other respiratory outbreaks in the past were seemingly more willing to start wearing masks our research also shows that air rage is an issue that mostly occurs in the united states according to jeffrey c lowe ceo of asian sky group in asia air rage is mostly an american phenomenon during an interview about air rage incidents in asia lowe stated i have not heard of any incidents zip none one youtube commenter wrote this shit is only happening in america another wrote probably none of these air rage incidents happen in india in or pakistan pk one comment on a youtube air rage video read this is an american video id assume its mostly americans acting out the people in this country cant behave this is why we cant have nice things another wrote i can assure you not much mostly what i see being frequent flyer the americans mostly behave like they are entitled that psychology never gets old another youtube commenter stated im an american i can do whatever i want one youtube commenter stated i live in europe and these type of incidents dont really happen here that being said the eu has incredibly strong consumer protections when it comes to airlines unexplained cancellations and delays are uncommon and when they do happen youre entitled to a lot if spirit stranded me in the middle of no where because they screwed up their scheduling i would be really on edge too our overview of the data in this section shows there is a general widespread disagreement among and within groups of people about masks and mask mandates outlined in this section we identified several ways that a lack of social solidarity exists regarding maskrelated issues on airplanes moreover based on comments made from both sides on this topic we found an outright rude and discourteous sentiment sometimes even a seeming hatred toward others we will now move on to the next section to see what the application of the interaction ritual framework may have on our categories discussion masks and contested meanings according to collins interaction ritual framework eight criteria are necessary for successful social interactions include copresence mutual focus of attention shared mood or emotion rhythmic entertainment social solidarity emotional energy collective symbols and moralities of right and wrong by comparing our research discoveries with collins ir framework we will attempt to shed light on where a breakdown in social interaction is occurring during incidents of air rage according to collins …successful interaction rituals are the microprocess that generates almost everything that we refer to as social order two components of the ir framework were consistent with our data analysis including copresence and mutual focus however the remaining six components of the ir framework were not consistent with what our categories suggest is taking place during incidents of air rage again for clarity purposes collins stated in order for social order to exist the ir framework suggests that all eight need to be agreed upon or understood by all sides during a social interaction however our analysis of the data shows that six of the eight criteria of his framework were not agreed upon or shared during the incidents we analyzed in other words our research shows that people did not share the same emotion about masks they did not have a rhythmic pace during their interactions there was no social solidarity or shared feelings of membership involved with masks or masking mandates on airplanes there was not a shared emotion present for people to bond over there was not a sense of collective agreeance over a central point of focus as a positive symbol and there was no shared sense of morality of right and wrong our research indicates that masks are highly contested symbols with varying meanings masks are symbols that polarize people and have the potential to bring out the worst in certain groups at the very least contested meanings surrounding masks can cause a great deal of frustration which often leads to aggression especially in cramped spaces and already stressful situations like air travel in other words certain groups of people feel differently about being mandated to wear a mask especially on an airplane therefore their frustration with others who feel or behave differently leads to aggression which results in physical or verbal outbursts during the next section we will discuss larger implications of our research along with our future areas of interest conclusions over the past 2 years travelers experienced many unforeseen circumstances during uncertain times along with traditional passenger stressors such as alcohol consumption long waits and delays effects of technologies etc we have shown evidence of a more recent factor that contributes to air rage as well masks and maskrelated issues as of 2022 although mask mandates are currently being lifted in many regions some businesses still recommend that people wear masks moreover regardless of the recent lift on mask mandates that occurred this year some people prefer to wear masks while others do not which has the potential to create future outbursts over this issue put shortly this social problem does not appear to be going away anytime soon it is staggering to see that more air rage incidents occurred in the year 2021 than occurred in over 30 years combined our research explored this social phenomenon indepth to look beyond the surface to better understand what is taking place with this ongoing social problem we found that one of the biggest changes in the airline industry today was the introduction of maskwearing passengers which we also discovered was at the center of this recent issue masks being at the center of the issue may not necessarily be a surprise to many however our research provides sociological insight into what it is about wearing masks that caused recordbreaking numbers of air rage incidents regarding interaction ritual collins wrote …successful interaction rituals are the microprocess that generates almost everything that we refer to as social order it gives people their identities makes them enthusiastic or antipathetic to various things in their social environment creates leaders heroes and villains the popular and the unpopular it fills our minds and discourse with meaningful ideasie those which are emotionally most marked and it generates morality both in directing us to positive goods and against emotionally repugnant evils collins passage above embodies our research insofar that we found unsuccessful interactions based on contested meanings of masks the division over this topic creates good guys and bad guys likable and dislikable people as well as positives and negatives however the reality of what the pandemic showed us is that we ought to unite and work together to find commonground to agree upon and to understand and respect opinions and feelings that are different than our own based on our findings important takeaways include insulting shaming or abusing others physically or verbally are not constructive ways to get others to adopt a certain behavior or to get them to understand a given position on an issue efforts toward overcoming this issue ought to focus on how we can achieve collective harmony and solidarity on important social issues while adapting to what is often referred to as the new normal it appears that the world of travel is no longer primarily focused on entertainment pleasure desires and consumption instead travel industry leaders are also increasingly focused on the safety of the experience itself along with the task of putting travelers at ease mentally and physically air rage is a complicated topic which makes maskrelated issues a compounding factor to contend with aviation and travel are typically about bringing people together they are not about tearing people apart airline policymakers can potentially design more effective public messages to increase compliance among nonmask wearers by better understanding what social cues either wearing or not wearing a face mask sends to other people our research has implications on airplane etiquette passenger safety security verbal and physical abuse and violence on the job for airline employees we are by no means claiming our research discoveries fully explain this extremely complicated social issue we are simply adding a piece to the puzzle to go along with several other pieces discussed during the literature review section of this paper thereby using qualitative methods and sociological concepts to update the literature on this topic our research may be useful for other groups and organizations such as teachers and school employees as well as businesses where large amounts of violent acts are taking place based upon maskrelated issues other areas not explored in this current study but we hope to explore in the future include conducting indepth interviews to find out how wearing masks or being mandated to wear masks impacts the values that americans hold such as independence freedom equality and achievement we are also interested in finding out how maskrelated issues impact peoples sense and ability to communicate verbally and nonverbally especially in unfamiliar settings such as those associated with travel we would like to find out more about race and ethnic age or gender associations involved in wearing masks for example we would like to find out if men are less willing to wear a mask than women or vice versa we would like to explore the role that religion plays in this issue and to what extent we are also interested in how groups perceive aspects of tourism including travel and vacation which have been affected by the pandemic in conclusion we explored collins claim that interaction rituals produce emotional energy the gathering of which is a central motivating force for individuals in which the effect is the driving force of social order further we addressed his statement that it is important to see what affects whether solidarity will be high or low in any particular situation specifically on airplanes in the case of our research we discovered when multiple elements of the ir framework are missing we see social disorder conflict or social instability surrounding maskrelated issues on airplanes overall we answered our research question as we have identified outlined and discussed what it is about masks and maskrelated issues that are related to incidents of air rage thereby providing sociological insight into why groups of people are fighting on airplanes over maskrelated issues data availability the authors confirm that data supporting the findings of this study are available within the article and its reference section all sources used are properly disclosed author contributions bo and hs contributed to study conception and design data collection analysis and interpretation of the results and draft manuscript preparation all authors reviewed the results and approved the final version of the manuscript funding there was no funding associated with this research ethical approval the authors confirm that the appropriate ethics and welfare protocols have been followed and that there are no known ethical conflicts associated with this study informed consent from participants was not necessary for this study as data and information gathered during the research process derived from public sources further to ensure anonymity usernames were not included in our study this material is the authors own original work which has not been previously published elsewhere and is not currently being considered for publication elsewhere this paper reflects the authors own research and analysis in a truthful and complete manner informed consent this article does not contain any studies with human participants performed by any of the authors

during the pandemic there was an alarming escalation in reports of air rage in the united states prior to the pandemic the yearly average of unruly airline passenger behaviors was around 100 incidents per year however after mask mandates were issued 5981 unruly passenger incidents in the united states were reported by the federal aviation administration faa in 2021 alone therefore we conducted a qualitative content analysis pertaining to maskrelated incidents of air rage to learn more about this recent social problem we also applied an interaction ritual ir framework to the results of our analysis to provide sociological insight concerning this issue the goal of our exploratory research is to understand what it is about masks that cause certain groups of people to lash out violently while on airplanes to date little or no scholarly efforts have researched incidents of air rage in relation to masks therefore our research provides a contribution by updating the literature on this topic

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introduction the way people prepare their food is an important expression of local culture that is also shaped by the surrounding environment and historical background 1 indeed different cultures often develop different recipes and the use of different ingredients the underlying ecological knowledge is in fact shaped by a number of factors including sociocultural aspects like religion 2 language 3 politics including governance systems 4 5 6 and economic features 7 such knowledge is not static but rather dynamic as it evolves over time according to changes in the abovementioned factors for instance a change in lifestyle was found to change the perceptions and the use of wild food plants 8 9 10 by changing motivations such as the desire for quality food and the pleasure of gathering wild plants 11 and also as a consequence of the disappearance of an agrarian lifestyle 12 wild food plants play an essential role in traditional cuisines across europe 13 not to mention their economic value especially in marginal rural areas in countries undergoing economic and governance transition 14 the study of wild food plants in multicultural contexts has only been partially researched among migrant communities and among coexistent ethnic groups use similar wild food plants as they share the same language and since 2015 can fr move across the border yet even with an untrained eye one can see that roman living under the same environmental conditions in the same historical province bu opposite sides of the border have different wild food plant uses however the que remains to what extent do the living conditions of the country and the social intercon tions that exist there influence local cuisine and wild food use materials and methods study areas bukovina province has long been inhabited by ukrainians and romanians it i lieved that the name derives from the fact that the region was covered by natural b forest in ukrainian бyкbuk means beech tree and bukovina means the beech land 43 a complex history under different governance systems eg the turkish em moldavian kingdom austrohungarian empire kingdom of rom and then division into southern and northern bukovina between rom and the soviet union respectively have influenced population structure and distin natural resource use 18 therefore in the study region the population predomina consisted of hutsuls in the mountainous part of bukovina 35 as well as romanians ukrainians the multicul population of bukovina was formed under the austrohungarian law freeing loca habitants from taxes for 30 years which led to the growth of the population from 80 t sand in 1800 to 850 thousand at the beginning of the 20th century via migrants from o overpopulated regions of the austrohungarian empire such as ukrainians germ polish people jewish people hungarians roma people etc 1834 bukovina was c acterized by ethnopolitical stability as there were no crossethnic conflicts 18 the sion of bukovina between romania and the soviet union in 1940 led to changes in multicultural population structure especially in northern bukovina soviet governor itiated depopulation and forcibly sent romanians germans and polish people away in southern bukovina jewish people were deported and hungarians and germ moved out 45 rich ukrainians were sent to siberia and later the romanians stayed in northern bukovina did not have the portunity to migrate to romania there are historical data that many romanians killed while trying to escape from the soviet union 4445 the study was conducted in a lowland area of northern bukovina ukraine and uplands of southern bukovina romania after romania joined the european union the economic situation improved and crossing the border to purchase consumer goods became popular 46 in 2015 the romanian and ukrainian governments signed an agreement on small crossborder movement 47 this allows residents of romania and ukraine who permanently live in the 3550 km border zone to cross the border without obtaining a visa people have to apply for a card which is issued once every two years and then they can cross into the other country but not outside the 3550 km small movement zone there is a list of villages on both sides that are included in this agreement and our study villages appear on this list this agreement allows romanians living in ukraine to freely travel to visit their relatives and vice versa 46 this also includes economic benefits for both areas as residents now commute and buy cheaper or better groceries on both sides of the border in june 2018 ukraine signed an agreement with the european union establishing novisa entry for ukrainian residents possessing biometric passports to member states of the schengen area our participatory observation in northern bukovina in 20182019 revealed a large number of cars with foreign plates as was explained by locals to officially register a car in ukraine costs a lot of money sometimes more than the price of the car so locals use foreign license plates this also helps to travel abroad because for a ukrainian registered car you need to buy insurance economic development in the area is seen in brand new houses built close to old ones with wooden roofs even though it is still northern bukovina the hutsul area of putyla 4 is much poorer with a worse infrastructure compared with the region of storozenetskyi and gluboka where romanians and ukrainians live after romania joined the european union the economic situation impro and crossing the border to purchase consumer goods became popular 46 in 2015 romanian and ukrainian governments signed an agreement on small crossbor movement 47 this allows residents of romania and ukraine who permanently liv the 3550 km border zone to cross the border without obtaining a visa people hav apply for a card which is issued once every two years and then they can cross into other country but not outside the 3550 km small movement zone there is a list of lages on both sides that are included in this agreement and our study villages appear this list this agreement allows romanians living in ukraine to freely travel to visit th relatives and vice versa 46 this also includes economic benefits for both areas as r dents now commute and buy cheaper or better groceries on both sides of the border june 2018 ukraine signed an agreement with the european union establishing nov entry for ukrainian residents possessing biometric passports to member states of schengen area our participatory observation in northern bukovina in 20182019 revealed a la number of cars with foreign plates even though it is still northern bukovina hutsul area of putyla 4 is much poorer with a worse infrastructure compared with region of storozenetskyi and gluboka where romanians and ukrainians live every household engaged in smallscale family farming including both animal breeding and vegetable gardens for home consumption every household engaged in smallscale family farming including both animal breeding and vegetable gardens for home consumption northern bukovina ukraine and southern bukovina romania northern bukovina corresponds to the southerneastern part of chernivci region the landscape consists of agricultural fields and some beech forests the glybotskyi and storozenetskyi region is situated in the foothills of the carpathian mountains and is located in the prutsirets interfluve the highest peak is 475 m asl romanians live in villages close to the romanian border in the regions of glybozkij gerzaivskyi and storozenetskyi which are dominated by a rural population based on the last country census in 2001 there are 114555 romanians living in chernivci region there are 76 romanian schools and 13 mixed schools that teach in both ukrainian and romanian there are also 12 local newspapers in the romanian language as well as three bilingual newspapers in addition there are 10 nongovernmental romanian national cultural organizations in chernivci region the visited villages included krasnoijsk chudej jizivci stara krasnoshora nova krasnoshora and prosika populated mostly by romanians in ukraine and straja in romania romanians reside in the lowlands of southern bukovina which nearly corresponds to presentday suceava county with around 635000 inhabitants in the municipality of straja where we conducted the study most of the approximately 5000 inhabitants are particularly devoted to mountain agriculture organized in smallscale farming activities including both animal breeding and crop cultivation northern bukovina ukraine and southern bukovina romania northern bukovina corresponds to the southerneastern part of chernivci region the landscape consists of agricultural fields and some beech forests the glybotskyi and storozenetskyi region is situated in the foothills of the carpathian mountains and is located in the prutsirets interfluve the highest peak is 475 m asl romanians live in villages close to the romanian border in the regions of glybozkij gerzaivskyi and storozenetskyi which are dominated by a rural population based on the last country census in 2001 there are 114555 romanians living in chernivci region there are 76 romanian schools and 13 mixed schools that teach in both ukrainian and romanian there are also 12 local newspapers in the romanian language as well as three bilingual newspapers in addition there are 10 nongovernmental romanian national cultural organizations in chernivci region the visited villages included krasnoijsk chudej jizivci stara krasnoshora nova krasnoshora and prosika populated mostly by romanians in ukraine and straja in romania romanians reside in the lowlands of southern bukovina which nearly corresponds to presentday suceava county with around 635000 inhabitants in the municipality of straja where we conducted the study most of the approximately 5000 inhabitants are particularly devoted to mountain agriculture organized in smallscale farming activities including both animal breeding and crop cultivation after joining the european union the government of romania has welcomed the issuing of a romanian passport if someone meets the required criteria respondents from the ukrainian side explained that with the help of that passport they can freely travel foods 2021 10 126 6 of 30 to other european countries for seasonal or permanent employment where salaries are much higher data collection fieldwork was carried out in the summers of 2018 and 2019 this study is part of the broader research project ethnobotany of divided generations which using the same method for data collection aims to compare ethnobotanical knowledge of groups divided by the creation of a border during or after the soviet time the sample comprised 30 people from each side of the border chosen pseudorandomly sometimes using snowball and convenient sampling methods people were approached in streets gardens and fields as well as in public places like libraries bus stops and markets oral informed consent was obtained prior to each interview the respondents were given full freedom to talk about the subject only people permanently living in the study area were interviewed sixty interviews were conducted mainly in romanian but also in russian or ukrainian depending on the preference of the interviewee participatory observation was performed during the summer of 2018 most of the interviews in both southern and northern bukovina were conducted with the help of a field assistant and facilitator native in romanian and in the local romanian dialect who asked the questions listened to responses and posed followup questions as romanian is not the native language of the authors the facetoface interviews lasted from 20 minutes to 2 h this study is part of a larger research project in which questions on the use of wild plants were grouped into food medicine ritual and other uses modules the food module consisted of questions specifying the use of wild plants for tea soups salads main dishes and desserts as well as any information the interviewee wanted to share about wild taxa use for culinary purposes oral consent was obtained prior to each interview in which the aim of the project and the anonymous status of the interviewee were explained as well as the condition that they could stop and withdraw all data and information at any stage of the interview we strictly followed the ethical guidelines prescribed by the international society of ethnobiology 52 and the study protocol was approved by the ethical committee of ca foscari university of venice during the interviews herbarium voucher specimens were collected the ukrainian voucher specimens are stored in the nature reserve roztochya uav with codes nb001nb289 and the romanian voucher specimens at ca foscari university of venice uvv bearing codes sb001sb094 the mentioned taxa were collected and then identified according to the local flora 53 taxonomic identification botanical nomenclature and family assignments followed the flora europaea 54 the plant list database 55 and angiosperm phylogeny group iv 56 participatory observation at local markets shops restaurants and near houses was performed focusing on the wild food plants and products made from various wild parts and fruits that are sold participatory observations at local markets and selling locations were carried out in order to identify supply and demand of wild products in both study areas while conducting interviews we also made observations of home gardens and the vegetables planted by households data analysis the gathered data were organized as detailed use reports where each interviewee mentioned the use of a plant and mode of preparation documented into the excel spreadsheet the spreadsheet includes informant code language of the interview latin name taxonomic family local name food use mode of preparation source of knowledge and comments for all calculations only wild and semiwild taxa were used while unusual uses of cultivated taxa are reported only in table 3 and the discussion following the methodology of gonzáleztejero et al 58 we calculated the jaccard similarity index as ji c × 100 1 where a is the number of recorded species in study area 1 b is the number of species recorded in study area 2 and c is the number of species common to both study areas 1 and 2 an index value close to 100 indicates that the plant uses of the two groups are very similar while a value close to 0 indicates that the groups are very different the respondents were selected using convenient sampling in which they were approached in gardens and yards during hay making or at local markets only two people refused to speak with us and so response rate was high everyone else was friendly and willing to discuss wild food issues and their life experiences in northern and southern bukovina 60 interviews were conducted in the ukrainian study areas romanian is the official language in schools while students study the ukrainian language some hours every week in the regional government offices ukrainian is used as the primary language while in local village councils romanian is spoken in the street romanian and local romanian dialects are used as there are ukrainians living in those villages or married to romanians ukrainian with a mixture of romanized words is used furthermore we classified the used plants into two categories based on their level of wildness wild plantstaxa that grow spontaneously in the surrounding environment without human intervention semicultivated plantstaxa that grow without direct human intervention but were once planted in gardens additionally we compared our results with the wild food plant uses collected by the authors using the same interview structure among hutsuls in the mountainous area of bukovina in ukraine and romania 6 to process the data statistically on the request of the academic editor we first ran a boxplot to graphically check the data we observed that use categories of romanians living in ukraine are more scattered than those of romanians living in romania therefore in order to test the observed difference between the two groups we performed a wilcoxon test on use categories reported by romanians living in ukraine and in romania we set α 005 in addition we verified significance with a kruskalwallis test using the same significance level both analyses were conducted using r software r foods 2021 10 126 8 of 30 factor of informant consensus the factor of informant consensus was calculated as the number of use citations in each category minus the number of species used divided by the number of use citations in each category minus one 59 fic the high values indicate that the majority of respondents propose a low number of taxa for cooking in this food category while low values indicate the respondents disagreement about taxa used for certain food categories results and discussion caveats of the study before discussing the results of the study we want to mention some caveats which may affect our interpretation and were considered in the following discussion as the research is qualitative the statistical analysis showed the following results we performed a wilcoxon test and a kruskalwallis test and both analyses revealed that there is no significant difference between the use categories of the two groups of romanians living across the border indeed the pvalue for the wilcoxon test was 016 and 0092 for the kruskalwallis test assuming that the null hypothesis for both tests was the equivalence of distributions of two groups and given that the pvalues are higher than 005 we accept the null hypothesis we conclude that the two groups of romanians do not present a statistically significant difference in the use of plant categories however we consider that the present differences even though statistically nonsignificant are important from a cultural perspective and we further focus on qualitative methods that are better suited for the analysis of cultural phenomena contemporary use of wild food plants in the wild food domain romanians living in bukovina used 46 plant taxa belonging to 20 families the most used plant taxa incorporating both sides of the border were rubus idaeus armoracia rusticana urtica dioica rubus spp including rubus fruticosus fagus sylvatica and fragaria vesca romanian interviewees in romania reported 27 taxa belonging to 15 families plus five cultivated taxa with uncommon uses used for food in ukraine romanians named 40 taxa belonging to 18 families plus four cultivated taxa cultivated taxa such as the wood of prunus avium p cerasus p domestica and malus domestica were used for smoking meat and vitis vinifera leaves were used for making sarmale which are uncommon uses and thus we included them in the study in both areas of bukovina the rosaceae family was the most used with 95 dur and 101 dur respectively romanians in ukraine used more families including the following that were distinctive betulaceae boraginaceae hypericaceae plantaginaceae only romanians in romania used vitaceae papaveraceae and cannabaceae twentyone taxa were common to both groups including rubus spp rubus idaeus rosa rugosa rosa centifolia quercus spp carum carvi fagus sylvatica fragaria vesca tussilago farfara urtica dioica vaccinium vitisidaea vaccinium myrtillus thymus vulgaris and sambucus nigrum in northern bukovina interviewees reported 19 taxa not named by romanians in romania with more than twice the number of uses these taxa included achillea millefolium crataegus spp hypericum spp matricaria chamomilla betula spp and rumex acetosa in northern bukovina interviewees reported 19 taxa not named by romanians in romania with more than twice the number of uses these taxa included achillea millefolium crataegus spp hypericum spp matricaria chamomilla betula spp and rumex acetosa five taxa were used only in southern bukovina atriplex hortensis humulus lupulus robinia pseudoacacia papaver rhoeas and vitis vinifera more than 70 of interviewees in both areas used rubus idaeus while fagus sylvatica and urtica dioica were used on both sides of the border but with different intensity fagus sylvatica was used four times more often in southern bukovina whereas urtica dioica was used three times more often in northern bukovina the division of used plant parts in southern bukovina was the following fruits aerial parts including leaves flowers and petals roots and wood in northern bukovina the division of used plant parts was as follows aerial parts including leaves fruits flowers roots and wood comparison shows that the most commonly used plant parts were fruits by romanians in romania and aerial parts by romanians in ukraine in northern bukovina interviewees reported 19 taxa not named by romanians in romania with more than twice the number of uses these taxa included achillea millefolium crataegus spp hypericum spp matricaria chamomilla betula spp and rumex acetosa five taxa were used only in southern bukovina atriplex hortensis humulus lupulus robinia pseudoacacia papaver rhoeas and vitis vinifera more than 70 of interviewees in both areas used rubus idaeus while fagu sylvatica and urtica dioica were used on both sides of the border but with different inten sity fagus sylvatica was used four times more often in southern bukovina whereas urtic dioica was used three times more often in northern bukovina the division of used plant parts in southern bukovina was the following fruits five taxa were used only in southern bukovina atriplex hortensis humulus lupulus robinia pseudoacacia papaver rhoeas and vitis vinifera more than 70 of interviewees in both areas used rubus idaeus while fagus sylvatica and urtica dioica were used on both sides of the border but with different intensity fagus sylvatica was used four times more often in southern bukovina whereas urtica dioica was used three times more often in northern bukovina the division of used plant parts in southern bukovina was the following fruits aerial parts including leaves flowers and petals roots and wood in northern bukovina the division of used plant parts was as follows aerial parts including leaves fruits flowers roots and wood comparison shows that the most commonly used plant parts were fruits by romanians in romania and aerial parts by romanians in ukraine seventeen taxa in southern bukovina and 26 taxa in northern bukovina were used by at least 10 of interviewees with 13 shared taxa figure 6 shows the most important differences between the two samples teas fermented preparations and fresh snack consumption are quite prevalent among romanians in ukraine while romanians in romania favor wild food plantbased jams compotes syrups and sarmale as well as smoking meat seventeen taxa in southern bukovina and 26 taxa in northern bukovina were used by at least 10 of interviewees with 13 shared taxa figure 6 shows the most important differences between the two samples teas fermented preparations and fresh snack consumption are quite prevalent among romanians in ukraine while romanians in romania favor wild food plantbased jams compotes syrups and sarmale as well as smoking meat this picture largely corresponds to the national cuisines of the respective countries 60 61 62 63 which seem to have greatly influenced the two divergent trajectories of romanians during the past century the predominance of lactofermentations among ukrainians is possibly linked to old slavic customs while the prevalence teas may have been introduced via the promotion of popular teas spread through popular literature in the former soviet union during the communist era 64 in romania sarmale jams compotes and syrups represent quintessential elements of romanian cuisine which historically was greatly influenced by the ottomans the prevalent custom of smoking meat at home in romanian bukovina may be linked to the persistence of this custom which has not been weakened by food industrialization as may have happened in ukraine during the administration of the ussr food system the deficit of meat may have contributed to a decline in the custom of smoking it among romanians in ukrainian bukovina in northern bukovina the most prevalent wild food preparation was tea while in southern bukovina it was jam winter preserves both fermented and marinated were also highlighted spring soups made with four wild taxa were mentioned as well birch sap as a beverage was only named this picture largely corresponds to the national cuisines of the respective countries 60 61 62 63 which seem to have greatly influenced the two divergent trajectories of romanians during the past century the predominance of lactofermentations among ukrainians is possibly linked to old slavic customs while the prevalence teas may have been introduced via the promotion of popular teas spread through popular literature in the former soviet union during the communist era 64 in romania sarmale jams compotes and syrups represent quintessential elements of romanian cuisine which historically was greatly influenced by the ottomans the prevalent custom of smoking meat at home in romanian bukovina may be linked to the persistence of this custom which has not been weakened by food industrialization as may have happened in ukraine during the administration of the ussr food system the deficit of meat may have contributed to a decline in the custom of smoking it among romanians in ukrainian bukovina in northern bukovina the most prevalent wild food preparation was tea while in southern bukovina it was jam winter preserves both fermented and marinated were also highlighted spring soups made with four wild taxa were mentioned as well birch sap as a beverage was only named by romanians in ukraine because it was considered medicinal by romanians in romania salads made with wild plants were named by ten interviewees on each side of the border in southern bukovina the fruits of rubus idaeus rubus spp vaccinium myrtillus and fragaria vesca were used for jam as were the flowers of rosa rugosa rosa centifolia and taraxacum campylodes the leaves of tussilago farfara atriplex hortensis rumex spp brassica oleracea vitis vinifera and armoracia rusticana are used for making sarmale sarmale was a popular preparation use of wild taxa for food romanian interviewees in ukraine called this dish gălus te but they used fewer taxa only the leaves of tussilago farfara and rumex spp for soups romanians in romania used the young leaves of urtica dioica and atriplex hortensis in springtime romanians in ukraine used more species for making soups including urtica dioica rumex acetosa rumex spp and thymus spp as seasoning urtica dioica was named in both areas as an early spring food used for making borshch another variety called green borshch is made with carrots potatoes boiled eggs sour cream and different green plants like urtica dioica or rumex acetosa in ukrainian bukovina urtica dioica was used for stew with sour cream in omelets and scrambled eggs and for frying with eggs nettle in the spring when it is young and small we boil it and stir fry it and eat it explained a romanian woman born in 1939 interviewees highlighted that they use nettle leaves only in early spring when they are tender fried young sprouts with sour cream were also mentioned as a vitamin food during spring time in both areas armoracia rusticana was the most popular fresh root that was used for salads with beetroot and as a seasoning for pickles and fermenting winter preserves romanians in northern bukovina used the young leaves of urtica dioica plantago major and taraxacum campylodes for salads whereas southern bukovinians only used armoracia rusticana it was referred to as semicultivated because it grows everywhere including home gardens foods 2021 10 x for peer review 15 of 30 that this practice of preserving meat was popular among inhabitants of the carpathian mountains 3443 plantbased beverages alcoholic beverages were only mentioned in southern bukovina this included rachiu which is prepared with carum carvi and homedistilled alcohol aromatized alcohol drinks were also popular the fruits of rubus idaeus and vaccinium vitisidaea macerated in alcohol were mentioned by romanians in romania in addition the fruits of vaccinium myrtillus were used for an alcoholic drink called afinătă which added colored and aroma to the alcohol four interviewees also mentioned homemade beer which was made from the flowers of humulus lupulus or sometimes the flowers of sambucus nigra syrups made from rubus idaeus fragaria vesca rosa rugosa or rosa centifolia and rubus fructicosus were mentioned by romanians in southern bukovina their use was intended for weekly fasting days usually when you fast on wednesdays and fridays you eat raspberry syrup with bread explained a man born in 1965 in both study areas romanians fasted on wednesdays and fridays and during four fasting periods throughout the dominant use of wild food for salads was that of grated roots of armoracia rusticana which was named by 47 of romanians in romania wild and cultivated plants for smoking fagus sylvatica was used in both areas for smoking meat the wood of prunus avium malus domestica prunus cerasus and prunus domestica was also used for smoking meat by romanians in romania meat smoking was explained as a way for meat to last long because when you raise your own pigs you have to be able to store the meat in earlier times when freezers were not available smoking was an important preservation practice for local livelihoods in northern bukovina besides fagus sylvatica the wood of carpinus betulus was used for smoking meat in addition in both areas of bukovina fruit trees branches were mentioned as adding taste and color which was explained as when you prune trees in your garden in the autumn and spring you keep the branches for smoking purposes as in southern bukovina the wood of prunus avium malus domestica prunus cerasus and prunus domestica was also used for smoking meat in northern bukovina the wood of cherry trees gives a reddish color to the meat and the more cherry wood you burn the deeper the color of red you achieve explained a retired interviewee smoking was mentioned as an important practice for the long preservation of pork meat in southern bukovina only one interviewee mentioned the practice of cheese smoking smoking practices and the use of both wild and cultivated taxa were not mentioned by researchers either in romania 433 or ukraine 724 historical sources show that this practice of preserving meat was popular among inhabitants of the carpathian mountains 3443 plantbased beverages alcoholic beverages were only mentioned in southern bukovina this included rachiu which is prepared with carum carvi and homedistilled alcohol aromatized alcohol drinks were also popular the fruits of rubus idaeus and vaccinium vitisidaea macerated in alcohol were mentioned by romanians in romania in addition the fruits of vaccinium myrtillus were used for an alcoholic drink called afinătă which added colored and aroma to the alcohol four interviewees also mentioned homemade beer which was made from the flowers of humulus lupulus or sometimes the flowers of sambucus nigra syrups made from rubus idaeus fragaria vesca rosa rugosa or rosa centifolia and rubus fructicosus were mentioned by romanians in southern bukovina their use was intended for weekly fasting days usually when you fast on wednesdays and fridays you eat raspberry syrup with bread explained a man born in 1965 in both study areas romanians fasted on wednesdays and fridays and during four fasting periods throughout the year meat and dairy products are not allowed to be eaten on those days and thus syrups and jams made from wild fruits are consumed by locals the use of food plants for fasting rituals and ceremonies needs to be more thoroughly studied in southern bukovina the fruits of rubus idaeus rubus spp and vaccinium myrtillus and the flowers of sambucus nigra were used for juice preparations interviewees also explained that the flowers of sambucus nigra are used for making a fermented drink called socată the flowers of sambucus nigra are collected and then 10 flower inflorescences 1 kg of sugar and a lemon are added to 10 l of warm water and a teaspoon of dry yeast after one day this mixture is bottled and stored in a cool place the dried flowers also were named as suitable for preparing homemade beer the beer is lactofermented and may contain a small amount of alcohol the same use was described in roztochya but it is called sparkling drink 7 homogeneity and inhomogeneity of wild plants use for food preparations as the analysis of factor of informant consensus reveals in southern bukovina among romanians consistently used the same taxa for smoking of meat seasoning and sarmale while for tea and borshch more diversity was used in northern bukovina romanians homogeneously use plants for jam and fermentation while there was disagreement meaning they made a not homogenous use of plant taxa for alcoholic drinks syrup and fresh food past uses of wild food plants in romania interviewees explained that in the past more forest products were used mainly to generate income in northern bukovina their function as a food substitute for deficit products was mentioned eg coffee was difficult to buy and so locals made coffee at home from the roots of arctium lappa and taraxacum campylodes the decline in the use of wild plants for food was mentioned in both areas of bukovina two interviewees in northern bukovina mentioned that in the past their grandparents used the leaves of urtica dioica for making tea and soup likewise tea made from achillea millefolium and matricaria chamomilla were named by 10 and 6 of interviewees respectively as past uses again by their grandparents compote and jam prepared from vaccinium myrtillus and rubus idaeus were mentioned as recently abandoned food practices by one interviewee in southern bukovina six percent of interviewees named jam made from rosa rugosa as a recently abandoned practice smoking meat with the wood of fagus sylvatica was also mentioned by one person as a recently abandoned practice romanians in romania did not mention past uses of wild food plants participatory observation in both study areas indicated that restaurants currently offer dishes with wild mushrooms and forest fruits and they even sell dried wild forest fruits in southern bukovina local restaurants serve wild mushroom sauce and desserts with wild forest fruits were offered on the menu in northern bukovina a variety of forest fruits and plants were sold at local markets in small local restaurants tea made from forest fruits and plants was served while blueberries were added to desserts which in the description indicated that they were forest blueberries the use of wild food in our study populations plays a food supply role as well as a culturally important role for example in southern bukovina wild foods were used to help generate income in the past and they are currently important in everyday cuisine wild edible forest plants in both groups of romanians wild forest taxa were the most used including rubus idaeus 40 6 and table 3 these results are unusual as the local landscape of the region consists predominantly of flat lowlands with agricultural fields and thus the distance to the forest and the fact that most of the forests are situated in the mountains were not seen as an obstacle we buy blueberries raspberries and a variety of mushrooms at the market because those products grow in the forest up in the mountains highlighted a romanian woman from northern bukovina born in 1966 our findings therefore show that forest products and forest taxa still play an important role in local ecological knowledge which is consistent with pieroni and sõukand 24 we use forest berries fruits blueberries raspberries blackberries but they grow in the carpathians and you have to go far to harvest them explained a young romanian woman from northern bukovina born in 1983 the better economic situation in the region is now allowing locals to buy forest products instead of collecting them themselves before we were going to harvest blueberries we started to go to the forest at 3 am it was so hard and so timeconsuming to collect blueberries now we buy them at the market explained a romanian woman born in 1947 in northern bukovina this year a friend brought me birch sap because it is too far to go to get it in the forest stated a retired woman from northern bukovina we buy forest mushrooms and berries they are tasty asserted a retired romanian woman in ukraine romanians in romania explained that in the past they used the forest fruits vaccinium myrtillus fragaria vesca and vaccinium vitisidaea to generate additional income in times of scarcity and economic crisis however nowadays they buy forest berries at the market or in shops romanians in ukraine also mentioned purchasing wild forest fruits but mostly because they grow far away in the mountains and one has to have time to harvest them so it is much more convenient to buy them at the market participatory observation at local markets revealed the sale of homemade dairy products and forest products in northern bukovina while in southern bukovina it was mostly produced goods the reason for this difference could be that in romanian bukovina milk collection from homes is still present so there is no need to process and sell milk yourself legislation in ukraine allows the selling of forest products by locals but there is currently discussion on banning the sale of dairy products by locals 65 by law in ukraine the harvesting of forest products with commercial purposes has to be carried out with a special permit which is a taxbased payment to local forest enterprises however this is not widely practiced due to bureaucratic complexity 14 more active enforcement of this legislation may influence the use of wild forest products due to a reduction in the number of collectors and an increase in prices in romania the collection of forest products is free of charge for personal consumption while it requires authorization for commercial purposes in both study areas wild plants including forest products continue to be used in daily cuisine while in southern bukovina interviewees explained that those products also played a role in income generation in the past therefore nowadays in both areas the purchase of wild forest products was mentioned much more often than collecting them in the wild this economic influence on wild product use is consistent with the findings of stryamets 22 in smăland sweden where locals buy rather than collect nonwood forest products so here economic factors have highly influenced the use of forest products first locals actively used them and sold them for additional income but as the economic situation has improved people have stopped selling them as they have money to buy them at local markets this is the first step toward losing this lek as children do not learn how and where to collect them the next step involves people stopping cooking them the situation in swedish smăland demonstrates that lek has been eroded because of the healthy economic situation 722 and the consequent loss of the practice of foraging for nwfps one interviewee from southern bukovina explained that border creation reduced his opportunities to go to the forest because most of the historical forest of straja now belongs to northern bukovina however forest cover in southern bukovina is 63 compared to 37 in northern bukovina a childhood delicacy the past to present fashion of dainty foods rose syrup and jam made from the flower petals minus the white part of rosa rugosa and rosa centifolia were considered delicacies and used on special occasions in the past we used a specific rose for sweets and it was a delicacy only respectable people made sweets with green walnuts and sweets with roses they were for guests means that sweets with roses were used for only special occasions for guests i know that my mother made syrup and jams and locked them up to be used only on special occasions and kept away from children they also made sherbet the little ones went to the forest for raspberries and sold them in the town center to have money to buy school supplies uniforms explained a romanian woman born in 1957 in the ukrainian part of bukovina rose jam was used for religious celebrations as an additive to cakes and doughnuts we also prepare raw jam with rose flowers what tasty buns you get with it they are delicious highlighted a romanian woman from ukraine born in 1953 nowadays for confectionery purposes one can buy rose syrup in specialty shops for uah 2700 per kg and the syrup is used in fashionable restaurants and by elite cakes producers historical ottoman influence introduced a few elements which can still be found among romanians living in bukovina one recipe is rose jam made with the petals of rosa rugosa and rosa centifolia this recipe can also be found among other groups that were under ottoman control such as hungarians 66 and bosniacs 67 interestingly this product was almost exclusively mentioned by romanians in romania in addition tea is also sometimes made from the petals of these roses both jam and tea can also be found in shops in romania another ottoman element is sarma 68 which is locally called sarmale and găluşte this dish consists of meat and rice wrapped in leaves for this purpose the leaves of tussilago farfara atriplex hortensis rumex spp brassica oleracea vitis vinifera and armoracia rusticana were used one interviewee used horseradish leaves i make sarmale with horseradish armoracia rusticana and loboda atriplex hortensis horseradish leaf is placed between sweetleafed cabbage rolls we also do it with grape leaves highlighted a romanian woman born in 1955 all the mentioned taxa are common plants for this preparation however they were not previously reported in romania 68 the fact that homemade alcoholic drinks were mentioned in southern bukovina but not in northern bukovina may be the result of soviet propaganda and punishment for preparing moonshine and homemade alcohol however alcoholic tinctures with a variety of forest fruits were used for medicinal purposes by hutsuls in bukovina 6 comparison with hutsuls comparison with hutsuls living in bukovina reveals that 19 taxa are used by all four groups hutsuls in ukraine and romania use the same taxa as romanians in ukraine for recreational tea arnica montana matricaria chamomilla and achillea millefolium hutsuls in romania and ukraine and romanians in romania however use viburnum opulus and humulus lupulus for this purpose the use of plantago major as a tea has also been documented among hutsuls in ukraine but not among boykos 7 crossborder comparison of wild plant uses shows that equisetum spp acer spp aronia melanocarpa elliott picea abies h karst sorbus aucuparia l and chenopodium album l were used only by hutsuls crosscultural analysis in ukraine reveals 29 shared wild taxa whilst five of them are in ukraine for recreational tea arnica montana matricaria chamomilla and achillea millefolium hutsuls in romania and ukraine and romanians in romania however use viburnum opulus and humulus lupulus for this purpose the use of plantago major as a tea has also been documented among hutsuls in ukraine but not among boykos 7 crossborder comparison of wild plant uses shows that equisetum spp acer spp aronia melanocarpa elliott picea abies h karst sorbus aucuparia l and chenopodium album l were used only by hutsuls crosscultural analysis in ukraine reveals 29 shared wild taxa whilst five of them are specific for northern but not southern bukovina in romania crosscultural analysis of food plants used by romanians and hutsuls in southern bukovina reveals the use of 22 shared taxa the jaccard similarity index calculated for romanians on the two sides of the border is 4565 the ji for taxa named by at least 10 of interviewees is 4333 comparison with other studies 46 shows that the calculated similarity index with regard to wild taxa used for food within the hutsul ethnic group across the border is 55 when considering all taxa and 44 when considering only those taxa mentioned by at least 10 of interviewees hutsuls and romanians living in romania share 22 taxa used for food with a ji of 5366 in ukrainian bukovina both hutsuls and romanians use a greater diversity of taxa whereas romanian bukovina hutsuls and romanians use fewer taxa but with greater intensity the jaccard similarity index calculated for romanians on the two sides of the border is 4565 the ji for taxa named by at least 10 of interviewees is 4333 comparison with other studies 46 shows that the calculated similarity index with regard to wild taxa used for food within the hutsul ethnic group across the border is 55 when considering all taxa and 44 when considering only those taxa mentioned by at least 10 of interviewees hutsuls and romanians living in romania share 22 taxa used for food with a ji of 5366 in ukrainian bukovina both hutsuls and romanians use a greater diversity of taxa whereas romanian bukovina hutsuls and romanians use fewer taxa but with greater intensity the calculation of ji without cultivated taxa revealed even more similarity in uses within a country ji for romanians and hutsuls in romania is 6111 and for romanians and hutsuls living in northern bukovina it is 52 the homogenization of lek among romanians living in ukraine and hutsuls which live in different environments but within same country may have been due to soviet influences as discussed by pieroni and sõukand 5 eg propaganda of wild plant use at schools as the availability of local foods was inadequate an older romanian interviewee who was born in ukraine in 1953 and worked at the library explained that she and a school biology teacher have made an excursion path into the forest for two km where they explain to children the medicinal and food plants that growth there it feels so good when kids go there and ask about the plants and collect plants it is so important to teach kids explained the retired librarian the calculation of ji without cultivated taxa revealed even more similarity in uses within a country ji for romanians and hutsuls in romania is 6111 and for romanians and hutsuls living in northern bukovina it is 52 the homogenization of lek among romanians living in ukraine and hutsuls which live in different environments but within same country may have been due to soviet influences as discussed by pieroni and sõukand 5 eg propaganda of wild plant use at schools as the availability of local foods was inadequate an older romanian interviewee who was born in ukraine in 1953 and worked at the library explained that she and a school biology teacher have made an excursion path into the forest for two km where they explain to children the medicinal and food plants that growth there it feels so good when kids go there and ask about the plants and collect plants it is so important to teach kids explained the retired librarian figure 10 shows in particular the prevalence of achillea betula matricaria taraxacum tilia tussilago and viburnum spp food uses among romanians in ukraine and of atriplex rosa sambucus and thymus spp as well as of vaccinium myrtillus among romanians in romania these remarkable differences correspond again following the pattern we outlined for plant preparations to the most prototypical wild food plants occurring in the foodscapes of ukraine and romania betula taraxacum tilia and viburnum are particularly crucial plants in the eastern slavic and wider postsoviet wild food domain 33 69 70 71 these remarkable differences correspond again following the pattern we outlined for plant preparations to the most prototypical wild food plants occurring in the foodscapes of ukraine and romania betula taraxacum tilia and viburnum are particularly crucial plants in the eastern slavic and wider postsoviet wild food domain 33 69 70 71 while atriplex thymus and vaccinium spp are salient ingredients of the romanian foodscape 3237 these data show again how the wild foodscapes of romanians have been diversely influenced in the past century by national cuisines on both sides of the border possibly via intense contact and cohabitation with neighbors facilitated by intermarriages and the celebration of an atheistic nonreligious ethos which communism provided attitudes and perceptions crossborder bukovina is very diverse and multifarious nice lawns with magnolias and decorative trees neighbor yards with home gardens growing a variety of crops a huge jeep car is followed by horses in a local pizza place a young woman buys pizza for the family dinner while in the next house we see homebaked bread and a cow kept for milk for the children the interviewees explained that most of the young people are abroad for seasonal work women or grandparents stay at home to take care of the kids visually the differences in the level of income are seen very clearly with expansive home and fence decoration and a wooden roof house close by there is no one to cook for in southern bukovina the demographical situation in both southern and northern bukovina regions over the past several years has changed dramaticallythe younger generation has moved to the cities or richer areas of the european union elderly individuals are the ones who remain in the region there are a few current trends the younger generation sends back money to build houses the men of the household leave for seasonal jobs and then return and younger individuals move out and never come back during our interviews we noted all of these trends some people including several middleaged men who worked in germany explained that they have tried the hard living in a foreign land and will eat bread and water but they would never go back others explained that because there is nowhere to work in bukovina they have to go for seasonal work to earn money there were cases in which children were left with grandparents while parents went abroad and talked with and educated kids via the internet but they physically did not see them for years we also observed the huge newly built houses in the area that stand empty all this trend has influenced the use of wild plants for food the youngsters have left on their own there is a missing chain in the transmission of knowledge economic influence also reduces the need to collect wild plants and the last trend the absence of children close to grandparents a romanian woman born in 1947 explained that because there are no younger children or grandchildren left with her she has no one to cook wild foods for any more i have bought one liter of blueberries now i live alone and i have no one to cook for before i was cooking a lot now my kids left so i dont need so much for myself like in italy in northern bukovina in northern bukovina besides the emigration trend we observed how the influence of experience locals gain abroad was transmitted to local cuisine meanwhile the locals sometimes perceived the wild food plants as famine food or poor food a woman born in 1928 explained that there was no holodomor like in other parts of ukraine so they do not use many wild plants for food this indicates that there is a view of wild plants as famine foods which is in line with previous studies 710 this is păpădie we use it for salads like in italy explained a romanian woman born in ukraine in 1966 i spent 8 years working in italy i just came back i buy tea i dont collect it declared a 54yearold man from northern bukovina i have tea from italy i dont drink tea from local herbs stated an older romanian woman in northern bukovina we are not poor to drink herbal tea explained a retired romanian woman nowadays some respondents see wild food as a famine or peasant food which is in agreement with many findings from contemporary europe 1028 two interviewees explained that they do not collect origanum vulgare nor buy bay leaves because they obtain them from italy among romanians in ukraine a widespread response was that they buy tea instead of collect it from nature we dont make other teas the majority we buy there are big and small packages i think they are called gruzinskii explained a romanian woman born in ukraine in 1939 one pensioner a romanian women living in ukraine asserted that we are not poor we have tea and coffee from italy so there is a view of wild food as poor food in contrast to food coming from abroad globalization and the homogenization of cultures languages and natural resource use is a trend nowadays 4041 in addition in both of our study populations results show that an open work market has negatively influenced wild food use including its abandonment and decline due to 1 the emigration of young and middleaged individuals from border areas to other european countries new knowledge and practices of wild plant use as a result of traveling and working abroad eg salad like in italy and i dont collect herbs from here the surrounding environment i have tea from italy 2 the idea of no one to cook for which involves a reduction in the use of wild foods due to depopulation of rural border areas by younger generations leaving only pensioners in the region this is about unwillingness to invest time in elaborate recipes because of the lack of loved ones to motivate such an effort 3 the decline in the use of wild plants because of replacement by mass market products eg i have origanum from italy i dont collect it anymore 4 the valorization of forest products and higher income level which allows people to buy forest products instead of harvesting them from the wild eg we buy blueberries our results demonstrate the use of wild plants was as a part of cultural identity and selfactualization it is shown with the childhood memories or use of wild plants for specific timerequiring dishes living in same ecological conditions but with different socioeconomic scenarios we discover differences in the use of wild foods by the same ethnic group problems with infrastructure and the lack of job opportunities in ukrainian bukovina compel locals to be more dependent on available wild food resources while in southern bukovina the incomegenerating function of wild foods is confined to the past the use of wild plants that are strongly associated with local cultural identity and are present in local culinary traditions 72 the maintenance of wild taxa used as childhood treats and specific local culinary recipes are less likely to disappear from local cuisines however our results demonstrate the strong influence of an open work market and social migration on the use of wild plants rapid changes in lifestyle and habits are one explanation for the abandonment of wild food use which is consistent with serrasolses et al 72 the majority of food taxa used by romanians in ukraine especially for making tea can also be used for medicinal purposes this foodmedicinal continuum when comparing the two groups was also observed in sõukand and pieroni 6 plants that are strongly associated with local cultural identity and are present in local culinary traditions 72 the maintenance of wild taxa used as childhood treats and specific local culinary recipes are less likely to disappear from local cuisines however our results demonstrate the strong influence of an open work market and social migration on the use of wild plants rapid changes in lifestyle and habits are one explanation for the abandonment of wild food use which is consistent with serrasolses et al 72 in bukovina 51 taxa were used for food compared to 40 taxa recorded by sõukand and pieroni 4 this number however is lower than the 70 taxa recorded in polissya region 24 yet higher than in roztochya with 26 taxa 7 or the 44 taxa used in maramures 33 romanians in ukraine used four wild taxa for soup preparations while romanians in romania used only two taxa in other parts of ukraine the number of plants use for green soup reaches 21 taxa 26 in southern bukovina atriplex hortensis is not seen as wild because it grows in gardens similar to that of rumex acetosa in the area of roztochya where this taxon grows in yards and gardens 22 birch sap was widely used in northern bukovina as a refreshing drink and also fermented for winter time it is popular in other parts of ukraine and eastern europe as well 571 and thus could have a soviet origin the flowers of robinia pseudoacacia were mentioned as a famine food during times of scarcity in polissya region 24 the possible attenuation in use of atriplex hortensis by romanians in northern bukovina may be related to the fact that it is seen as a famine food 73 the prevalent use of recreational tea by romanians in ukraine could have soviet roots as teatime and herbals tea were promoted during this era sweets being the dominant preparation mode in southern bukovina may be explained in a couple of ways the deficit of sugar during economic crises and sweets being seen as rich peoples food and the turkish influence of using jams and sweets the difference in the use of winter preserves and fermenting may be due to the unstable economic situation in northern bukovina which forces people to have their own food security system for winter time and times of uncertainty the taste of wild foods was also one of the factors influencing the use of plants eg jam made from rosa rugosa is considered to be a delicacy and nowadays there is a trend toward the valorization of products made from rosa rugosa in both areas of bukovina studies have demonstrated that taste is culturally developed 74 therefore in our case taste was not the main factor influencing wild food use 72 the use of wild foods not only serves nutritional and safetynet functions 75 but it is a source of selfactualization and contributes to wellbeing 42 eg i cook as my mom and grandma used to cook using wild herbs complex humannature relationships are formed with the use of wild foods growing in the surrounding landscape creating a unique local cuisine however socioeconomic and governance systems have produced differences in uses by the same ethnos in the same environment an improved economic situation leads to a decline in the use of wild taxa for food as well as harvesting practices and cooking practices eg it is hard to cook and there is no one to cook for differences across the border are remarkable along with the use of 21 shared taxa we recorded 25 different wild food taxa the most remarkable differences between the two sides were related to mode of preparation we suggest that those differences are the result of the influence of intense contact and cohabitation with neighbors in romania bukovinians were part of a larger group and did not have to preserve any ethnic belonging and cultural identity while in northern bukovina romanians had to somehow integrate with ukrainians yet remain romanian in order to save their cultural identity in northern bukovina interviewees mentioned that their children were studying in ukrainian universities even though schools in the region are romanian they study ukrainian and some teachers are ukrainian the peaceful coexistence of these two ethnic groups has resulted in intermarriages and close connections interviewees also highlighted moldova as a state with a similar language and education in moldavian institutes during soviet times therefore the factors possibly influencing local cuisine and the use of wild food plants include 1 the border that has divided bukovina for the last 80 years has resulted in different sociopolitical scenarios and thus in different food behaviors and the use of wild plants in local cuisine longstanding borders have had a tangible effect in shaping divergent wild plant foodscapes since the respective national states of northern and southern bukovina and possibly different neighbors have shaped the romanian dining table in different ways 2 intermarriage and neighbor influence at least three interviewees in northern bukovina explained that they were married to a ukrainian which may have influenced their food behavior i cook green borshch as ukrainians do and my daughterinlaw is ukrainian from kolomyya she cooks 12 dishes for christmas eve and she teaches me another male interviewee stated in the neighboring novoselecjk region they ferment apples and melons but we dont 3 economic differences in order to smoke meat one has to be able to afford it and during soviet times meat was deficit while during the economic crisis between 1990 and 2000 rural individuals could not afford it in contrast herbal teas are easily affordable and among romanians it was twice as popular in northern bukovina as in southern bukovina the use of birch sap clearly has soviet roots as it was promoted as a healthy and tasty drink winter preserves as a way to survive during economic crises are still popular in northern bukovina as a food security practice 4 market influence romanians live in close proximity to other ethnic groups with whom they interact at local markets for example participatory observation in northern bukovina has revealed the possible exchange of culinary experiences at babushka markets 65 5 the media local newspapers and television food shows may also influence local cuisine as recipes for different dishes have been published in the local press the latest un report 76 highlighted that in terms of global food issues locally grown foods and the use of wild foods from local landscapes are the answer to the challenges that humankind currently faces that is why documenting and discussing lek on wild food use is a crucial and timely endeavor conclusions contemporary use of wild taxa by romanians in bukovina region was diverse and different across the border romanians in romania use fewer taxa in a less intensive way while romanians in ukraine use more diverse species and have more diverse uses including those that support food security in winter time in the wild food domain romanians living in bukovina used 46 plant taxa despite the flat landscape with extensive agricultural fields romanians on both sides of the border used forest taxa the most as wild food the limitation of the study is that the two groups of romanians do not present a statistically significant difference in the use of plant categories therefore the qualitative results of this study represent the contemporary use of wild plant taxa for food purposes showing 566 durs limitations of the study in both case study areas the women were the dominating interviewees therefore we consider this division as relevant to these conditions and qualitative methods as in both areas the help of the field assistant was used some small details of the interviews might be lost in the translation our results show that the use of wild food plants in bukovina is more similar between ethnic groups within the same country than within groups across the border which supports the main hypothesis of the dige that sociopolitical scenarios influence the use of wild foods indeed crossborder studies can greatly contribute to enhance our understanding of the impacts of political contexts on the local ecological knowledge this can be crucial to shape effective policies according to the perceptions and management of local resources adapted to different political contexts such policies can be especially important in areas rich of biological andor cultural diversity which therefore would require contextbased conservation and valorization policies the 80 years spent living under different governance systems has resulted in different ways of using wild plants in daily cuisine the use of food plants by romanians is more markedly shaped by intermarriage and neighbor influence as well as the recent phenomenon of globalizationopen work market as a result making use of some plants similar to those found in countries where interviewees worked the improved economic situation and the availability of industrially produced goods have also influenced current uses eg decrease in the use of wild plants in everyday cuisine depopulation of rural areas and a growing disconnect with nature has also significantly influenced the decline in the skills and practices of wild plant use in addition the valorization of forest products and a higher income level allows for buying forest products instead of harvesting them from the wild this research gives the opportunity to understand the dynamic structure of local cuisine influences by the sociopolitical scenarios globalization intermarriage and coexisting of different cultures and media influence market flow of products as well as the economic situation which allows limitation of wild plants use based on these results the prognoses of more disconnection with nature less wild plants use for everyday cuisine could be reached therefore the internal global crises events eg the covid19 pandemic or issues with food supply in the remote areas might increase the wild plant use for food complex humannature relationships are formed with the use of wild foods growing in the surrounding landscape creating a unique local cuisine there is a need for further research into how sociopolitical scenarios under conditions of globalization in terms of the flow of people investment market product and knowledge influence lek and food habit changes focusing on biocultural values and dynamics of local cuisine the use of wild food as a selfactualization and contribution to wellbeing also requires future studies further research is needed to explain food uses for cultural purposes for example religious celebrations another issue that was frequently mentioned by locals and seen as an important culinary practice and thus needs more thorough analysis and consideration including crossborder comparison is food habits connected to ceremonies and ritual behaviors in the framework of recent debates on the significance of wild food plants especially during the covid19 crisis current research is vital in terms of the application of lek and understanding the driving forces of wild plant use the next issue that demands research is homegrown foods as a food security measure during the participatory observations and during interviews locals named the food gardens close to homes as an important source of both supplementary food and healthy selfgrowing food the use of wild foods as ethnomedicine for humans and for animals is another important subject for our future research data availability statement the datasets generated for this study are available from the authors upon reasonable request data from erc project dige will be fully available after the project ends author contributions rs and ns designed the study ns and gm conducted the fieldwork ap structured the study ik has input to structure and discussion ns analyzed the data and drafted the manuscript with contributions from all the authors all authors approved the final manuscript all authors have read and agreed to the published version of the manuscript declaration of helsinki and approved by the ethics committee of ca foscari university of venice on the 9 november 2017 informed consent statement oral informed consent was obtained from all subjects involved in the study abbreviations

local cuisine is an important reservoir of local ecological knowledge shaped by a variety of sociocultural economic and ecological factors the aim was to document and compare the current use of wild and semicultivated plant food taxa by romanians living in romania and ukraine these two groups share similar ecological conditions and historically belonged to the same province but were divided in the 1940s by the creation of a state border we conducted 60 semistructured interviews with rural residents the contemporary use of 46 taxa plus 5 cultivated taxa with uncommon uses belonging to 20 families for food consumption were recorded romanians in romanian bukovina used 27 taxa belonging to 15 families while in ukraine they used 40 taxa belonging to 18 families jams sarmale homemade beer and the homemade alcoholic drink socată are used more by romanians in southern bukovina while tea soups and birch sap are used more in northern bukovina we discuss the strong influence of sociopolitical scenarios on the use of wild food plants crossethnic marriages as well as markets and womens networks ie neighbors do so may have had a great impact on changes in wild food use in addition rapid changes in lifestyle open work market and social migration are other explanations for the abandonment of wild edible plants

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background it is said that everyone has the freedom to make decisions about their own sexuality and reproduction regardless of their age gender or other traits as long as they also respect the rights of others 1 since the international conference on population and development held in cairo in 1994 human rights legal standards have significantly advanced and those involved in sexual and reproductive health programming have largely become important rights to be realized 2 these rights are based on the recognition of all individuals basic human rights which include the right to access information and services to support these choices and promote sexual and reproductive health rights 13 due to the fact that the majority of university students are young adults they require extensive sex education in order to learn about srhr and how to preserve their rights all throughout their life 4 their characteristic early sexual initiation highrisk sexual behaviors and insufficient levels of awareness about how to safeguard their sexual health demonstrate the need for sex education 5 formal education on sexuality and reproductive health is restricted to biology and science syllabi and does not address all topics related to sexual and reproductive health rights in general 6 because of hurdles including shame guilt embarrassment not wanting friends and family to know confidentiality and fear of not being believed as well as a lack of understanding individuals are still unable to cope with reproductiverelated violations 7 and partially due to their lack of knowledge and experience regarding sexualityrelated issues especially the legal tools that would give them the chance to assert and defend their sexualityrelated rights 6 due to the enormous taboo that surrounds it and is derived from culture religion tradition and the very personal nature of its several subtopics sexual and reproductive health rights continue to be a topic that is challenging to discuss in many circumstances 8 despite the fact that it is crucial for everyone at all stages of life sexual and reproductive health however far too many individuals particularly young people males and poor women in developing nations like ethiopia are denied the right to sexual and reproductive health 9 many sexually active young women believe they are unable to discuss or regulate certain aspects of their sexual conduct as a result 10 evidence suggests that most young people are not even aware of the extent to which their sexual rights are being violated worse yet they continue to be unaware of where they can turn for legal or social advice 5 and the poor quality of rightsbased interventions for sexual and reproductive health rights reported in low and middleincome countries like ethiopia 11 as a result the issue continues to be a major concern for university students with limited studies indicating that their knowledge of sexual and reproductive health rights is grossly inadequate in nepal for example the mean level of knowledge about reproductive and sexual health rights was barely more than fifty percent 12 it was around 603 in ikeja and 621 in ikorodu nigeria 13 and ethiopian university students average level of sexual and reproductive health rights knowledge ranged from a very low 164 to 577 14 15 16 17 18 19 according to studies different backgrounds and other related variables influence students knowledge of sexual and reproductive health rights for instance according to studies conducted among university students urban resident 1519 information and education faculty 19 availability of reproductive health service in the campus clinic 19 attending high school in private schools 15 being student of faculty of health sciences 14 15 16 participation in reproductive health clubs 1524 utilization of reproductive health services 15 and discussing sexual issues with someone else 141524 were all significantly related to knowledge on sexual and reproductive health rights although 179 nations including ethiopia agreed to take action for universal access to sexual and reproductive health the programs development has been sluggish 20 in order to address the needs of adolescence through a holistic approach the ethiopian ministry of health designed programs and policies that target vulnerable young people and those at risk of irreversible harm to their reproductive health and rights by recognizing and diversifying services with age sex life stage and vulnerability status 21 yet unsatisfactory implementation of these programs and policies in practice was looked over in public institutions like universities in ethiopia a vast number of the population were reported as adolescents in which most of the university students fell into this age group despite the fact that the country has over 40 governmental universities there have been few studies on the level of knowledge on srhr at the university level in addition from the findings that have been observed so far the issue of reproductive and sexual rights remains unsatisfactory as a result the purpose of this study was to determine the level of knowledge on srhr among regular undergraduate students at madda walabu university methodology study duration and design from february march 2022 an institutionalbased crosssectional study was conducted at madda walabu university study area the research was carried out on undergraduate regular students at madda walabu university among the universities in the nation madda walabu university was chosen by lottery method the university was founded in 2006 and is located in bale zone in the town of robe about 430 kilometers from addis ababa the capital city the university currently has 46 undergraduate and 28 postgraduate programs according to data obtained from the registrars record office it currently has 11000 regular undergraduate students on three campuses robe goba and shashamene 22 population the source population consisted of all regular undergraduate students at madda walabu university while the study population consisted of randomly selected students who were present in class at the time of data collection this study included all regular undergraduate students at madda walabu university but students who were ill or transferred in or out during the data collection period were excluded sample size calculation the sample size was calculated using a single population proportion formula assuming 522 knowledge of sexual and reproductive health rights 16 a 95 confidence interval and a 5 margin of error n 2 0522 2 383 the final sample size was 483 after accounting for a 5 nonresponse rate and the design effect of 12 sampling procedure the participants in the study were chosen using a multistage stratified sampling procedure to properly allocate the sample size the mwu registrars office first verified the campus number and number of students on each campus as a result during the study period the three campuses namely goba shashamene and robe had approximately 700 500 and 9800 regular undergraduate students respectively after determining the number of students on each campus samples were assigned to each campus based on the number of undergraduate students enrolled during the study period consequently the campuses in goba shashamene and robe each contributed 31 22 and 430 students respectively the students were then split up into colleges schools and departments students were then further stratified by class year under particular colleges schools and departments finally systematic random sampling was performed utilizing a student list obtained from the registrar as a sampling frame per chosen parts every 22 intervals variables sociodemographic factors such as place of residence monthly stipend from family and relatives attending secondary school in private schools being a students faculty of health science and reproductive healthrelated factors such as participation in reproductive health clubs utilization of reproductive health services and discussing sexual issues with someone else were study variables while level of knowledge on sexual and reproductive health rights was an outcome variable a total of thirteen questions about sexual and reproductive health rights were asked for those who answered yes correct the value 1 is assigned and for those who answered no incorrect the value 0 is assigned the questions in the opposite order were recoded the values were then computed participants with at least a mean level of knowledge on sexual and reproductive health rights out of 13 points were classified as having good knowledge while those with less were classified as having poor knowledge tools and procedures for data collection data was collected using a selfadministered questionnaire after the classroom was properly set up a questionnaire was developed from different literature pertinent to the topic of interest 915 17 18 19 an english version tool was used to collect information from the participants because english is the language of instruction in higher education the questionnaire was divided into three parts the first section was used to evaluate the study participants sociodemographic characteristics the second section was used to assess study participants use of reproductive health services and sexual experience the third section assessed participants knowledge of sexual and reproductive health rights the outcome variable was measured using a 13question survey with yesno options for those who answered yes the value 1 is assigned and for those who answered no the value 0 is assigned the questions in the opposite order were recoded the values were then computed and a score of at least mean or higher was considered to indicate a good level of knowledge about srhr to help with data collection six data collectors and six supervisors were assigned data quality control a pretest was performed on 5 of the sample size to improve the clarity ease of understanding and simplicity of the tool messages prior to data collection on sections that were not reincluded in the study after the pretest ambiguous words were simplified based on recommendations from the participants furthermore the minutes taken for filling out these self administered questionnaires improved from 510 minutes to 1015 minutes considering the participants who had returned the questionnaire first and last prior to data collection data collectors and supervisors were trained for two days on the objective method sampling technique ethical issues data collection instrument and data collection procedure the study participants were arranged in the classroom so that one participants privacy was not compromised by the other participants before analysis all questionnaires were checked for completeness and accuracy both during and after the data collection period after the data was exported to the fitted model clearance was granted data processing and analysis the data was coded and entered into epidata 4620 the data was then exported to spss version 260 and cleaned before being analyzed the variables descriptive statistics were computed to assess the statistical significance and strength of the association between independent variables and outcome variables a binary logistic regression model was used to account for confounding effects variables with p values less than 025 were transferred to a multivariable binary logistic regression model the model was run using the enter method the goodness of fit model of hosmer and lemeshow was tested and the data fit the model well the crude and adjusted odds ratios as well as their 95 confidence intervals were computed a p value of less than 005 was considered significant during the multivariable binary logistic regression model analysis finally based on the data obtained the studys findings were presented in the form of tables graphs and texts results the response rate of the study participants was found to be 100 in this study however only 434 of the total participants completed the questionnaire correctly and their data was analyzed while the remaining 49 participants data were excluded from analysis due to the questionnaires incompleteness participants sociodemographic characteristics in the study the participants average age was 172 years with a standard deviation of 208 years 314 of the total participants were male 310 had been nonhealth students and 316 were year ii and above students in terms of ethnicity 288 of the participants were oromo with 118 being amhara the use of reproductive health services and sexual experiences of study participants according to the table below nearly sixtyfive percent of study participants had ever heard about sexual and reproductive health rights with peers serving as the primary source of information for 84 almost threequarters of study participants did not discuss their sexual and reproductive health rights with anyone else in terms of sexual behavior more than half of the study participants had sexual intercourse at some point in their lives with approximately having sexual intercourse before the age of eighteen the level of knowledge of srhr among study participants to assess the study participants knowledge of sexual and reproductive health rights thirteen yesno questions were used those who answered yes received a value of one while those who answered no received a value of zero the questions with the opposite answers were recoded the participants mean level of knowledge on sexual and reproductive health rights is calculated using a corrected answer as a result the sum of questions ranged from 5 to 13 with an 825 mean knowledge of sexual and reproductive health rights and a 136 standard deviation only 120 of the total participants correctly answered all of the questions 312 of those polled responded correctly to the question of whether a man should have sex whenever he wants regardless of his wifes wishes in addition 298 of participants responded correctly to the question of whether girls have the right to autonomous reproductive choices without the consent of their partners and 271 dovepress adolescent health medicine and therapeutics 202314 6 responded correctly to the question of whether reproductive age groups have the right to the highest attainable standard of health according to the current finding 52 of the participants had an optimal level of srhr knowledge which was at or above the mean of 825 with a standard deviation of 136 factors related to sexual and reproductive health right knowledge bivariate binary logistic regression analysis revealed associations between knowledge of sexual and reproductive health rights and place of residence field of study year of study monthly income from family or relatives secondary school attendance in a private school talking about reproductive rights with someone else having heard of them before the presence of a reproductive health club on campus and membership in a reproductive health club these variables were all transferred to the multivariable binary logistic regression model since they all satisfied the predetermined criterion with a pvalue of less than 025 in a multivariate binary logistic regression analysis the origin of residency field of study attending secondary school in a private school discussing sexual and reproductive health rights with someone else the availability of a reproductive health club on campus and participation in a reproductive health club were found to be statistically significant predictors of optimal knowledge on srhr according to table 4 participants from urban areas had nearly twice the odds of discussion as the majority of the worlds countries strive for universal health coverage making every effort to ensure that sexual and reproductive health rights are effectively incorporated becomes increasingly important 2 due to a lack of knowledge about srhr university students are less likely to use existing health services 23 the goal of this study was to assess university students in southeast ethiopias knowledge of sexual and reproductive health rights in this study the level of knowledge on sexual and reproductive health rights was found to be 521 95 ci this finding is consistent with research from nepal 12 522 16 and 545 15 in ethiopia however it is higher than studies conducted elsewhere in ethiopia 14 18 17 and lower than studies conducted elsewhere in ethiopia 19 24 and 603 in ikeja and 621 in ikorodu in nigeria 13 the disparity could be attributed to differences in study settings and methods for example the nigerian study used a mixed study design 13 whereas ours is only a quantitative crosssectional study another reason could be that different countries implementation of adolescentbased sexual and reproductive health education according to the study participants from urban origins were nearly twice as likely to have good knowledge of sexual and reproductive health rights the rationale behind this could be that participants from urban areas have more exposure to information and media furthermore participants from urban areas are more likely to come from educated families and to freely discuss the issue with family members and peers than participants from rural areas in a developing country like ethiopia a study of regular undergraduate students at wolaita sodo and gonder university backs up the findings 1519 participants from the faculty of health sciences were also 1221 times more likely to be knowledgeable about sexual and reproductive health issues this could be because health students are taking a course on sexual and reproductive health it could be explained better because the curriculum of health science programs included information about reproductive health and family planning in particular a previous study on university students found that being a student in the faculty of health science was more likely to have good knowledge of sexual and reproductive health rights 14 15 16 similarly participants who attended secondary school in private schools were six times more likely to be knowledgeable about srhr the most likely reason is that when compared to governmental schools the total number of students in private schools was lower allowing information to reach the majority of students easily through either reproductive health club or minimedia also students from private schools were closer to their teachers so they could easily inform them about the scenario similarly a study found that students who attended secondary school in private school were twice as likely knowledgeable about sexual and reproductive health right 15 the study discovered that participants who discussed sexual and reproductive health rights with someone else were 9 times more likely to have good knowledge of sexual and reproductive health rights similarly discussing sexual issues with someone else is associated with greater knowledge of sexual and reproductive health rights 141524 those who discussed the issue with someone else surely got full information about srhr and may be free of fear of getting reproductive health services and be able to use their rights appropriately furthermore having access to reproductive health services on campus and participating in reproductive health clubs were linked to having a good understanding of srhr participants who were aware of the availability of reproductive health services on campus knew nearly twice as much about their sexual and reproductive health rights the reason for this could be that students who were aware of the existence of reproductive health clubs on campus could join them and easily share information with one another similarly a study of haramaya and gondar university students found that the presence of reproductive health clubs on campus was significantly associated with optimal knowledge of sexual and reproductive health rights 1619 participants in this study who were members of a reproductive health club were nearly four times more likely to have a good knowledge of sexual and reproductive health rights similarly another study among university students found that dovepress adolescent health medicine and therapeutics 202314 students who participated in reproductive health clubs were more likely to have good knowledge about sexual and reproductive health rights 151624 understanding current students knowledge of srhr in general is useful for assessing the accessibility of reproductive health services and the need for interventionbased sexual and reproductive health education on campus the finding implies that university authorities are expected to check the availability of reproductive health club on the campus prepare training on the sexual and reproductive health rights for the students have program invite the nongovernmental organization on the area to improve the students knowledge since it has great social impact limitations of the study even though it strictly adheres to scientific procedures the current study has some flaws for example because the study was limited to one public university in ethiopia it lacked representation from all governmental and private universities in the country furthermore data collection using selfreport tools may be biased and incomplete finally due to the crosssectional nature of the study we were unable to account for temporal relationships between variables conclusion four out of ten students in this study had inadequate knowledge of srhr being a city dweller a health student attending a private secondary school having a reproductive health club on campus and play a part in rh clubs were all independently associated with a high level of srhr knowledge srh education should be included in nonhealth department courses srh training should be prepared on campus reproductive health clubs should be established and students should be encouraged to participate in these clubs in addition practice and interventionbased studies are recommended for assessing university students knowledge of srhr data sharing statement the data set used in the current study is available upon reasonable request from the corresponding author abbreviations informed consent madda walabu universitys research and ethical committee granted ethical clearance with a letter of reference number rdd004814 permission was obtained from the appropriate colleges schools and departments additionally the study followed the declaration of helsinkis principles for conducting human subjects research after thoroughly explaining the studys objectives each study participant provided written informed consent the study participant was given the option to refuse discontinue or withdraw from participation at the time of data collection throughout the study the privacy and confidentiality of information and responses were guaranteed disclosure the authors report no conflicts of interest in this work adolescent health medicine and therapeutics dovepress publish your work in this journal adolescent health medicine and therapeutics is an international peerreviewed open access journal focusing on health pathology and treatment issues specific to the adolescent age group all aspects of health maintenance preventative measures and disease treatment interventions are addressed within the journal and practitioners from all disciplines are invited to submit their work as well as healthcare researchers and patient support groups the manuscript management system is completely online and includes a very quick and fair peerreview system visit to read real quotes from published authors submit your manuscript here dovepress adolescent health medicine and therapeutics 202314

in many situations it can still be challenging to talk about sexual and reproductive health rights and the little scientific research available indicates that university students have a poor understanding of these issues therefore the aim of this study was to assess the knowledge of sexual and reproductive health rights among university students in southeast ethiopia methodology from february to march 2022 483 study participants took part in an institutionally based crosssectional study the study participants were chosen using a srs method epidata version 4620 was used to enter data and spss version 260 was used to analyze it a bivariate and multivariable binary logistic regression model was used to identify factors associated with srhr knowledge the odds ratio and a 95 confidence interval were used to calculate the significance levelthe optimal level of knowledge on srhr was discovered to be 521 95 ci 47325508 among university students in southeast ethiopia the multivariate binary logistic analysis indicated that being urban in the origin of residency aor152 95 ci 102114 being a health student aor 1221 95 ci 7271488 attending secondary school in private aor612 95 ci 102114 accessibility of a rh club on campus aor612 95 ci 102114 and participating in rh club aor395 95 ci 347590 to be variables that are strongly related to the optimal level of knowledgefour out of ten students had poor knowledge of srhr the variables associated with a high level of knowledge about srhr were urban residency health students attending a private secondary school the availability of a rh club on campus and participation in a rh club including sexual education in the nonhealth departments course establishing rh clubs on campus and encouraging participation of students in these clubs are recommended

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extension it is expected that the underrepresentation of aapis is consistent across aapi ethnic groupings this fragile assumption has not been experimentally validated but if it is incorrect it might be detrimental to eliminating disparity and ensuring that aapi students get timely treatment it is important to examine special education patterns among aapi ethnic groupings since they constitute the fastestgrowing demographic in the nation doing so may help advance theories of disproportionality and provide light on current discussions regarding the underrepresentation of children of colour we add to the body of knowledge on racial disparity and aapis in special education with this article we examined changes in special education for 11 aapi ethnic subgroups overall and by disability using longterm data from 10 cohorts of kindergarteners from a school region we also investigated whether aapis get special education at a different grade level and we evaluated if representation gaps are linked to variances in student backgrounds tohara provided the viewpoints of malaysian educators on the topic of digital literacy skills as they relate to the students education with special requirements the cognitive skills technology and ethics that make up the digital literacy skills model serve as a foundation upon which to build an investigation of effective digital literacy pedagogy for students with special needs mustafa et al 2020 investigated the elements that contribute to the beginning of the workload for instructors participating in the se integration program battal examined the origins growth and current state of special education in saudi arabia the ministry of education is the primary service provider hence the studys focus is only on its initiatives aldabas investigated saudi arabias special education system and provide a historical outline of it since the introduction of se in 1958 saudi arabia has made great progress in the service provision for students with impairments ruppar et al evaluated special education teachers assessments of their readiness to put suggested strategies for students with severe impairments into practice literature review masonwilliams et al evaluated special education teachers assessments of their readiness to put suggested strategies for students with severe impairments into practice davila built on three academic semesters worth of ethnographic observations and provides incidents of disability microaggressions that are directed at latina students who are enrolled in special learning programs morgan et al aimed to determine whether or not a disproportionate number of minority students registered in elementary and middle schools in the united states get special learning services kent and giles were to assess the efficacy of a field component integrated into a revised teacher education program with the ultimate result being the recommendation of undergraduate candidates for both k6 common and se certification odongo and davidson focused on kenyan educators and their thoughts on including students with special requirements in their normal courses teachers from 10 different primary schools in a single school district in western kenya were recruited for the research zhang et al looked at the emotional cognitive and conative perspectives of chinese university educators on inclusive higher education teachers at chinese universities seem to have a good attitude and analyse the rights of students with impairments to pursue higher education according to the results of a recent survey research questions study question 1 what percentage of aapis across aapi ethnic groupings are underrepresented in special education as compared to white students study question 2 how different is the scheduling of se compared to white students for aapi ethnic subgroups study question 3 what proportion of discrepancies in aapi students representation in se compared to white students may be attributed to students and their family background factors method to study the experiences of aapi students researchers chose a suburban school area in california this work is part of a wider districtresearcher cooperation aimed at reducing racial inequities in the areas special education services especially for aapi students more than 62000 students were under the districts care during the school year of the year 20152016 approximately 286 percent of all pupils identify with one of 11 aapi ethnic groupings students from aapi backgrounds make up 117 of californias student body 56 of the nations publicschool enrolment and 51 of the countrys overall population in the district 11 of children get special education which is comparable to the states and the countrys overall percentages the district choice reflects tradeoffs between the findings generalizability and the model size and environment required to break down aapi ethnic groupings since aapis are usually undersampled by ethnicity in many studies across fields the latter is a common methodological problem although the studys conclusions can only be applied to regions with comparably sizable and varied aapi populations the researchs conclusions are nevertheless useful for districts where the aapi population is expanding quickly additionally the districts student characteristics and data sets provide a unique chance to investigate patterns among aapi students in se and develop hypotheses regarding disparity that might inspire further research in other districts data sample this study investigated academic information and demographic on every student in a suburban california school area from 2004 to 2013 the sample used for the analysis consisted of longitudinal data collected on ten groups of kindergarteners while the kindergarten class of 2004 had nine years of data the class of 2013 has just one full year of information this is because not all cohorts begin at a similar time and give a similar number of years as required by the staggered design only children who had just entered kindergarten were included to study the scheduling placement of special education throughout grade transitions cohort sizes have increased annually the number of students has increased from 3800 in 2004 to over 4600 in the most recent year the last sample includes 167262 files representing 42807 students from 41 communal institutions measurement the primary result was a continuous timevarying binary indicator with the value 1 indicating that the pupil got special education and the value 0 indicating that they did not the following disabilities each have their own timevarying special education indicator as a result of this study difficulties with speech or language particular learning disability and other health concerns indicator variables were developed for each of the eleven aapi subgroups to analyse trends in special education for this population all analyses in this research accounted for variations among students of different races including those of african american american indian hispanic and white backgrounds student and family covariates placement in special education programs may be influenced by several variables gender el status lunch assistance parental education and country of birth are all factors were all background factors that i accounted for additionally to parental guidance and free meals the latter serves as a standin for acculturation circumstances that may affect childrens school experiences student progress student accomplishment is a crucial indicator of special education beginning in the second grade students in california were obliged to take the consistent test and information in arithmetic and english language arts every year from 2004 to 2013 on each exam the raw scale values assortment from 150 to 600 the fact that pupils only start receiving scores for the achievement measures in 2nd grade which would entail omitting data from kindergarten and 1st grade is a problem additionally studies utilizing the state results for students with more severe impairments who did not take the standard unmodified test were omitted due to these factors this research compared variations in model performance by race and ethnicity in childrens ela and math results from the second grade as a sensitivity analysis features of schools several school characteristics may affect choices in special education but they may be difficult to assess practices in special education could also vary by school to account for reported and unnoticed school features this study utilized schoolfixed impacts in my models analysis strategy this study utilized discretetime survival analysis to analyse the analysis of longitudinal data on the association of aapi with se admission the approach accounts for the filtering of students who do not encounter the occasion within the data duration when estimating the incidence of an event 𝑙𝑜𝑔𝑖𝑡 𝑔 𝑗𝑠 ∑ 𝛼 𝑙 𝑙 𝑙0 𝐶 𝑗𝑠 𝑙 𝛽𝑅𝐴𝐶𝐸 𝑗 𝛾𝑊 𝑗 𝛿 𝑧 𝜑 𝑡 this research indicates the risk of placing student 𝑗 in special education in grade 𝑠 as 𝑔 𝑗𝑠 or the likelihood that student 𝑗 will get se in grade 𝑠 supposing the student has not yet been recognized the vector 𝑊 𝑗 in the discretetime hazard model represents the logit of a hit as a function of grade the students race and ethnicity and student variables this research includes a set of kindergarten enteringyear cohort fixed impacts in y to adjust for unobserved variations across cohorts this research uses schoolfixed impacts in 𝑡 to adjust for school variations that may have manipulated se choices this research integrated the fixed impacts of their first school since the majority of pupils who enrolled in special classes did so throughout the primary school years to answer research question 1 this research used an unconditional hazard model without variables to determine if aapi subgroups are underrepresented in se the parameters in the vector which depicts the likelihood ratios of aapis and other student groups being placed in special education in comparison to white students are of interest for study question 2 the research examined the scheduling of se for aapi students by using scheduling duplicate parameters to illustrate the likelihood that archetypal pupils from each aapi grouping would be placed in special education over grades this research incorporated interactions between the scheduling duplicate parameters and racial groupings to account for the possibility that the risk of special education may fluctuate over time this research used a general linear hypothesis test to see if the values collectively were tactically different from 0 given several communications as the results of the glh test were not tactically important this study fixed models that only included the major impacts of the grade stage for parsimony to answer study question 3 this research examined differences across aapi subgroups after adjusting for baseline traits to do this models including statistics about students and their families student accomplishment and school fixed impacts were compared to a baseline model without covariates results and discussion in this research we conduct an indepth analysis of the thorough examination of special education for students of asian american and pacific islander ancestry study question 1 special education disparities the models for discretetime survival analysis provide the regression findings shown in table 1 model 1 takes into consideration the longitudinal nature of the data and examines the question of whether aapi students lack representation in special education compared to white students there is a trend of underrepresentation of aapi pupils compared to white students in the parameter evaluation connected with every aapi grouping the odds ratios for special education placement were lower for all aapi subgroups than for white students ranging from 042 for cambodian and korean students to 056 for vietnamese and white students a linear hypothesis test of equality revealed that there were in fact distinguishable differences across aapi subgroups among aapi groupings laotian students had the lowest likelihood of being placed in special education while vietnamese students had the highest model 1s findings corroborate both the widespread underrepresentation of aapi groups and the need to disaggregate trends in special education enrolment for aapi pupils according to the us branch of education idea statistics the odds ratios demonstrating the disproportionate presence of african aapi students are in line with expectations study question 2 special education scheduling figures 1 and 2 depict hazard and survival functions respectively that may be used to characterize the scheduling of special education the general pattern in the hazard functions by asian american and pacific islander subgroups and for the district indicates that childrens likelihood of receiving special education assistance increases through kindergarten then decreases precipitously through first grade before levelling out again in later years in ninth grade the risk likelihood significantly rises which may be indicative of a problem with transitioning to higher school however the overall risk probabilities are modest suggesting that only a small percentage of students need and are likely to get special education except for korean children aapi students hazard possibilities of receiving special education assistance were lower than the predicted district average in comparison to the district as a whole the hazard probabilities for four of the eleven aapi subgroups were around half as low when compared to the average hazard likelihood across grades the scheduling of se for cambodian students was consistent the likelihood that a pupil will make it through school without needing any kind of specialized instruction is shown in figure 2 by the survival functions study question 3 taking student background variables into account this research used variables in table 1 of the unconditional model to determine whether or not variations in student backgrounds may account for the underrepresentation and inequities in special education across aapi subgroups the primary socioeconomic factors and kindergarten cohort fixed effects are accounted for in model 2 nine of the eleven aapi subgroups continue to be underrepresented compared to white pupils when it comes to special education as shown by the parameter estimates linked with those groups model 3s control for student performance does not change this trend students of hmong and laotian descent who scored below the district average had a 63 reduced likelihood of being placed in special education than their white counterparts to account for changes in schools that can affect special education choices across student groups the last model includes schoolfixed impacts aapi minorities continue to be underrepresented in special education with a 33 62 lower likelihood of enrolment compared to white pupils africanamerican and latino students face similar representational challenges with or without additional confounding factors aapis were underrepresented across the board and in most subgroups for the most common types of disabilities table 2 provides models detecting the risk of special education services null findings may have been the consequence of inadequate statistical power owing to the reduced sample numbers by disability table 1 show that the complete model reveals parity with white students for half part of the aapi categories while the unconditional model shows a similar pattern to special education generally for students with speech or language impairment compared to white students aapis are more likely to be underrepresented when it comes to having a particular learning impairment as shown by their lower odds ratios however after accounting for demographic variables korean students still had a greater chance of accessing learning disability treatment than white students most aapi groupings had rates of autism representation comparable to white children in both the unconditional and adjusted models similarly no underrepresentation or inequality was seen for aapi subgroups across all forms of health impairment recent research on the uneven enrolment of students in se and it has highlighted trends of underrepresentation among certain students of colour in comparison to white students although there are substantial variances in the backgrounds of students prior studies believed that the under representation of aapis was consistent among aapi ethnic groupings to enhance services for all aapi students and contribute to discussions concerning disproportionality it is necessary to examine se trends by aapi subgroups the timeliness of services and variations in special education rates within a significant racial group in the united states are being examined for the first time in this research conclusions the under representation of aapis in se both overall and across the majority of aapi ethnic groupings as discovered in this research is a warning sign that the system isnt fair to aapis these patterns reflect how aapi students are becoming marginalized in schools and how difficult it is for them to get treatment for a variety of problems such as poor academic performance and peer harassment it is hoped that by offering a fresh perspective on how aapi students experience school to their disabilities and special education this studys use of longitudinal analysis and disaggregated data will inspire other ethical considerations not applicable declaration of interest the authors declare no conflicts of interest

over the past 45 years state and federal statistics have clearly shown that students of colour outnumber white students in se notably native american students and to lesser extent latino students bal et al 2019 concerned that students of colour and other historically oppressed children would be treated unfairly or forced to attend separate schools when these disparities are conjunctions with worries about the efficiency and lack of opportunity in special education possibly disability discrimination including lower instructors expectations for students with impairments cooc 2022 however several studies have found that these same colour students are underrepresented in special education compared to statistically similar white students raising more concerns about the degree of inequality in this field as well as what factors might contribute to their lower representation morgan 2020 for one student population aapis the current discussion concerning the lack of demonstration of students of colour in special education is nothing new connor et al 2019 according to the definition used in this survey aapis are americans of asian heritage who live in the country national statistics from the last ten years show that aapis had half the possibility of accessing assistance as their white counterparts singh et al 2020 only 23 of students receiving se assistance identify as aapis although making up around 51 of all students registered in schools approximately 119 of all students in california identify as aapi while only 67 of se students cooc and yang 2017 even after taking into consideration the different backgrounds of aapi students and other students underrepresentation persists it seems that previous empirical research on the underrepresentation of aapis in special education is reliable however despite significant intergroup disparities in socioeconomic position linguistic proficiency and academic success aapis have been considered as a single group in prior studies of se disproportionality sullivan et al 2020

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introduction p opulation ageing is a global phenomenon and an increasingly serious problem for many countries along with common chronic diseases and functional degradation in elderly individuals the longterm care needs of the elderly will also increase as more people choose to stay in the community for longterm care home care workers can also successfully provide care services to those elderly people who stay at home demonstrating the importance of home care services in the longterm care industry home care workers are indispensable manpower in longterm care programs the us bureau of labor statistics has predicted that demand for home care jobs will increase rapidly by 38 through 2024 making it the fifth fastestgrowing industry in the united states past research has indicated that insufficient manpower can be seen as a compromise concerning elder care because home care workers occupy an industry with a relatively unstable income and work environment numerous manpower loss problems have arisen home care workers usually work alone and face considerable stress at work needing to care for sick dying aggressive or unconscious service recipients as home care workers may be some of the most frequent visitors to the home with longterm contact with patients they occupy a special position as they can effectively stay informed on the health status of their elderly patients and provide information and feedback through effective communication with them to avoid possible problems before they arise these features help reduce the elderly mortality rate and prolong the time spent in home care thus representing a broader connection between the elderly and the health care system because home care workers frequently interact with the elderly alone their values attitudes physical and mental health and the quality of the elder care services they provide are very important resources for the medical team however while home care workers provide the most direct care for the elderly at home these workers have not been studied sufficiently in taiwan home care workers are not only the main service providers within the elderly welfare service program but also the frontline professionals who reach out to the elderly however the unique nature of home care work due to the heavy workload of home care workers the lack of support from peers and leaders the need to serve alone outside the organization and the daily changing working environment makes it difficult for home care service agencies to effectively supervise and control service provision and to predict the effectiveness of work and achieve organizational goals it will be a challenge to stabilize this group of workers who provide home care services and help them provide better care services for elderly patients to retain the growing group of home care workers ensuring their physical and mental health and stable working environment has become an important issue for families employers and policymakers in taiwan the shortage of manpower is not limited to care services but includes increasing demand for residential service manpower in general even welltrained home care workers are difficult to retain and thus how to reduce turnover and improve employee loyalty has become an important issue leadership style plays an important role in maintaining employee loyalty to the organization from a management perspective institutions have been deeply interested in how employees feel about their work and the extent to which they are willing to contribute to the organization from the employee perspective when supervisors show support and respect for home care workers the workers will also show that they value their supervisors and feel grateful home care workers want most to be able to establish more contact and communication with their supervisors and one another and feel that they are valued and listened to by their supervisors an empirical study confirmed that transformational leaders were more likely than nontransformational leaders to help home care workers continue to choose this career most people spend considerable time at work regard work as an important part of life and may also be stimulated by work and become involved with it so work engagement has become an indispensable and important factor in most peoples lives when employees feel an important connection to their work their work is meaningful which is often reflected in work results and effectiveness turnover intention is the main predictor of actual turnover behavior and has a positive relationship with work engagement organizational citizenship behavior is an important part of the organization and can effectively assess employees intention to quit help stabilize organizational growth and is a kind of civic behavior that is beneficial to both the organization and service users the negative impact of home care workers unfavorable working environment and working conditions is significant not only for the recruitment and retention of outstanding residential service talent but also for the performance of longterm care institutions and even the effectiveness of elder care past research on home care worker behavior has focused on the effects of work stress working conditions and willingness to leave but there has been less exploration of the potential influencing factors of employees loyalty particularly among home care workers there has been a research lack of literature on the employee loyalty of home care workers therefore this study aims to investigate the factors influencing the employee loyalty of home care workers in longterm care institutions based on the above research motivations this study is expected to fill the gap in the research on the impact of home care workers employee loyalty in practice it is expected that the results and findings of the research will help home care service providers understand the factors influencing home care workers employee loyalty and can serve as a reference for the development of followup longterm care policies enabling institutions and competent authorities to evaluate good working environments stabilize human resources reduce personnel turnover retain residential talent and improve the operational performance of institutions furthermore such advancements will also help home care workers meet the physical psychological and social needs of the elderly with the most appropriate longterm care and quality services thereby improving comprehensive care and quality of life for elderly and disabled patients literature review employee loyalty employee loyalty can be defined as the intensity of an individuals identification with the organization and is most often explored as an underlying psychological construct that differs from an attitude or behavioral construct employee loyalty refers to an employee taking the companys goals as their own developing an attachment to the company and wanting to stay there loyalty comprises the employees positive attitude towards the company willingness to learn new skills knowledge sharing a strong sense of belonging and pride in the organization protecting the organization from criticism at all times and committing to contributing to the organization to achieve goals employee loyalty represents the individuals preference to stay with the original employer and can be used to assess the organizations working environment and management quality which are especially important indicators for growing organizations loyal employees can effectively reduce costs related to the recruitment and training of new employees especially in the health care industry environment which requires highly skilled professionals employee turnover in an organization not only increases organizational costs such as rerecruitment and training but also directly affects the quality of service and security issues for customers skilled and loyal employees are seen as a true source of profit within an organization and having a team with high loyalty is an organizational advantage that can reflect its overall performance in other words talent retention and employee loyalty can lead to a successful organization because employee loyalty involves a sense of responsibility and emotional response to the organization previous studies have incorporated organizational commitment into employee loyalty as an internal loyalty to the organization expressed through emotions attitudes and behaviors organizational commitment is linked to employee loyalty when employees and organizations share the same values or employees want to fulfill the organizations obligations this commitment encourages employees loyalty and willingness to contribute beyond their own interests for the welfare of the organization because frontline employees form a relationship between customers and service quality employee loyalty can be seen as a predictor of an organizations revenue growth and could even be more important to the organization than customer loyalty past research on home care workers has also pointed out that it is difficult to directly supervise employees due to the characteristics of the nursing service industry so it is important to establish good human resource management to gain employees trust and loyalty to maintain the continuous growth and sustainability of the organization organizations can regularly assess employee loyalty to help them fully understand employees support which is key to improving organizational competitiveness and to building a highperformance team the organizational commitment questionnaire is most commonly used to evaluate employee loyalty scholars have also noted that the measurement results of ocq have high international consistency and reliability and more specifically can show the degree of employees loyalty trust and willingness to achieve organizational goals published studies have found that the loyalty scale has slightly lower reliability so numerous studies have also applied organizational commitment to measure employee loyalty therefore in accordance with the research purpose of this study and the literature review the measurement of employee loyalty in this study references two aspects organizational commitment and loyalty according to the job demandsresources model the main cause of employees job burnout is the imbalance between job requirements and job resources resulting in poor employee mental or physical performance job resources enhance employees motivation at work such as work engagement and job satisfaction sufficient job resources can not only balance the negative effects of job requirements but also satisfy employees psychological needs thus enhancing their work willingness and work efficiency thus this study seeks to investigate the factors that influence home care workers loyalty based on the jdr model job satisfaction employees attitudes towards work are reflected in work behavior and while not all employees who are dissatisfied with their work will resign dissatisfaction may lead to reduced effectiveness and turnover intention published studies have found evidence that employees with high job satisfaction are willing to put more effort into their work thereby improving work effectiveness many previous studies have considered home care workers job satisfaction finding that home care workers who are satisfied with their work will regard finding joy in work by helping service users as a life goal even if the work is stressful and busy they still have a high willingness to stay with their company there is a positive correlation between employee satisfaction and the intention to stay with ones organization supervisor support job challenges training and the benefits that can be derived from the institution are positively correlated with job satisfaction a singlequestion survey to measure the overall job satisfaction of elderly care workers has been used by various previous studies based on the above literature on the definition and measurement of job satisfaction this study uses a single question to measure home care workers job satisfaction for employees job satisfaction increases a sense of accomplishment productivity intention to stay and loyalty satisfied employees are more loyal to their organization which they demonstrate by working hard to provide customers with highquality services home care workers with higher job satisfaction also have lower turnover rates job satisfaction is positively correlated with employee loyalty and numerous studies have also shown that employees job satisfaction positively affects employee loyalty scholars have pointed out that according to management theory supporting employees job satisfaction and adopting a coordinated policy exert an important impact on improving employee loyalty inferring from the above literature job satisfaction positively affects the employee loyalty of home care workers so this study proposes the following hypothesis h1 home care workers perception of job satisfaction exerts a significant positive impact on employee loyalty work engagement schaufeli bakker and salanova considered work engagement as not a temporary status but a more permanent situation of emotional cognition work engagement is an individuals psychological belief in his or her work a state of belief regarding the importance of work a persons enthusiasm and dedication to work and a positive attitude towards his or her organization schaufeli and bakker divided work engagement into three characteristics vigour is a mental state at work that makes people willing to engage in work and able to persevere even through difficulties dedication refers to feeling that work is meaningful enabling one to participate actively in the work and be constructive enthusiastic proud and challenging absorption refers to concentrating on work and feeling difficulty withdrawing from it the utrecht work engagement scale scale is based on these three configurations vigour dedication and absorption and has been used in many past studies as long as the organization adopts a commitment policy that motivates employees to be actively engaged employees will find meaning in their work and show loyalty to the organization employees who think that their work is meaningful have higher loyalty and less chance of leaving the organization than those who do not the study by beukes and botha also found that caregivers engagement was positively correlated with organizational commitment therefore based on the literature review this study proposes the following hypothesis h2 home care workers perception of work engagement exerts a significant positive impact on employee loyalty organizational citizenship behavior organizational citizenship behavior describes a variety of behaviors that employees are willing to perform spontaneously through inherent selfmotivation without being subject to the formal reward system of the organization that are in addition to the formal norms of the organization and actively exceed the work roles regulated by the organization although ocb is not formally regulated by the organization it is an organizational requirement because it helps effectively promote operations podsakoff et al divided ocb into seven facets helping behavior individual initiative civic virtue organizational loyalty organizational compliance sportsmanship and self development individual initiative is beneficial to the organization and is also known as ocborganization ocbo involves voluntary acts of helping others and innovating in the organization performing work with extra effort and enthusiasm and encouraging others in the organization to do the same research has shown that high ocbo represents a closer relationship between employees and the organization therefore if managers can improve the organizational atmosphere or communication channels with employees employees attachment to the organization can be increased which will promote their ocb to improve organizational effectiveness ocbo particularly types such as constructive advice and principled views for the organization can help the organization operate effectively and also sends a behavioral message regarding employee culture based on the definition of ocb and the purpose of this study this study applies the ocb scale from ginsburg et al and lee and allen to measure home care workers perception of ocb the organizational loyalty in the ocb includes employees loyalty drivers which can protect organizations from external threats and support organizational goals past empirical studies have surveyed caregivers in public and private hospitals and found that ocb is a source of competitive advantage in hospital performance improving not only patient satisfaction and employee loyalty but also service quality inferring from the above literature this study proposes the following hypothesis h3 home care workers perception of organizational citizenship behavior exerts a significant positive impact on employee loyalty transformational leadership a leader refers to a person who has the ability to influence motivate and promote the ability of members of an organization to contribute to its success leadership is the most critical factor for any type of organization and plays an important role in determining its work effectiveness transformational leadership theory is one of the most highprofile leadership theories and has been discussed increasingly often in the literature in recent years this type of leadership is a process of emotional leadership that tends to be more efficient than occasional rewards and other forms of leadership making it one of the most important styles among the many theories of leadership such leadership can focus on the needs of followers influence their behaviors and attitudes and stimulate employees potential to surpass themselves transformational leadership can also help employees have better relationships with their superiors make greater contributions and be more willing to make additional efforts for the organization transformational leadership includes idealized influence inspirational motivation intellectual stimulation and individual consideration idealized influence is the setting of a spiritual example for employees to imitate or follow up inspirational motivation is the delivery of visions and goals to inspire in employees a sense of mission and identification with the purpose of the organization intellectual stimulation means that intellectually stimulating leaders can devise rational solutions to teach employees to solve old problems from new perspectives individual consideration is the understanding of differences among employees allowing leaders to give individualized guidance and care and to meet the emotional needs of each employee transformational leaders can cultivate employees pride and give them greater confidence to improve their work effectiveness based on providing proactive care respect and support this study used the scale of transformational leadership from a previous study that surveyed 1828 home care workers in the united states based on four dimensions idealized influence inspirational motivation intellectual stimulation and individual consideration as a measurement of the perceived transformational leadership of home care workers in primary health care managers leadership style is defined as an attitude behavior belief and value prior surveys of caregivers in nursing facilities have found that when leaders provide support caregivers become more engaged and regard mistakes as opportunities to learn home care workers managers are formally hired by their organization to manage and support it provide coordination services to customers and home care workers assign and supervise the relationship between home care workers and customers and decide whether to continue or end the home care workers employment in addition in the field of elder care only the home care workers provide care services at home and leaders do not directly contact elderly patients nor do they know their health status through reports from home care workers all the leaders can do is to encourage home care workers to solve problems and take responsibility this situation shows that transformational leaders play a particularly influential role in the field of health care transformational leaders can provide home care workers with available resources and social support and encourage employees to learn domainrelated skills thereby helping employees find their work goals more meaningful through social recognition and positive support attitudes published research papers have found that the vision sharing of transformational leadership can help employees feel that their place in the organization is important in addition to building trust between supervisors and employees transformational leadership can also encourage employees and has been confirmed to positively influence their loyalty to the organization studies have also shown that female transformational leaders have a lower sense of trust and employee loyalty in addition transformational leaders regarded as a job resource could elevate home care workers motivations according to the jdr model when home care workers supervisors adopt transformational leadership home care workers psychological needs can be satisfied and motivations at work can be encouraged this will enhance home care workers work willingness and work efficiency and increase their loyalty toward to their works the above literature review suggests that transformational leadership can positively influence home care workers loyalty so this study proposes the following hypotheses h4 home care workers perception of transformational leadership exerts a significant positive impact on employee loyalty h5 increases in home care workers motivation will mediate the relationship between transformational leadership and employee loyalty methods to explore the relevance and predictive capacity of home care workers perceptions of job satisfaction transformational leadership work engagement and ocb to employee loyalty based on the literature discussed above this study derives the following four research hypotheses h1 home care workers perception of job satisfaction exerts a significant positive impact on employee loyalty h2 home care workers perception of work engagement exerts a significant positive impact on employee loyalty h3 home care workers perception of organizational citizenship behavior exerts a significant positive impact on employee loyalty h4 home care workers perception of transformational leadership exerts a significant positive impact on employee loyalty h5 increases in home care workers motivations will mediate the relationship between transformational leadership and employee loyalty this study adopted a crosssectional research design that used the questionnaire survey method the questionnaire content was designed based on relevant literature and the work characteristics of home care workers in taiwan five scholars with high educational backgrounds and experts with practical experience were invited to review the semantics and relevance of the questionnaire after the content was corrected based on these suggestions the questionnaire was summarized and modified to meet the research aims the instrument used in this study included six questionnaires on employee loyalty job satisfaction transformational leadership work engagement ocb and home care workers personal information the questionnaire on home care workers employee loyalty was divided into two categories with eight questions examining organizational commitment and five questions examining loyalty based on the suggestions from previous studies by matzler and renzl and yee et al the statements of items concerning organizational commitment included i talk up this organization to my friends as a great organization to work for i am proud to tell others that i am part of this organization deciding to work for this organization was a definite mistake on my part i am willing to put in a great deal of effort beyond that normally expected in order to help this organization be successful i truly care about the fate of this organization it would take very little change in my present circumstances to cause me to leave this organization theres not too much to be gained by sticking with this organization indefinitely and i find it difficult to agree with this organizations policies on important matters relating to its employees the statements of items concerning loyalty were i speak positively about my company when talking to customers i speak positively about my company when talking to friends and relatives i can recommend the products and services of my company to others i would like to stay with this company also in the future and turn down other jobs with more pay in order to stay with this company a fivepoint likert scale was used to measure the degree to which the subject subjectively felt the statement of the question home care workers job satisfaction is a response to the overall state of their current work compared to multiple questions the overall evaluation method which used a single question to measure job satisfaction not only collects all the key points concerning job satisfaction but is also more efficient and easier for subjects with different education levels to complete and can reduce the occurrence of resistance psychological phenomena caused by survey fatigue the single question about job satisfaction also has stability and effectiveness scholars have noted that the minimum reliability coefficient for a single question concerning job satisfaction is between 070 and 080 which is comparable to the internal consistency and reliability of multiple measures of job satisfaction therefore this study referred to the studies of nielsen et al and lee in its use of a single question how satisfied are you with your current job as the measurement of home care workers perception of job satisfaction a fivepoint likert scale was applied to measure the degree of satisfaction this study used the uwes scale in reference to schaufeli et al s study as a tool to measure work engagement as it has also been shown to be suitable for health care workers the work engagement scale was divided into three aspects vigour dedication and absorption for a total of 9 questions when i get up in the morning i feel like going to work at my work i feel bursting with energy at my job i feel strong and vigorous my job inspires me i am enthusiastic about my job i am proud on the work that i do i get carried away when i am working i feel happy when i am working intensely and i am immersed in my work a fivepoint likert scale was used to measure the degree to which the subject subjectively agreed with each statement this study referenced the previous studies of ginsburg et al and lee and allen the ocb scale has a total of 12 questions including two facets effective and innovative work behaviors and behaviors that are beneficial to the organization the statements included were i often come up with new ways to do my work i often suggest to my coworkers new ways about how to improve work i often suggest ways to improve rules or policies i often change how i work to get more done in the time i have attend functions that are not required but that help the organizational image keep up with developments in the organization defend the organization when other employees criticize it show pride when representing the organization in public offer ideas to improve the functioning of the organization express loyalty towards the organization take action to protect the organization from potential problems and demonstrate concern about the image of the organization the scale applied a fivepoint likert scale to measure the degree of the subjects subjective response to each statement based on the definitions by bass and avolio and in reference to lee s research this study adopted four questions as the scale of transformational leadership my supervisor provides clear instructions when assigning work my supervisor tells me when i am doing a good job my supervisor listens to me when i am worried about a patients care and my supervisor is supportive of progress in my career such as further training a fivepoint likert scale was used to measure the degree to which the subject agreed with each statement in addition to maintain the reliability and validity of the measurements this study performed reliability analyses according to the collected data the overall cronbachs α coefficients of the scales of employee loyalty transformational leadership work engagement and ocb ranged between 085 and 095 the measurement results of the display questions had high internal consistency and reliability the results of factor analysis showed that the questions concerning the four variables were extracted as the same factor and the total variance explained ranged between 49412 and 73216 in summary this study used the mature scales proposed by previous research as the basis for factor classification and analyzed the factors based on the variables of transformational leadership work engagement ocb and employee loyalty the international consistency and reliability of the variables has been verified before the factor analysis the kaysermeyerolkin values and the bartletts test of sphericity had been processed the results showed that the four scales used in this study all had highly significant correlation coefficients and the factor loadings of all questions were greater than 050 demonstrating that the questionnaire had good construct validity this study targeted seven longterm care service providers in taiwan that provide home care services all home care workers at these institutions were invited to participate this study regardless of their working experience in this study the home care workers of each home service institution were issued a selffilled structured questionnaire when they routinely returned to the institution once a month allowing the respondents to select the most suitable answers for each option according to their actual situation and feelings this research questionnaire was approved by the research ethics committee of national taiwan university and has been classified in accordance with the research ethics code the survey was conducted anonymously with a total of 455 home care workers and the content of the answers was kept confidential to ensure the privacy of individuals and institutions the data collected is for academic analysis purposes only after defects and consolidation were checked a total of 442 valid questionnaires remained for a recovery rate of 97 the sample size was sufficient and representative multiple regression analysis hierarchical regression analysis and structural equation modeling were adopted to analyze the relationships among the variables home care workers transformational leadership job satisfaction work engagement and ocb and their potential influence on employee loyalty research results this study descriptively analyzed the sample data of 442 valid questionnaires to understand the information collected from the home care workers at the selected institutions the basic personal information included seven variables gender age education marital status work experience service seniority and parttime fulltime work the research results of descriptive statistical analysis are shown in table 1 the respondents were mostly female accounting for 887 of the total sample the 49 males comprised only 111 of the sample this difference illustrates the considerable gender gap among home care workers who are predominantly female in terms of age 9 respondents were aged 2030 27 were aged 3140 106 were aged 4150 168 for more than 10 years the respondents average seniority in home care services was 786 years showing that most respondents had provided home care services for between 5 and 10 years regarding respondents total seniority in their current job 68 respondents had worked in their current job for less than one year 122 for 15 years 153 for 510 years and 99 for more than 10 years the respondents average seniority in their current job was 701 years showing that the majority of respondents had less than 10 years of seniority at their current institution the number of fulltime respondents was 418 accounting for 946 of the total so home care workers still primarily hold fulltime jobs in taiwan table 1 displays the analysis of variance results showing that home care workers of different ages and education levels showed significant variances in employee loyalty home care workers with different seniority levels in home care services and in their current job also showed significant variances in employee loyalty the other variables showed no significant variance indicating no evidence that home care workers employee loyalty varies by gender marital status and fulltime parttime employment status female home care workers comprised the majority of the sample this result may be explained by the characteristics of home care services as gender role norms assert that women are better at providing caregiver support than men and women are most likely to assume the caregiver role as a result the home care workers in this sample were disproportionately female similar to previous studies even so this study found no significant differences by gender in home care workers perceptions of job satisfaction transformational leadership work engagement ocb and employee loyalty participants age was concentrated in the 5160 age range with an average of 5433 years old which was consistent with sayin et al former studies have also pointed out that most elder care workers are over the age of 45 and for women who are older and have passed the childrearing period are in good physical health and wish to continue working home care work may be a better job choice at this stage in addition the sample showed that the majority of home care workers had a high school education level were married and were employed fulltime which was also consistent with past research most participants had 510 years of overall seniority in home care service work with an average of 786 years and their seniority in their current job was between 5 and 10 years with an average of 701 years these results are similar to other research on the home care workers labor force subsequently this study conducted twotailed pearson correlation coefficients analysis to test the correlations among home care workers perception of job satisfaction transformational leadership work engagement and ocb and employee loyalty the results are summarized in table 2 pearson correlation analysis showed positive correlations among job satisfaction work engagement ocb transformational leadership and employee loyalty the highest correlation coefficient was between the two variables of ocb and employee loyalty in this study the four variables of age education home care workers seniority in home care services and home care workers seniority in their current job were used as control variables to perform partial correlation analysis even when controlling these variables there were still positive partial correlation coefficients among job satisfaction work engagement ocb transformational leadership and employee loyalty the correlation coefficients of the independent variables showed weak correlations indicating that there was no collinearity problem among the independent variables the results of multiple regression analysis are shown in table 3 prior to regression analysis this study used the variance inflation factor to determine whether there was collinearity between the variables and all vif values from table 3 were less than 10 indicating that there was no collinearity problem between the independent variables the results of the regression analysis showed a significant effect of job satisfaction on employee loyalty with an impact coefficient of β 0251 indicating that job satisfaction exerted a significant positive influence on employee loyalty and supporting h1 the more satisfied home care workers were with their jobs the higher their employee loyalty which is consistent with previous findings employees who are confident in their work can handle their work more efficiently are more satisfied with their work and have less intention to leave the effect of work engagement on employee loyalty was significant with an impact coefficient of β 0092 indicating that work engagement exerted a significant positive influence on employee loyalty and supporting h2 the greater the home care workers perceptions of work engagement were the higher their employee loyalty which is consistent with previous studies when employees find their work highly meaningful they will show more active and engaged behaviors and higher loyalty to the organization the correlation analysis also showed a high correlation between work engagement and ocb the same results as in ariani s study the employees studied had a high degree of work engagement indicating their responsible attitude towards work the effect of ocb on employee loyalty was also significant with an impact coefficient of β 0400 indicating that ocb exerted a significant positive influence on employee loyalty and supporting h3 home care workers with higher perceptions of ocb also demonstrated higher employee loyalty which is consistent with previous studies of the four independent variables ocb had the highest impact coefficient with employee loyalty meaning that home care workers employee loyalty is principally affected by ocb this result might be because ocb concerns the ethics and sense of mission required by health care service providers and their high degree of selflessness and the behavior of caring for others may lead home care workers to feel a sense of belonging to the organization as expressed through ocb moreover ocb also creates a stronger sense of bonding between colleagues which also provides the needed social support for home care workers who are always working alone the effect of transformational leadership on employee loyalty was significant with an impact coefficient of β 0245 indicating that transformational leadership exerted a significant positive influence on employee loyalty and supporting h4 home care workers supervisors are responsible for scheduling home health aides for patient visitations and work assignments and for monitoring the quality of care performed by home care workers although home care workers may not meet with their supervisors often supervisors nonetheless play an important supporting role as home care workers usually take care of patients alone without any other coworkers and their supervisors might become their only contact when they need support through supervisors transformational leadership home care workers can feel trusted and recognized which will enhance their autonomy and loyalty to the organization this result is consistent with past literature research therefore the leadership style of the home care workers supervisor is directly related to talent retention the more the home care workers supervisor adopts transformational leadership the greater the home care workers loyalty to the organization regarding the control variables the results showed a significant effect of age on employee loyalty with an impact coefficient of β 0112 indicating that age exerted a significant positive influence on employee loyalty that is the older the home care workers were the higher their loyalty to the organization in contrast the results for home care workers education level seniority in home care and seniority in their current job showed no significant effect on employee loyalty published studies have also found that older workers with lower educational attainment have higher employee loyalty to institutions although others have found no significant effect of age and educational attainment on employee loyalty the analysis of variance revealed that there were significant differences in home care workers employee loyalty by age education seniority in home care and seniority in their current job however the multiple regression analysis found a significant effect on employee loyalty only for age as mentioned in previous research the independent work environment of home care workers is more suitable for older people who may prefer to work in an environment where they enjoy autonomy control their own schedules and are not bound by their direct supervisor another possible explanation is that older female home care workers might have greater family responsibility and thus prefer to avoid uncertainty in their work life giving them greater motivation to be loyal to the organization in addition there was no statistically significant correlation between seniority in home care services and employee loyalty which was the same result as in singh and rangnekar there was also no statistically significant correlation between seniority in current job and employee loyalty which was the same result as in agyemang and ofei these results indicate that there was insufficient evidence to verify whether home care workers working experience could influence their employee loyalty as shown in table 3 the adjusted coefficient of determination of the multiple regression model was 0656 indicating that the four independent variables can explain 656 of the variance of the dependent variable indicating that the multiple regression model was highly explanatory the influences of the four independent variables of job satisfaction transformational leadership work engagement and ocb on employee loyalty were all positive with the greatest being that of ocb followed by job satisfaction and then transformational leadership the fvalue of the regression model was 94777 significant at p 0001 which also indicated that the four independent variables significantly affected the dependent variable this study conducted three hierarchical regression models to test mediation effects among the variables based on the jdr model the results of which are shown in table 4 transformational leadership was regarded as the job resource provided by longterm care institutions and employee loyalty was defined as work willingness or performance the three employee motivations of work engagement job satisfaction and ocb were employed as the three mediators for these hierarchical regression models these results not only suggested a direct positive effect of transformational leadership on employee loyalty but also a partial mediating effect of work engagement job satisfaction and ocb on employee loyalty thereby supporting h5 transformational leadership contributed to an increase in employee loyalty by helping home care workers feel satisfied and engaged with their job supporting their development of workplace ocb and motivating them to be loyal to the organization since work engagement job satisfaction and ocb have partial mediation effects this study further verifies whether the mediation effects were significant by bootstrap method on sem the three sem models were visualized in fig 1 and the results of mediation effects were displayed in table 5 in fig 1 the three models tested separately three mediation effects between transformational leadership and employee loyalty from the three mediators work engagement job satisfaction and ocb the path coefficient of the three models were also shown in fig 1 the results showed that mediation effects of the three mediators work engagement job satisfaction and ocb exist between transformational leadership and home care workers loyalty the indirect effect is the multiplication of the two path coefficients of the independent variable to the mediator and the mediator to the dependent variable the path coefficient of transformational leadership to work engagement was 049 and the path coefficient of work engagement to employee loyalty was 027 so the indirect effect was 013 the direct effect was the path coefficient of transformational leadership to employee loyalty which was 055 and the total effect was the indirect effect plus the direct effect and its value was 068 the variance accounted for is the indirect effect divided by the total effect the explanatory variation ratio of work engagements mediation effect on the relationship between transformational leadership and employee loyalty was 0132306823 01939 that is vaf was 1939 similarly the path coefficient of transformational leadership to job satisfaction was 069 and the path coefficient of job satisfaction to employee loyalty was 023 the indirect effect was 016 the direct effect was 051 and the total effect was 067 the vaf value of job satisfactions mediation effect on the relationship between transformational leadership and employee loyalty was 2373 the path coefficient of transformational leadership to ocb was 046 and the path coefficient of ocb to employee loyalty was 083 the indirect effect is 038 the direct effect is 028 and the total effect is 066 the vaf value of ocbs mediation effect on the relationship between transformational leadership and employee loyalty was 5769 regarding the vaf of the three mediators this study found that home care workers ocb had the strongest mediation effect followed by job satisfaction and work engagement according to the standard proposed by published research vaf greater than 80 means full mediation between 2080 is partial mediation and less than 20 indicates no mediation effect as a result ocb and job satisfaction had partial mediation effects between transformational leadership and home care workers loyalty and the vaf value of work engagement was slightly under the proposed standard that is h5 was partially supported conclusion this study confirmed through empirical data the significant positive impacts of transformational leadership job satisfaction work engagement and ocb on home care workers employee loyalty and the partial mediating effect of work engagement job satisfaction and ocb between transformational leadership and employee loyalty through the results of the multiple regression analysis this study found the four significantly positively impact factors of home care workers loyalty which were transformational leadership job satisfaction work engagement and ocb the adjusted r 2 of the regression model was 656 it means this regression model has high explanatory power in the longterm care policy promoted by the taiwan government strengthening the prioritized development of homebased longterm care services has become an important measure based on the principle of local ageing the subsequent improvement of care quality and service system efficiency are important topics given that quality orientation has been listed as an indicator of longterm care policy progress high perceptions of transformational leadership from supervisors work engagement job satisfaction ocb and employee loyalty among home care service workers are related to the quality of the services they provide the quality of home care services affects the safety of the elderly and can help them maintain a good quality of life and reduce medical costs hence an effective and sustained strategy must be developed to stabilize the workforce prior to the implementation of a service quality improvement program it is recommended to start by training home care workers in professional skills including basic care knowledge related to various diseases rather than simply the tasks of caring cleaning and assisting with personal hygiene give home care workers the opportunity to learn and grow help them improve their professional selfefficacy and their relative sense of personal achievement will increase when the role of home care workers is professionally affirmed and dignified they can effectively reexamine the value of the individual and the meaning of their work resulting in higher identification and greater engagement with the organization according to the concepts of jdr model this study found empirical evidences to prove the mediation effects of employee motivations between job resource and work willingness or performance that is transformational leadership not only directly positively affected home care workers loyalty but also has indirect influences through the mediators it could be suggested that managers of home care institutions should adopt a transformational leadership style such as establishing vision fueling the engine of the workplace solving problems and providing individual support which will help home care workers feel challenged and satisfied by their work thereby stimulating their personal potential and their devotion to their work as high organizational performance is linked to employees high work engagement it is also suggested that home care institutions could actively encourage employees to participate in educational training courses to strengthen their awareness of work this study further found that home care workers ocb had the strongest mediation effect between transformational leadership and employee loyalty the ocb displayed by home care workers is a source of organizational performance creation consolidating the employee loyalty to the organization and offering organizational advantages the results of this study could be provided to home care service organizations when recruiting new employees in addition to the selection of candidates with a high degree of trust in the organization employees who show a high degree of ocb within the organization can also be supported and encouraged to implement and cultivate good behavior among employees ultimately improving overall employee loyalty to the organization workers can develop ocb that is beneficial to the organization which will motivate employee loyalty to the organization and willingness to continue to provide services such an environment will also help attract more young people to join the ranks of the home care profession which will help solve fundamental shortstaffing problems this study employed a rigorous and detailed research process that included data collection a literature review determination of structure and hypothesis formation questionnaire distribution and data analysis however due to manpower and time constraints information was collected only from home care workers at longterm care service institutions in taiwan and not more widely from other regions due to the different sizes of longterm care institutions in different countries and the differences in welfare systems the extrapolation of the research results might be affected it is suggested that future research on related topics could be expanded to include more indepth comparative discussions to increase the generalizability of the research to avoid an overly complex research structure this study only used job satisfaction work engagement ocb and transformational leadership as independent variables meaning that it may not have considered all the factors impacting employee loyalty at the same time it is suggested that future studies could include more factors that affect home care workers employee loyalty such as personality work motivation and incentive systems to explore employee loyalty in more depth data availability the data that support the finding of this study are available from the corresponding author upon reasonable requests the data are not publicly available due to privacy or ethical restrictions competing interests the authors declare no competing interests ethics approval the questionnaire for this study was approved by the institutional review board informed consent participant consent was approved by the institutional review board the participants were informed during the recruitment process that their participation was voluntary and that all information was treated with confidentiality additional information correspondence and requests for materials should be addressed to wei hsu reprints and permission information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

given the high prevalence of clinical disease and disability among elderly individuals there is an evergreater demand for social care services despite this demand the elder care sector has the largest labor shortage levels among all frontline providers of longterm care services strategies to reduce turnover and improve employee loyalty have therefore become an important issue the purpose of this study is to identify the factors that affect the loyalty of home care workers following a literature review wedetermined four independent variablesjob satisfaction work engagement organizational citizenship behavior ocb and transformational leadershipand investigated their relevance to and ability to predict home care workers employee loyalty a total of 455 home care workers participated in the anonymous survey the results of multiple regression analysis indicate that the adjusted coefficient of determination r 2 of the model explained 656 of the variance of the dependent variable showing high explanatory capacity the influences of the four independent variables on employee loyalty were all significant and positive with the greatest impact on employee loyalty being exerted by ocb adjusted ß 0400 followed by job satisfaction and then transformational leadership the three hierarchical regression models provided evidence for the partial mediating effect of job satisfaction work engagement and ocb between transformational leadership and employee loyalty our findings suggest that managers of home care institutions should adopt a transformational leadership style to motivate home care workers job satisfaction work engagement and ocb such an environment not only help retain employee but also attract more young people to join the ranks of the home care profession which will help solve fundamental shortstaffing problems

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manner that benefits the privileged 4 the presence of this hierarchization does not preclude the use of human rights in struggles that do not align with those interests 5 but leads to the incorporation of bias into the way in which freedom of speech can be exercised 6 there is a double standard for the conceptualization of what it means to exercise free speech those who are already privileged operate from a sphere of protection closely aligned with their practices 7 for instance the traditional dress of bavarian women as seen during oktoberfest and involving sexualized displays of their breasts does not interfere with their ability to engage in speech on facebook 8 in contrast the brazilian national foundation of indigenous peoples had their facebook account suspended in 2018 for a post about traditional knowledge portraying two waimiri atroari in their traditional dress which leaves the nipple bare 9 the nipple being the one body part facebook explicitly bansin order to prevent uncivilized pornographic material inconsistent with western values 10 against this bias toward western values the brazilian indigenous women had to defend their dress to the extent of needing a judicial decision to have their accounts reinstatedbefore being able to exercise their right to speak in short facebooks restrictions on nudity differ across cultures with regard to their impact on speech this structure has substantial marginalizing effects in ratna kapurs words the liberal tradition from which human rights have emerged not only incorporates arguments about freedom and equal worth it also incorporates civilization cultural backwardness racial and religious superiority 11 in our example bare nipples do not accord with facebooks standard of civilization while expansive décolletage does consequently bavarian women are immediately free and equal while indigenous women need to take additional steps to climb up into that free space they are pushed further to the margin 12 structural bias in social media content management increasingly social media platforms are not only spaces for human rights struggles to exercise free speech and document evidence of rights violations but also spaces for the repression of rights popular social movements such as blacklivesmatter 13 demonstrate that marginalized groups can carve out a space on platforms to express their concerns however bias remainsoften with exacerbating socioeconomic implications for instance facebook uses seemingly neutral knowledge to enable gentrification lookalike audience allows one to advertise housing to those who share similar interests14 thus empowerment arising out of blacklivesmatter may lead to increased barriers in the housing market in regions where there is less enthusiasm about that movement prejudice against marginalized groups content is particularly attributable to contextblindness that replicates existing structural inequalities content management relies on static rules that are not sufficiently attentive to meaningdefining contexts this contextblindness regularly requires those at the margins to defend and explain how their specific context changes the meaning of their speechact in the wampum belt case 15 the facebook oversight board assessed the removal of a post made by indigenous north american artists in canada for featuring the phrase kill the indiansave the man as a violation of facebooks hate speech community standard the post was intended to denounce the history of native americans having to renounce their identity in order to survive as the applicant successfully explained to the ob leading to readmittance of the post the initial platform decision was blind to this specific contextmeta was unable to explain how two human reviewers failed to understand the phrase the sole purpose is to bring awareness to this horrific story so as to qualify the post as permitted counterspeech 16 despite explicit labeling of the post the artists speech was misaligned with presumably neutral but contextinsensitive platform policy with the result that they had to carve out their space for political activity before being able to use their freed speech in contrast the display of a weapon a statement that is arguably as supportive of violence as the word kill is not automatically removedsometimes even after the authors have been banned for illegal trade in weapons 17 bias in platforms content management tends to replicate and amplify existing vulnerabilities and inequalities with implications not only for free speech but also for socioeconomic rights 18 for instance human rights groups criticized facebook and twitter for systematically silencing protests about the livelihooddisrupting conditions of palestinians in sheikh jarrah 19 such asymmetries in takedowns have been highlighted by human rights activists more generally to the extent that the advised strategy for investigations on human rights violations is to race against the takedown time to save the social media content offline 20 this adds another burden in the struggle to denounce any human rights violation the incorporation of human rights considerations into a platforms architecture is a possible avenue for alleviating the potential biases of decision making in social media 21 however there are significant obstacles for such emancipatory use as will be detailed below human rights are not the main priority most social media platforms policies and rules particularly that of facebook and its ob explicitly refer to the human rights responsibilities of platforms in speech regulation nevertheless the application of human rights standards remains secondary to metas articulated values those values focusfar from proclamations of liberty and equalityfirst and foremost on giving voice not on ensuring equal and free speech 22 this is well aligned with the corporations business model more speech means more profit 23 in this setting the protection of human rights is regularly secondary to the corporations priorities 24 assessing the myanmar violence in 2017 amnesty international pointed to facebooks business modelgeared toward leaving content online even if it fuels hatredas a major reason for the belated and inadequate content review that allowed for a vast range of human rights violations 25 leaked internal documents demonstrate that facebook knew that a subsequent change in its algorithm in 2018 increased divisive and violent speech leading to human rights violations 26 so instead of reassessing its structure in order to reflect human rights facebook exacerbated what had caused human rights violations before knowing as said files testify as well that contentmoderation was unable to keep hate speech in check 27 in this regard the obs role in highlighting ambiguities in metas rules and policies in consideration of human rights provisions could be viewed in a positive light 28 but its lack of diversity limited impact and financial dependence on meta limit this optimism 29 in fact that the ob reviewed 176 recommendations out of over 25 million cases qualifies not even as a drop in the ocean 30 in sum facebooks structure is less attuned to a fairly balanced marketplace of ideas than to a marketplace for revenue creation through advertisement 31 limitations in human rights to the extent that human rights considerations are implicated in the framework for decisions on free speech in social media the process has to contend with the bias implicit in human rights that is there is a tendency to hierarchize and privilege dimensions of individual liberties with minimal consideration to societal dimensions that cannot always be addressed through protections for individual liberty 32 in fact the focus on speech exacerbates the tendency to overemphasize individual liberty to the detriment of considerations about social economic and cultural rights in the example of the indigenous women in brazil facebooks community guidelines do not provide for a group right to culture but require that the post is taken downthat freedom of speech is reclaimed and reassessed in light of the interest to talk about cultural rights to dress in traditional clothing 33 furthermore most biases on platforms are manifestations of existing socioeconomic hierarchies and marginalization that cannot be addressed through the individualistic lens of human rights 34 the marginalization of indigenous communities amplification of disinformation against minorities in myanmar and silencing of palestinians are all rooted in preexisting inequalities the root of such marginalization is more profound than an incident of individual rights violation 35 and the resultant harm such as perceived and reported discrimination is a symptom of a deeper structural problem such as racism and other forms of prejudice 36 it is thus crucial to pay attention to potential obstacles such as limitations within the human rights system itself and platforms business models which decenter human rights concerns with those priorities in mind the effort to incorporate human rights considerations into platforms system of speech regulation may become a positive step toward countering bias human rights to counter bias structural bias in human rights and content management need not be mutually reinforcing in fact the emancipatory potential of human rights can play a part in resistance against prejudice in and beyond platforms content management there is a conceivable space for human rights work and struggle on social media platforms the transnational and accessible character of social media networks is enabling global cooperation around the exposure of human rights violations by counterpower movements 37 for instance the movements during the arab spring relied on communication via facebook 38 while this appraisal has been celebrated as a facebook revolution movements less aligned with western values received less favorable treatment in other words as long as the social movement promotes what the west deems universal social media platforms provide a welcoming space to promote their cause 39 for those adversely affected in order to overcome the limits of human rights in addressing structural bias on platforms a focus on human rights emancipatory power is promising human rights claimmaking can push beyond the structural constraints of rights and can organize and unify people in their struggle against bias 40 returning to our example of the brazilian indigenous women their cultural rights provided them with a tool to combat exclusion for facebook a next step toward equality and inclusion would mean on the one hand to push these cultural rights further into the structure of facebooks content management so that takedown protocols are more careful in the assessment of cultural rights and on the other hand to expand and 33 protect the digital space in which indigenous communities can discuss promote and transform their cultural rights 41 conclusion free speech is a central object of concern both in a human rights framework and in the regulation of content on social media platforms it can become a site of contention when hegemonic values encounter positions and inputs from those at the margins challenging said values certain kinds of speech are more robustly protected than others thereby marginalizing those whose practices are at odds with dominant speech acts in other words the way in which freedom of speech is protected both as a human right and in social media is biased while there are emancipatory unifying elements in a human rights framework that carry the potential for using it as a framework to better regulate social media without careful consideration there is a risk of merely reinforcing and amplifying bias when selectively protecting free speech most importantly typical human rights formulations are unable to capture structural bias and therefore tend to neglect or even exacerbate such problems from within and against those constraints these platforms potential as a space for the struggles of human rights movementsmobilizing the emancipatory power of human rightsmay provide a path to counter bias and toward positive transformations of rights and social media platforms for marginalized peoples 41 see for an example of such space creation godfried asante where is home negotiating comm and unbelonging among queer african migrants on facebook in queer and trans african mobilities migration asylum and diaspora 135

in a global context where political campaigning social movements and public discourse increasingly take place online questions regarding the regulation of speech by social media platforms become ever more relevant companies like facebook moderate content posted by users on their platforms through a mixture of automated decision making and human moderators 1 in this content moderation process human rights play an ambiguous role those who struggle with marginalization may find a space for expression and empowerment or face exacerbation of preexisting bias 2 focusing on the role of human rights in metas content management this essay explores how the protection of speech on social media platforms disadvantages the cultural social and economic rights of marginalized communities this is not to say that speech on social media platforms is devoid of emancipatory potential but that this potential is not uniformly or equally accessible we see the incorporation of human rights considerations into decisionmaking processes as an avenue for alleviating this challenge this approach faces obstacles from the platforms business models which decenters human rights concerns and from the limitations of liberal accounts of human rights from within and against these constraints human rights can be mobilized as emancipatory power in an effort to decrease marginalizationnorms protecting speech as a human right have developed and continue to be reiterated through practice dominated by the values and interests of those already privileged 3 in fact there is a general tendency to hierarchize and privilege dimensions of individual liberties to minimize societal concerns and to frame freedom of speech in a the authors would like to thank abhimanyu george jain and all reviewers for their helpful comments

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introduction in an increasingly digitalized world as society grapples with complex socioscientific issues the realm of education encounters evolving challenges and opportunities ssi inherently controversial necessitates students to apply evidencebased reasoning holds personal significance for them and offers a contextual framework for understanding all while requiring moral judgment and ethical assessment during the decisionmaking process concerning potential solutions to these issues integrating ssi into science education offers several benefits for both students and society as a whole including relevance to realworld problems enhanced critical thinking and problemsolving fostering interdisciplinary learning ethical and moral development effective citizenship education heightened cultural and social awareness and improved scientific literacy there has been a plethora of additional pedagogical curriculum and epistemic outcomes and benefits that have been welldocumented in reviews of the global extant literature involving hundreds of empirical and conceptual studies that have served as a foundation for the integration of ssi into science education however it is imperative to acknowledge that while ssi integration does face new questions regarding its implementation as the rapid advancements in digital technology have ushered in a new era of both challenges and creative possibilities in this digital age traditional approaches to ssi education are being reshaped offering emerging trends and unexplored frontiers that demand our attention hence the significance of this review teaching ssi in the digital age emerging trends and unexplored frontiers becomes apparent as technology becomes increasingly integrated into education and society at large we must critically examine how these digital tools and platforms can augment ssi education this review aims to uncover the latest developments innovative pedagogical approaches and technological tools that are reshaping the landscape of ssi education by exploring the intersection of ssi pedagogy and the digital age our review provides valuable insights for educators researchers and policymakers it not only informs the current state of ssi education but also highlights the pressing need to adapt and evolve in response to the opportunities and challenges presented by the digital era hence this review seeks to shed light on the dynamic and everevolving landscape of ssi education in the digital age equipping stakeholders with the knowledge and guidance needed to prepare students for the complex socioscientific challenges of the 21st century method in the review a literature review was conducted by systematically analyzing and synthesizing the existing research and publications on ssi and the digital age the steps involved in this methodology are defining the research scope screening and selecting relevant literature analyzing and synthesizing relevant literature identifying gaps and trends and critical evaluation and interpretation firstly the research scope was determined the focus of our research is to examine the use of digital tools in sbk teaching for this purpose academic databases google scholar eric and web of science search engines and indexes were searched to gather information on ssi pedagogy digital technologies and their intersection specific keywords and criteria were used to select appropriate articles and studies after collecting the relevant literature the information from these sources was analyzed and synthesized to provide information about the challenges and opportunities that can be encountered when teaching socioscientific topics with digital tools digital tools and platforms for ssi education in the digital age the arsenal of educational resources has expanded significantly offering an array of digital tools and platforms that hold immense potential for enhancing ssi education digital tools have emerged as invaluable allies in this endeavor providing educators with innovative means to engage students in meaningful socioscientific discourse and enhance socioscientific reasoning in this section we explore the diverse array of digital tools that facilitate the integration of ssi into education figure 1 digital tools and platforms for ssi education we explore the functionalities and advantages of various educational tools highlighting specific examples such as moodle google classroom and microsoft teams in the category of learning management systems flip phet nearpod pear deck and kahoot as interactive classroom tools zoom and x for virtual meetings and communication socrative for assessment youtube and miro for content sharing and creation scistarter for citizen science and research and google workspace for education for comprehensive educational solutions through an examination of these digital resources this review aims to offer educators researchers and educational policymakers a comprehensive insight into how technology can enhance the integration of ssi into education having the potential to promotes critical thinking informed citizenship and deeper engagement with realworld challenges learning management systems modular objectoriented dynamic learning environment moodle a versatile learning management system serves as an effective platform for the seamless integration of ssi into education this robust tool offers a centralized repository for class materials enabling educators to share a wide range of resources such as articles videos research papers and other pertinent materials related to ssi within the groups dedicated library it encourages students not only to explore these resources but also engage in thoughtful discussions surrounding them moreover a professor has the capability to generate a brief survey to assess students comprehension aiding in making informed choices regarding specific courserelated matters moodle can be used to gauge students opinions and perspectives on specific socioscientific topics these polls serve as catalysts for discussions allowing students to comprehend the diverse array of viewpoints that complex issues often entail to delve even deeper moodle discussion forums can be harnessed for profound conversations on ssi educators can pose openended questions present ethical dilemmas or introduce realworld scenarios associated with ssi fostering an environment where students feel empowered to express their viewpoints critically analyze information and participate in respectful debates lastly the feedback feature within moodle empowers educators to provide constructive input to students regarding their contributions to ssi discussions assignments and projects this iterative feedback loop encourages students to refine their arguments and broaden their comprehension based on the received guidance further enhancing their engagement with ssi in a meaningful and educational manner google classroom google classroom originally designed for class management and assignment distribution can be a powerful tool for integrating ssi into education to achieve this a dedicated ssi class can be created to provide a central hub for organizing materials and discussions relevant resources can be shared ssirelated tasks can be assigned and discussions can be sparked through the classwork sections openended questions ethical dilemmas or realworld scenarios can also be posed to encourage thoughtful conversations among students additionally incorporating individual or group blogs and journals within google classroom allows students to reflect on their evolving thoughts ethical considerations and personal growth as they engage with ssi over time microsoft teams microsoft teams offers an enriched learning experience with its integrated features realtime communication and collaboration tools setting the stage to foster the development of critical thinking ethical reasoning and indepth exploration of intricate realworld challenges by harnessing microsoft teams filesharing capabilities users can seamlessly upload and share a diverse array of resources about ssi this comprehensive resource repository ensures effortless access for students the platforms assignments feature empowers educators to craft and disseminate ssibased projects and assignments with ease educators can provide students with clear instructions welldefined deadlines and transparent assessment criteria lastly microsoft teams encourages active student engagement within dedicated ssi channels facilitating dynamic ssi discussions in this forum educators can pose thoughtprovoking questions present ethical dilemmas or introduce realworld scenarios linked to ssi this interactive platform enables students to participate in live discussions thereby enhancing their critical thinking and communication skills interactive classroom tools flip flips interactive video platform offers a dynamic avenue for students to delve into and deliberate upon ssi creatively and engagingly to effectively promote ssi engagement educators can craft tailored ssi discussion topics prompting students to articulate their thoughts and viewpoints through video responses moreover integrating realworld scenarios related to these issues encourages students to consider implications ethical dilemmas and potential solutions facilitating peer interactions by encouraging responses to fellow students video contributions fosters a collaborative learning environment flip also allows for a multifaceted approach where students can present their research findings on specific ssi topics through video presentations organizing structured debates on socioscientific topics encourages students to critically analyze articulate and defend their perspectives furthermore educators can seamlessly intertwine ssi discussions with various subjects emphasizing crosscurricular connections assessment and selfreflection are seamlessly integrated into the platform enabling educators to evaluate students work and provide constructive feedback encouraging students to share their video discussions with a wider audience perhaps even engaging in public discourse on ssi extends the reach and impact of these vital conversations beyond the classroom in summary flip empowers educators to create an enriched learning environment that cultivates critical thinking ethical reasoning and active engagement in the multifaceted realm of ssi phet interactive simulations phet interactive simulations offers free researchbased science and mathematics simulations these simulations provide students with the opportunity to explore complex scientific phenomena in a handson digital environment these simulations can immerse students in realworld problemsolving scenarios allowing them to experiment with variables and observe outcomes thus gaining a deeper understanding of ssi topics interactive simulations which are both engaging and researchbased provide a handson digital platform for students to delve into complex scientific phenomena while they serve as versatile tools across various science and math topics their utility extends to addressing ssi as well educators can seamlessly integrate phet simulations into lessons making abstract concepts more accessible by encouraging students to actively explore these simulations instructors foster inquirybased learning prompting questions hypotheses and experiments within the virtual environment this approach not only nurtures critical thinking and problemsolving skills but also enables students to engage deeply with ssi topics in an informal environment after student interactions with the simulations class discussions provide a platform for debriefing experiences and promoting collaborative learning through group exploration thus phet interactive simulations prove invaluable for both traditional scientific concepts and their application to ssi facilitating a holistic and immersive educational experience nearpod nearpod emerges as a potent instrument for educators seeking to seamlessly incorporate ssi into their teaching methodologies this versatile platform empowers the creation of interactive nearpod lessons meticulously designed to introduce chosen real world problems replete with background information multimedia resources and thoughtprovoking inquiries with nearpods array of engagement tools students are actively immersed in the learning process leveraging nearpods realtime feedback and formative assessment tools educators gain valuable insights into student comprehension this datadriven approach enables instructors to adapt their teaching methods dynamically to cater to the evolving needs of their students moreover nearpod facilitates the hosting of debates and discussions through its collaboration features this setting empowers students to articulate their viewpoints and engage in constructive dialogues fostering a rich exchange of ideas the culmination of a nearpoddriven lesson is marked by reflection and analysis encouraging students to contemplate how their perspectives on the ssi topic may have evolved subsequently educators can assign followup homework or research tasks related to the ssi topic eliciting feedback from students this iterative process serves to refine ssi integration efforts for subsequent lessons the adaptability of nearpod further shines as it accommodates both inclass and remote learning activities rendering it a versatile platform for cultivating meaningful discussions and facilitating decisionmaking processes concerning realworld socioscientific challenges pear deck pear deck seamlessly integrated with google slides emerges as a powerful ally for educators seeking to create dynamic engaging presentations its core objective is to elevate student participation transforming passive observers into active contributors to the learning process through the integration of interactive elements like polls quizzes and discussions educators can not only assess student understanding in real time but also nurture peer interactions fostering a collaborative and engaging classroom environment moreover pear deck catalyzes integrating realworld scenarios into presentations illustrating the practical implications of ssi and promoting critical thinking it encourages student reflection on evolving perspectives regarding the ssi topic and facilitates discussions enabling peer feedback and collaborative learning beyond the presentation pear deck extends its interactive components to enrich followup activities such as research projects thereby enhancing the overall learning experience kahoot kahoot a gamebased learning platform offers diverse opportunities to integrate ssi into education educators can engage students by creating ssithemed kahoot quizzes that challenge their understanding of complex issues ethical dilemmas and potential solutions these quizzes serve as valuable tools for debate preparation ethical dilemma discussions and scenario analysis fostering critical thinking and informed decisionmaking kahoot also enables interactive classroom polls historical perspectives exploration and case study analysis making ssi topics relevant and engaging moreover educators can use kahoot to assess research findings encourage current events analysis and assess student knowledge on ssi topics promoting active learning in a fun and interactive way virtual meeting and communication tools zoom researchers can effectively employ zoom and x as virtual meeting and communication tools to integrate ssi into education zoom provides a robust platform for hosting virtual ssi discussions debates and seminars allowing researchers to connect with students colleagues and experts worldwide it facilitates realtime engagement screen sharing for presentations breakout rooms for group discussions and recording for later reference researchers can organize ssifocused webinars or guest speaker sessions on zoom to expose students to diverse perspectives and expert insights x on the other hand x with its broad reach and realtime nature can serve as a dynamic platform for ongoing ssi discourse researchers can create dedicated ssifocused x accounts or use relevant hashtags to curate and share resources news articles ethical dilemmas and research findings related to ssi engaging with the education community through tweets retweets and discussions fosters networking collaboration and the exchange of ideas researchers can also encourage students to participate in x discussions allowing them to explore current ssi topics follow influential voices and contribute to broader societal conversations by harnessing both zoom and x researchers can effectively cultivate an immersive and participatory ssi learning environment promoting critical thinking and active engagement assessment and feedback tools socrative socratives versatile quiz creation features enable researchers to design quizzes tailored to specific ssi topics fostering comprehension and critical thinking by posing thoughtprovoking questions and ethical dilemmas related to ssi within these quizzes researchers can gauge students understanding and ethical reasoning in real time moreover socratives realtime response gathering empowers researchers to adapt their teaching strategies based on immediate feedback researchers can identify areas where students may require further clarification or delve deeper into specific aspects of ssi additionally socratives data analytics offer insights into individual and collective student performance helping researchers tailor their instructional approach furthermore socrative can be employed for interactive discussions related to ssi by creating polls or openended questions that encourage students to share their perspectives and engage in dialogues researchers can then use the gathered responses as a basis for fostering deeper ssi discussions and explorations incorporating socrative into ssifocused educational initiatives allows researchers to evaluate student comprehension ethical reasoning and opinions on complex realworld challenges systematically it serves as an invaluable tool for promoting active learning and informed decisionmaking in the realm of ssi content sharing and creation youtube as a videosharing platform youtube offers a wealth of educational opportunities for ssi integration researchers can curate or create videos that delve into various aspects of ssi topics providing students with engaging visual content these videos can include documentaries expert interviews or simulations illustrating realworld scenarios related to ssi youtubes interactive features such as comments and discussions enable researchers to foster ssirelated dialogue and encourage students to share their thoughts questions and perspectives by curating or producing highquality ssi content on youtube researchers can provide students with accessible and engaging resources that promote critical thinking and informed discussions miro miro is a versatile online whiteboard platform that researchers can employ to facilitate collaborative content creation and knowledge sharing in the context of ssi researchers can create virtual boards dedicated to ssi topics where students can collectively brainstorm visualize complex issues and collaborate on projects miros visual nature enables researchers to map out ssi concepts ethical dilemmas and potential solutions fostering a deeper understanding of these issues furthermore miros realtime collaboration features allow for synchronous group work enabling students to collectively analyze data create mind maps and collaborate on research projects by leveraging miro researchers can provide students with an interactive and visually engaging platform for content creation enabling them to explore and synthesize ssirelated information collaboratively incorporating youtube and miro into ssifocused educational endeavors enriches the learning experience by providing students with multimedia content and collaborative tools that promote active engagement critical thinking and a deeper understanding of complex ssi citizen science and research scistarter scistarter a digital platform to foster and study sustained engagement in citizen science empowers students to actively participate in citizen science initiatives where they can contribute to real scientific research projects related to ssi topics researchers can identify and curate citizen science projects on scistarter that align with specific ssi topics by engaging students in these projects researchers encourage them to actively participate in realworld scientific endeavors while addressing complex socioscientific challenges moreover scistarters comprehensive database of citizen science projects and resources enables researchers to explore interdisciplinary connections between ssi topics and scientific investigations this fosters a holistic understanding of the multifaceted nature of ssi researchers can also employ scistarters tools to track and measure student engagement and contributions to citizen science projects providing valuable insights into the effectiveness of ssi integration efforts additionally scistarters community features facilitate discussions knowledge sharing and networking opportunities among educators students and citizen science practitioners by incorporating scistarter into ssifocused educational initiatives researchers can empower students to become active participants in authentic scientific research enhancing their critical thinking problemsolving skills and ethical reasoning while contributing to meaningful societal change comprehensive educational suites google workspace for education researchers can develop ssithemed projects and assignments using google docs sheets and slides encouraging collaborative research data analysis and presentation creation google drive provides a centralized repository for storing and sharing ssirelated resources including articles research papers and multimedia content google classroom serves as a centralized hub for educators to organize ssi lessons assignments and discussions researchers can create dedicated ssi classes within google classroom facilitating seamless content delivery and student interaction utilizing google forms researchers can design surveys and quizzes to assess student comprehension and gather feedback on ssi topics google meet offers a platform for hosting virtual ssi discussions debates and guest speaker sessions connecting researchers students and experts in realtime google sites enables researchers to build interactive ssithemed websites or portfolios providing students with a dynamic platform for showcasing their understanding and insights moreover researchers can encourage students to use google workspaces communication tools such as gmail and google chat for collaborative ssi projects and to facilitate ongoing discussions by integrating google workspace for education into ssifocused educational initiatives researchers create a comprehensive and cohesive digital environment that fosters critical thinking information sharing and active engagement in complex ssi google workspace for education has transformed the way students engage with ssi discussions by providing students with realtime collaboration features allowing them to work together on ssi projects and discussions regardless of their physical locations for example students in different parts of the world can collaborate on a shared document conduct research and engage in discussions simultaneously this realtime collaboration enhances peertopeer interaction and fosters a sense of global connectedness these platforms facilitate discourse and knowledge sharing among students enabling collaborative research peer review and the cocreation of solutions to socioscientific dilemmas students can collaborate in realtime regardless of their physical locations fostering a sense of global connectivity and shared responsibility for addressing pressing societal issues this also helps to bring what might be placebased ssi contexts and initiatives into the local classroom in addition to the extensive range of educational tools mentioned the integration of ai technologies is fundamentally transforming the educational landscape virtual reality and augmented reality can serve as a dynamic catalyst in the creation of immersive placebased learning experiences by harnessing augmented reality educators can transport students to realworld locations and scenarios enabling them to explore historical sites cultural landmarks or even environmental ecosystems this not only enhances the engagement and relevance of the learning experience but also promotes critical thinking and problemsolving skills by allowing students to interact with and analyze these environments in a meaningful way aidriven simulations offer a costeffective and efficient means to study placebased phenomena fostering a deeper understanding of realworld challenges in this way ai acts as a bridge between digital tools and realworld contexts empowering educators researchers and policymakers to further advance the integration of ssi into education in summary the integration of these digital tools into ssi education offers a holistic approach to fostering critical thinking ethical reasoning and active citizenship among students each tool contributes unique features and capabilities that collectively enhance the ssi learning experience creating a rich and immersive educational environment researchers can tailor their use of these tools to align with their curriculum objectives fostering a deeper understanding of ssi and empowering students to make informed decisions in a complex world the impact of digital tools on student decisionmaking argumentation skills and ethical reasoning in the context of socioscientific dilemmas the impact of digital tools on student decisionmaking argumentation skills and ethical reasoning in the context of socioscientific dilemmas is significant and multifaceted these tools offer a range of benefits that enhance students abilities in the following areas decisionmaking in the realm of ssi digital tools play a pivotal role in enhancing students decisionmaking abilities through three key avenues increased access to information exposure to realworld scenarios and the provision of valuable feedback and assessment firstly these tools grant students unparalleled access to a diverse array of information pertinent to ssi topics this unfettered access empowers them to gather a wide range of viewpoints evidence and data laying the foundation for wellinformed decisionmaking secondly digital tools facilitate engagement with realworld scenarios through simulations interactive discussions and citizen science platforms like scistarter this practical exposure enables students to delve into the complexities of ssi and comprehend the tangible consequences of their decisions finally assessment tools such as socrative and kahoot offer students immediate feedback on their decisionmaking processes allowing for reflection and adjustment this multifaceted approach driven by digital tools empowers students to make informed thoughtful and effective decisions in the face of socioscientific dilemmas argumentation skills digital tools have a profound impact on the development of students argumentation skills fostering engagement and collaboration providing visual aids and nurturing research and critical thinking abilities firstly interactive classroom tools such as flip nearpod and pear deck along with virtual meetings on platforms like zoom create an environment where students are encouraged to articulate and defend their viewpoints collaboratively this collaborative setting not only promotes the development of persuasive argumentation skills but also cultivates the ability to consider diverse perspectives secondly visual tools like miro offer students visual aids to structure their arguments effectively this includes creating mind maps diagrams and visual representations that enhance the clarity and persuasiveness of their reasoning lastly digital tools facilitate research and critical thinking by offering resources for gathering evidence evaluating sources and strengthening argumentation through critical analysis by incorporating these tools students not only refine their ability to construct persuasive arguments but also become more adept at evaluating and synthesizing information contributing to their overall skill development in the context of socioscientific dilemmas ethical reasoning the central role of ethics in science education has been acknowledged by scholars as in integral part of classroom pedagogy and character development particularly as it conceptualized within the ssi framework within the context of ssi digital tools play a pivotal role in nurturing ethical reasoning among students through the presentation of ethical dilemmas fostering community engagement and providing immediate feedback firstly these tools introduce students to ethical dilemmas related to ssi challenging them to delve into the moral dimensions of their decisions through discussion platforms and simulations students are prompted to consider the ethical implications of their choices fostering a deeper understanding of the ethical complexities surrounding ssi secondly virtual communication tools like x and collaborative online environments facilitate community engagement enabling students to participate in discussions on ethics within a broader community this exposure to diverse perspectives and ethical viewpoints encourages critical thinking and ethical reflection lastly assessment tools such as socrative incorporate questions that encourage students to reflect on the ethical implications of their decisions this immediate feedback loop not only reinforces ethical reasoning but also instills a sense of responsibility and mindfulness in students as they navigate the intricate ethical landscapes of socioscientific dilemmas in this way digital tools become catalysts for the development of ethical reasoning skills within the ssi educational context however its important to note that the impact of digital tools on these skills depends on various factors including the effectiveness of tool implementation teacher guidance and the willingness of students to engage actively effective integration of these tools into the curriculum along with teacher support and guidance plays a crucial role in maximizing their impact on student decisionmaking argumentation skills and ethical reasoning regarding socioscientific dilemmas the challenges and opportunities of teaching ssi in online and blended learning environments teaching ssi in online and blended learning environments offers both challenges and opportunities particularly in the context of the global shift toward remote education figure 2 challenges and opportunities teaching socioscientific issues in online and blended learning environments one of the foremost challenges is the limitation of handson experiences in traditional settings students benefit from practical laboratory work and interactive experiments which play a pivotal role in comprehending the practical dimensions of ssi topics in online environments replicating these handson experiences can be challenging potentially leading to a gap in the students understanding of the realworld applications of ssi another challenge arises from disparities in access to resources students access to digital tools and resources may vary significantly depending on their geographical location socioeconomic status or institutional support this variance in access can impact their ability to engage effectively with ssi materials and digital tools potentially creating inequalities in learning outcomes additionally the shift to remote education can result in reduced interpersonal interaction facetoface interactions in traditional classrooms foster peer collaboration lively discussions and debates on ssi topics in an online setting these opportunities for rich interpersonal engagement may be limited potentially hindering the development of students critical thinking argumentation skills and ethical reasoning maintaining student motivation and engagement is another significant challenge in remote settings online learning can sometimes lead to feelings of isolation making it essential for educators to employ innovative strategies and digital tools to sustain student interest in ssi discussions and ethical reasoning activities furthermore educators themselves may face challenges related to professional development to effectively integrate digital tools and ssi topics into online instruction educators may require additional training and support this includes mastering the use of various educational technologies adapting their teaching methods to online environments and finding creative ways to foster deep engagement with ssi issues for instance implementing ongoing professional development initiatives can equip educators with the requisite skills and knowledge to excel in the art of online teaching simultaneously fostering supportive ecosystems through collaboration with educational institutions administrative bodies and edtech companies can nurture an environment conducive to educators growth and effectiveness encouraging a sense of shared learning within the educational community such as through the establishment of community of practice networks can enable educators to share experiences best practices and insights thereby collectively navigating the dynamic landscape of online education in these ways educators can be better prepared to meet the challenges posed by remote learning and elevate the quality of ssi education in digital environments despite these challenges online and blended learning environments present a myriad of opportunities that can be used to effectively teach ssi one of the most notable opportunities is the global perspective that online learning affords through digital connectivity students can engage with ssi topics from a global standpoint connecting with peers and experts worldwide this global network allows them to gain diverse viewpoints fostering a deeper understanding of the complexities surrounding ssi additionally the flexibility inherent in blended and online formats is a significant advantage these formats provide students with the freedom to explore ssi topics at their own pace accommodating various learning styles and preferences this flexibility can result in more personalized and effective learning experiences moreover the wealth of digital tools and platforms available in online environments enriches the depth of ssi exploration virtual simulations discussion forums collaborative tools and interactive multimedia resources offer dynamic and immersive learning experiences facilitating a comprehensive understanding of ssi topics online environments also provide unprecedented access to a treasure trove of digital resources students can easily access a vast array of articles videos expert discussions and research materials related to ssi augmenting their learning journey and broadening their knowledge horizons furthermore digital assessment tools offer immediate feedback mechanisms educators can use these tools to gauge students comprehension of ssi topics in real time and tailor their teaching strategies accordingly this timely feedback loop enhances the effectiveness of the learning process lastly online platforms including social media and discussion forums serve as catalysts for community building and networking educators students and experts interested in ssi can come together in virtual spaces to share insights exchange ideas and collaborate on projects creating a vibrant and supportive community that nurtures engagement and innovation in the field in essence the opportunities presented by online and blended learning environments significantly enhance the teaching and learning of ssi fostering a dynamic and interconnected educational landscape by recognizing these opportunities and addressing the challenges proactively educators can create enriching and impactful learning experiences in the realm of ssi even in remote education settings future research directions the globalization of ssi education opens doors for research on crosscultural perspectives shedding light on how diverse cultural backgrounds influence students engagement with and comprehension of ssi topics complementing this research in teacher professional development is poised to explore effective strategies for equipping educators with the knowledge and skills needed to proficiently employ ssi pedagogy and integrate digital tools into their teaching furthermore as digital tools continue to play an integral role in ssi education research may delve into ethical considerations surrounding ai use in assessment data privacy concerns and the development of strategies that foster a safe and inclusive online learning environment these interconnected research directions collectively contribute to the ongoing evolution of ssi education ensuring its relevance and effectiveness in the digital age while maintaining ethical and crosscultural sensitivity in conclusion this summary of opportunities and challenges serves as a compass guiding educators and researchers through the dynamic terrain of ssi education in the digital era this comprehensive literature review highlights the symbiotic relationship between pedagogy and technology showcasing how the integration of digital tools enriches students ssi learning experiences by investigating the impact on students decisionmaking abilities argumentation skills and ethical reasoning this review underscores the transformative potential of digital tools in shaping responsible and informed citizens of the 21st century moreover it confronts the challenges and opportunities posed by online and blended learning environments emphasizing the need for adaptable strategies in an everevolving educational landscape as the world grapples with intricate socioscientific dilemmas this review encourages educators to harness the power of technology and innovative pedagogical approaches ultimately equipping students to navigate and contribute meaningfully to a complex and interconnected global society türkçe geni̇şleti̇lmi̇ş özet 21 yüzyıldaki gelişmeler toplumu her alanda etkilemektedir hızla dijitalleşen dünyada geleneksel eğitim öğretim yöntemleri yerini dijital öğretim araçlarına bırakmasa da bu araçların derslere entegre edilmesi kaçınılmaz olmuştur 21 yüzyıldaki bu hızlı gelişmelerin toplum hayatına olumlu ve olumsuz bir çok etkisi olduğu bilinmektedir örneğin dijitalleşme ve teknolojik ilerleme iş dünyasında verimliliği artırır iletişimi kolaylaştırırken dijital eğitim araçları öğrencilere farklı öğrenme yöntemleri sunarak öğrenmeyi daha etkili hale getirebilir ve bilgiye erişimi artırabilir öte yandan bilgiye erişimin kolaylaşmasıyla birlikte bilgi kirliliği ve yanlış bilgilere erişim artabilir teknolojiye bağımlılık artabilir dijitalleşmeyle birlikte kişisel bilgi gizliliği ve çevrimiçi güvenlik konuları daha büyük bir önem kazanabilir bu noktada bilim ve teknolojideki bu gelişmelerin toplum hayatına etkilerini inceleyen sosyobilimsel konuların derslere entegre edilmesi bu sayede öğrencilere bilimsel düşünceyi geliştirme toplumsal meselelere eleştirel bir bakış açısı kazandırma ve etik değerlendirme becerileri kazandırma olanağı sunulması oldukça önemlidir sosyobilimsel konular bağlamında ele alınan derslerin öğrencilerin karmaşık toplumsal sorunlarla başa çıkmalarına yardımcı olmakla kalmayıp aynı zamanda bilimsel okuryazarlık ve sosyal bilimsel akıl yürütme becerilerini geliştirdiği bilinmektedir bilinen bu yanları düşünülerek dijital çağın topluma sunduğu fayda ve zararları dijital araçları kullanarak sosyobilimsel konular bağlamında tartışmak öğrencilere gerçek dünya sorunları üzerinde düşünme eleştirel düşünme ve problem çözme etik ve ahlaki gelişim disiplinler arası öğrenmeyi teşvik etme ve vatandaşlık eğitimi gibi önemli becerileri kazandıracağı düşünülmektedir sosyobilimsel konular üzerine hazırlanmış alanyazın incelendiğinde sbknin fen eğitimine entegrasyonu için birçok çalışmaya rastlanmaktadır ancak dijital teknolojilerin gelişimi sbk eğitimine yönelik yeni soruları gündeme getirmektedir dijital çağda geleneksel sbk eğitim yaklaşımları yeniden şekillenmekte ve yeni eğilimler ve fırsatlar ortaya çıkmaktadır bu nedenle dijital çağda sbk öğretimi ortaya çıkan eğilimler ve keşfedilmemiş sınırlar başlıklı bu derleme büyük önem taşımaktadır teknolojinin eğitim süreçlerine ve topluma daha fazla entegre olduğu bir dönemde bu dijital araçların ve platformların sbk eğitimini nasıl geliştirebileceği eleştirel bir şekilde incelenmelidir bu derleme sbk eğitimini etkileyen en son gelişmeleri yenilikçi pedagojik yaklaşımları ve teknolojik araçları ortaya çıkarmayı hedeflemektedir i̇nceleme sbk pedagojisinin ve dijital çağın kesişimini keşfederek eğitimciler araştırmacılar ve politika yapıcıları için değerli bilgiler sunmaktadır ayrıca dijital çağın getirdiği fırsatlar ve zorluklara uyum sağlama ve gelişme ihtiyacını da vurgular derlemede sbk ve dijital çağ üzerine mevcut araştırma ve yayınları sistematik bir şekilde analiz ve sentez ederek bir literatür taraması yapılmıştır bu yöntemde yer alan adımlar şunlardır araştırma kapsamının belirlenmesi ilgili literatürün taranması ve seçilmesi ilgili literatürün analizi ve sentezlenmesi boşlukların ve eğilimlerin belirlenmesi ve eleştirel değerlendirme ve yorumlama öncelikle araştırma kapsamı belirlenmiştir araştırmamızın odak noktası dijital araçların sbk öğretiminde kullanımını incelemektir bu amaçla sbk pedagojisi dijital teknolojiler ve bunların kesişimi ile ilgili bilgi toplamak için akademik veri tabanları google akademik eric ve web of science arama motoru ve indeksleri taranmıştır uygun makale ve çalışmaları seçmek için belirli anahtar kelimeler ve kriterler kullanılmıştır i̇lgili literatürü topladıktan sonra bu kaynaklardan gelen bilgileri analiz ve sentez edilerek sosyobilimsel konuların dijital araçlar ile öğretilmesi sırasında karşılaşılabilecek zorluklar ve fırsatlar hakkında bilgi verilmiştir dijital araçlar öğrencilerin sosyobilimsel düşünmeyi geliştirme ve gerçek dünya sorunlarına katkıda bulunma becerilerini güçlendirmelerine yardımcı olur bu çalışmada ele alınan dijital araçlar 7 alt kategoride sunulmuştur her bir kategori için örnek teşkil edebilecek bir veya daha çok dijital araca yer verilmiştir öğrenme yönetim sistemleri kategorisinde moodle google classroom ve microsoft teams etkileşimli sınıf araçları olarak flip phet nearpod pear deck ve kahoot sanal toplantılar ve i̇letişim için zoom ve x değerlendirme için socrative i̇çerik paylaşımı ve oluşturma için youtube ve miro vatandaş bilimi ve araştırma için scistarter ve kapsamlı eğitim çözümleri için google workspace for education gibi belirli örnekleri vurgulayarak çeşitli eğitim araçlarının işlevlerini ve avantajları açıklanmıştır bu dijital kaynakların incelenmesi yoluyla bu derleme eğitimcilere araştırmacılara ve eğitim politikası yapıcılarına eleştirel düşünmeyi bilinçli vatandaşlığı ve gerçek dünyadaki zorluklarla daha derin bir etkileşimi teşvik etme potansiyeline sahip teknolojinin sbknin eğitime entegrasyonunu nasıl geliştirebileceğine dair kapsamlı bir fikir sunmayı amaçlamaktadır dijital araçlar sosyobilimsel konularda öğrencilerin karar verme argümantasyon becerileri ve etik muhakemelerini etkileyen önemli faydalar sunar karar verme dijital araçlar geniş bilgi erişimi gerçek dünya senaryoları ve anında geri bildirimle karar verme becerilerini artırır öğrenciler farklı bakış açılarına erişir pratik senaryolarla çalışır ve etkili düşünme becerilerini geliştirirler argümantasyon becerileri bu araçlar işbirlikçi tartışmayı teşvik eder görsel yardımcılar sunar ve araştırma ile eleştirel düşünmeyi geliştirir öğrenciler bakış açılarını ifade eder görsel temsillerle mantıklı düşünceyi artırır ve bilgiyi değerlendirme ile sentezleme yeteneklerini geliştirirler etik muhakeme dijital araçlar etik sorunları ele alır topluluk katılımını destekler ve anında geri bildirim sunar öğrenciler ahlaki boyutları keşfeder farklı etik perspektiflerle etkileşime girer ve etik düşünceyi geliştirirler dijital araçların bu becerilere etkisini en üst düzeye çıkarmak için etkili uygulama öğretmen rehberliği ve öğrenci katılımı önemlidir bu derleme teknolojinin sbk eğitimine nasıl katkıda bulunabileceği konusunda eğitimciler araştırmacılar kapsamlı bir bakış sunmayı amaçlamaktadır aynı zamanda sbk eğitiminin küreselleşmesi ve farklı kültürel bağlamlardaki etkilerini ele alarak kültürler arası perspektifler sunar öğretmenlerin mesleki gelişimine yönelik araştırmalar eğitimcileri sbk pedagojisini ustalaşmaları ve dijital araçları etkili bir şekilde öğretimlerine entegre etmeleri için gereken bilgi ve becerilerle donatmaya yönelik stratejileri inceler çevrimiçi eğitimde karşılaşılan temel zorluklardan biri sosyobilimsel konuların uygulamalı deneyimlerinin sınırlı olmasıdır geleneksel sınıflarda bulunan laboratuvar çalışmalarını ve etkileşimli deneyleri çevrimiçi olarak yeniden oluşturmak zor olabilir ayrıca öğrencilerin dijital kaynaklara ve araçlara erişimindeki eşitsizlikler coğrafi konumları sosyoekonomik durumları veya kurumsal desteklerine bağlı olarak değişebilir bu erişim eşitsizliği öğrencilerin sbk materyalleri ve dijital araçlarla etkileşimini etkileyebilir ayrıca uzaktan eğitime geçiş tipik olarak yüz yüze sınıf ortamlarında gelişen eleştirel düşünme tartışma becerileri ve etik muhakeme gelişimini sınırlayabilir aynı zamanda çevrimiçi öğrenme öğrenciler arasında izolasyon hissi yaratabilir ve bu öğrenci motivasyonunu ve katılımını sürdürmeyi zorlaştırır eğitimciler sbk tartışmalarını ve etik muhakeme etkinliklerini sürdürmek için yenilikçi stratejiler ve dijital araçlar kullanmalıdır bununla birlikte dijital araçların ve sbk konularının çevrimiçi eğitime entegre edilmesi eğitimcilerin ek eğitim ve destek gereksinimleri ile karşılaşmalarına neden olabilir çevrimiçi ve karma öğrenme ortamları etkili sbk eğitimi için birçok fırsat sunmaktadır özellikle çevrimiçi öğrenmenin sunduğu global perspektif öğrencilere sbk konularına dünya çapından bir bakış açısı kazandırır dijital bağlantılar sayesinde öğrenciler dünya genelindeki akranları ve uzmanlarla iletişim kurarak farklı bakış açıları kazanabilirler bu global ağ sbk konularını daha iyi anlamak için farklı perspektifler sunar ayrıca çevrimiçi ve karma formatların esnekliği öğrencilere sbk konularını kendi hızlarında keşfetme özgürlüğü sunar dijital araçların bolca bulunduğu çevrimiçi ortamlar sbk araştırmasının derinliğini artırarak öğrencilere dinamik ve etkileşimli öğrenme deneyimleri sunar çevrimiçi ortamlar ayrıca öğrencilere benzeri görülmemiş bir dijital kaynaklara erişim sağlar diğer bir avantaj dijital değerlendirme araçlarının öğrencilerin sbk konularını anlama düzeyini ölçmelerine ve öğretim stratejilerini buna göre uyarlamalarına yardımcı olmasıdır son olarak çevrimiçi platformlar topluluk oluşturma ve ağ kurma için katalizör görevi görerek bu alandaki katılımı ve yeniliği besler özetle çevrimiçi ve karma öğrenme ortamlarının sunduğu fırsatlar sbk öğretimini zenginleştirir ve

as society navigates complex socioscientific issues ssi in an increasingly digitalized world science education faces evolving challenges and opportunities this study aimed to conduct a literature review by systematically analyzing and synthesizing existing research and publications on ssi pedagogy and the digital age the steps involved in this method include identifying the research scope searching and selecting relevant literature analyzing and synthesizing relevant literature identifying gaps and trends and critical evaluation and interpretation the study explores the intersection of ssi pedagogy and the digital age shedding light on both emerging trends and uncharted frontiers the review delves into the dynamic landscape of ssi education emphasizing the integration of digital technologies as a means to engage students in authentic realworld problemsolving it examines the role of technology in enhancing ssi learning experiences from virtual simulations to online collaborative platforms furthermore the review critically evaluates the impact of digital tools on student decisionmaking argumentation skills and ethical reasoning in the context of socioscientific dilemmas this review also addresses the challenges and opportunities of teaching ssi in online and blended learning environments particularly in light of the global shift toward remote education in summary this review informs educators and researchers and underscores the pivotal role of digital technologies in preparing students to navigate the complex socioscientific challenges of the 21st century

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introduction participation in community and family activities is an important aspect of quality of life for older adults the social participation literature shows that social participation is related to better functional skills 12 healthrelated quality of life 34 and even survival 3 5 6 7 the favorite activities of older adults of almost any age include physical activities and activities that require leaving the house 8 however many older adults have difficulty or are unable to leave their dwellings the homebound are increasingly recognized as a population of special needs 9 in the context of understanding the vital importance of community participation it is important to study such participation in older homebound people they are on a trajectory of decline in which inability to participate accelerates the participation itself provides activation and motivation to prolong participation there has been prior quantitative and qualitative work on community barriers to participation by homebound older adults in small geographically restricted samples sanders et al 10 found that among an allfemale sample of homebound older adults in one housing complex in canada access to and cost of transportation knowledge of available programming and ability to access the programs offered limited activity participation bendixen et al 11 in a sample in western new york state found that older adults were limited by transportation poor health lack of companionship and accessibility in a qualitative study of disabled older adults turcotte et al 12 found that lack of social activities was the largest source of unmet need however little is known from nationally representative samples about what kind of social and community participation is important to this population of older adults and what issues they face in remaining active outside their homes as locality climate supports and building design may differ across regions of the usa examining this issue in a nationally representative sample will provide a muchneeded overview on the state of the homebound in the usa we used the nhats sample to examine issues for homebound in the usa in examining the association between homeboundedness and community participation verbrugge and jettes 13 disablement theory posits that both intrinsic and extrinsic factors contribute to the development of impairment from pathology according to their theory intrinsic characteristics such as pain as well as extrinsic factors such as community services are separate domains with different intervention targets on the pathway to disability it is therefore important to examine both intrinsic and extrinsic barriers to participation among the homebound the conceptual framework for disability used in the nhats study is freedmans framework 14 this conceptual framework for disability advances the work of the nagi model 15 and the world health organization international classification of functioning model 16 to support investigations of the participation of older adults in social and community activities this advanced framework which undergirds the national health and aging trends study serves four key functions allows for the study and consequences of participation explicitly includes testable links between the physical and social environment participation and disability supports research focusing on maximization of function in any stage of the disablement process and distinguishes between the capacity to perform and the actual performance which allows study of assistive devices and environmental changes thus we apply the nhats conceptual framework to test hypotheses about the importance of community and social participation of homebound older adults and the barriers to such participation we hypothesized that the majority of homebound older adults would report that community participation was important but that both intrinsic and extrinsic factors present barriers to participation among older adults we currently know very little through nationally representative samples about outside activities older adults wish to engage in and what issues they face in remaining active outside their homes understanding this information can be useful to designing appropriate home and communitybased social support programs that facilitate meaningful social and community engagement for a full range of older adults rather than just for physically robust ones methods study sample we used data from the nhats survey a longitudinal nationally representative survey of medicare beneficiaries 65 years of age and older with information on latelife functioning economic and social wellbeing and quality of life factors of aging beginning in 2011 annual inperson interviews were conducted with respondents andor proxies selected from the medicare enrollment database using a stratified threestage sample design with oversampling of older age groups and black nonhispanic individuals the baseline response rate was 71 yielding a total sample of 8245 respondents 17 for our analyses we used data from round 1 of the nhats survey our analytic sample included only communitydwelling older adults which excluded persons living in facilitieseither assisted living or nursing homesdue to our focus on understanding the lives of those aging at home participants gave informed consent and ethical approval for the study was given by the institutional review board of the johns hopkins medical institutions measures main exposure homebound status we analyzed homebound status using three groupsthe homebound semihomebound and not homeboundusing the question within the last month how often did you go outside individuals were classified as homebound if they answered never or rarely respondents were considered semihomebound if they went out two or more days a week but never by themselves needed help or had difficulty leaving the home the nonhomebound went out two or more days per week never needed help and did so without difficulty these delineations reflect the established measures of homebound status developed by ornstein et al 9 this variable is considered ordinal covariates demographic measures each respondents birthdate was confirmed with the participant and used to calculate age at interview race was selfreported and answers were reduced to four categories nonhispanic white nonhispanic black hispanic and nonhispanic other income was a respondents estimate of total pretax income for the last year including a spouse or partner if applicable missing income values were imputed by nhats and included within the public use file income was categorized into six levels less than 10000 10001 20000 20001 35000 35001 65000 65001 100000 and 100000 education was condensed into four categories less than high school high school diplomageneral education development examination some college and a bachelors degree or greater similar to other published studies with nhats data we grouped respondents who did not identify their highest level of education with those who had less than high school 1819 medical conditions respondents were asked whether a doctor had ever told them they had one of the following conditions heart attack heart disease high blood pressure arthritis osteoporosis diabetes lung disease stroke alzheimers disease or dementia cancer or a broken or fractured hip the patient health questionnaire4 was administered to identify symptoms of depression and anxiety depression and anxiety were each scored on a scale of 06 a score of 3 or greater indicated the presence of symptoms for each condition 20 using these answers we created a count of chronic conditions ranging from 0 to 13 functional status in round 1 nhats included questions from the 2004 national longterm care survey screener on activities of daily living and instrumental activities of daily living 21 functional limitation prevalence was estimated from this nltcs module respondents who identified having a problem performing one of the following adls without help were considered to have a disability in that area eating getting in or out of bed getting in or out of chairs walking around inside dressing bathing and toileting if a respondent was not able to perform one of the following iadls without help they were considered to have a disability in that area preparing meals doing laundry light housework shopping for groceries managing money taking medicine and making phone calls if a person did not do an iadl activity but said they were able the respondent was marked as having no disability in that area a total count of adl and iadl difficulties was calculated by adding up the number of limitations creating a scale of 07 for both areas there was also a separate binary measure of the ability to go outside without the help of another person or special equipment we separated this from the total adl count and analyzed it as an individual variable pain respondents were categorized as having pain if they answered yes to the question in the last month have you been bothered by pain 22 outcomes level of participation degree of importance and barriers to participation respondents were asked whether they had performed four activities in the last month visit friends and family who lived separately attend religious services participate in clubs classes or other organized activities or go out for enjoyment they were also asked whether they experienced limitations performing the activities in the last month due to health or transportation issues regardless of whether the activity was performed or not these answers to these questions about limitations to the activities were the barriers the answers were coded as yes or no respondents were also asked to rate the level of importance of performing these four activities very important somewhat important or not so important for our analyses activities endorsed as somewhat or very important were combined and considered valued activities to the respondent if respondents rated one of the four activities important we examined whether they participated in the activity within the last month and what barriers they experienced to that participation respondents were also asked whether they provided care to another adult or child who could not care for themselves in the last month as this can be an important social outlet statistical analyses we examined the demographic and socioeconomic characteristics health conditions and functional limitations of sample adults by homebound status each group was compared to the completely homebound group via chisquare analysis for categorical variables and students t test for continuous variables to test the hypothesis that the majority of homebound older adults would report that community participation was important but that both intrinsic and extrinsic factors present barriers to participation among older adults we calculated frequencies of activity importance participation and barriers according to homebound status analyses included survey weights to adjust for the nhats survey design and to generalize the national sample all analyses were performed using stata 131 results study participants based on the ornstein et al measure of homebound status our analytic sample was comprised of 473 homebound individuals 1257 semihomebound individuals and 5467 nonhomebound individuals applying population weights and extrapolating to the entire usa the group who never or rarely left the house in the last month defining our homebound sample represents 1551121 older adults the sample of those who found it difficult to leave the house represents 3832428 and the sample that did not leave without another person represents 960255 totaling 4792683 semihomebound individuals nonhomebound individuals represent 27011310 older adults the homebound sample mean age was 801 and respondents were significantly more likely to report limitations in adls as well as iadls than those who were not homebound the iadls with which the highest percentage of homebound reported restrictions were shopping for groceries doing laundry and preparing meals which have important implications for daily life and for community participation percentages for other iadl difficulties were managing money light housework taking medicine and making phone calls the top three adl impairments for homebound individuals were bathing walking around inside and getting in or out of chairs followed by dressing getting in or out of bed toileting and eating as described previously 9 nonhomebound individuals were younger more likely to be male and white than those who are homebound they are also significantly more educated and have higher income than those who are completely homebound nonhomebound individuals are much less likely to have depressive symptoms than the homebound and less likely to report having been bothered by pain in the last month community participation despite these functional limitations and pain homebound and semihomebound older adults report a strong interest in community participation the homebound frequently report that activities outside the home were important to them ranging from 252 to 700 similarly a majority of the semihomebound reports that visiting in person with friends and family attending religious services and going out for enjoyment are important to them a full 433 report that participating in clubs classes and other activities is important to them barriers to participation despite this importance homebound and semihomebound individuals reported that health concerns often kept them from participating in various activities of those who endorsed the activities as important many homebound reported health and some reported transportation issues as barriers to participation among the semihomebound who reported that these activities were important to them 238410 reported barriers due to health concerns and 65102 reported transportation barriers interestingly 66 homebound older adults provide care for others and 97 of the semihomebound provide care for others discussion findings to our knowledge this is the first study to report on valued family and communitybased activities by communitydwelling homebound older adults using nationally representative data we found that despite functional limitations large percentages of homebound and semihomebound older adults seek to participate in family and community life community participation can be an important part of health promotion 23 can decrease depression 24 and is actionable which makes it an important intervention target as we hypothesized we found that homebound older adults have more activitylimiting health problems than their nonhomebound counterparts they also have transportation issues these patterns are relevant because it is both harder to reach homebound older adults and more important to understand what deficits they need to overcome to engage in the community it is important to note that in our sample the homebound had the lowest percentage of valued activities of the three groups on the positive side we found that both the homebound and the semihomebound are able to see family frequently that was the most highly b nominal data were missing with a range of 0196 valued activity and is accomplished by 783 of the homebound and 842 of the semihomebound the semihomebound group was the larger of the groups this is a less restrictive definition and combines two subgroups of individuals that may not necessarily progress to homeboundednessthose who need help to go out and those who do not go out unaccompanied the semihomebound is potentially the more robust group for intervention because they are healthier have less impairment and have more available social support finally from our findings shopping for groceries doing laundry and preparing meals were the most common selfcare difficulties each one of these is more amenable to outside help than adls like bathing and grooming targeted programs such as meals on wheels and also light housecleaning and laundry could provide semihomebound or homebound older adults the ability to participate in valued activities findings in context our findings add to the literature on homebound older adults participation preferences previous studies have examined single communities lack of opportunity for social and community engagement is among their prominent findings murayama et al 25 found that walkability and crime safety affect community participation of homebound older adults in a japanese community turcotte et al 12 found that older disabled adults were not receiving enough social participation opportunities both home and community adaptations are associated with community participation among mobilitylimited older adults in the us state of georgia 26 bendixen et al 11 found that those who cannot participate suffer lower selfesteem and may subsequently have more role losses hammel et al 27 found that toilet and bath modifications had the largest association with going out into the community for those with mobility limitations our study findings extend those of others in their nationally representative scope limitations the current study has important limitations first although the definition of homebound and semihomebound has strong convergent validity with illness and the same definitions have been used by others 925 the measure identifying homebound older adults is based on whether respondents left the house in the last month this question has seasonality issues as someone in a cold wintry or hot summer locale may not leave in the recent month but not be considered homebound during temperate weather or theoretically it could have been an unusual month in an otherwise active life this seems unlikely because an unusually weakened older adult would not likely volunteer for a 3h research interview but it is possible a second limitation to our findings is the possible endogeneity people may be more likely to say that an activity is important to them if they were able to have done it recently similarly transportation difficulty could be confounded with homebound status because respondents could have answered that they did not go out due to transportation also we are unable to determine whether the fact that homebound older adults value participation less than the nonhomebound is due to other factors beyond the existence of intrinsic and extrinsic barriers to participation while the sample size of 473 is modest this is a nationally representative sample of 473 people representing 15 million adults further this sample size is larger than the overwhelming majority of previous work on homebound older adults who are especially difficult to recruit to research studies because of their poor health and inability to access routine medical care or other services also those who were homebound were less educated than those who were not homebound there may be a cohort effect as new generations of older adults are more educated participation in general for an aging society having 63 million homebound and semihomebound older adults who want to participate in societal life can be an opportunity in recent years many communal networks such as the village model and naturally occurring retirement communities have sprung up to meet community needs if homebound and semihomebound adults can more easily leave the house they may be able to contribute to these communities there are also new internetbased options such as skype magic window and virtual senior centers which can remove barriers to participation using electronic connections for those who are semior fully homebound and want to get out into the community their vulnerability makes their safe participation more difficult to facilitate the high risk of falls in the homebound is of particular import as we think societally of how best to facilitate their social and community engagement it will be important to target environmental needs 28 and other services that might facilitate leaving home to participate in community events such as mobility services and other paratransit services

purpose participation in social and community activities that require leaving ones home is important to older adults however many older adults have difficulty or are unable to leave their dwellings and little is known from national samples about issues related to remaining active outside the home or the barriers faced by these older adults design and methods we used the national health and aging trends study a nationally representative study of older adults n 7197 to understand the following 1 the importance that homebound and semihomebound adults place on involvement in social or community activities 2 their current level of involvement and 3 reported barriers to participation results despite the heavy burden of functional limitations depression pain and falls homebound adults reported that activities outside the home were important to them ranging from 252 attend clubs to 700 visit family similarly semihomebound older adults had a strong interest in such participation including visiting friends and family 818 attending religious services 726 and going out for enjoyment 725 many homebound adults reported health 429641 depending on the activity and transportation 122182 as barriers to participation semihomebound adults also identified health 238410 and transportation 65102 as participation barriers implications this information can be useful in designing community programs that will foster meaningful social and community engagement for older adults which may improve their quality of life

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faculty advisor tehia starker glass phd dr tehia starker glass is an associate professor of elementary education and educational psychology in the department of reading and elementary education at the university of north carolina at charlotte her research interests include preparing preservice and inservice teachers culturally responsive teaching selfefficacy examining motivational factors that influence teachers behavior towards culturally diverse students culturally responsive classroom management the impact of teacher education at historically black colleges and universities and instructional design university of north carolina at charlotte undergraduate research journal culturally responsive teaching racerelated teaching practices and multiculturalism the importance for classroom cultural responsiveness is growing as educators develop their understanding of the impact of cultural relevance this shift has spurred new practices and theories surrounding culturally responsive teaching and racerelated teaching practices crt is a conceptual framework that positions the recognition of students cultural backgrounds interests and experiences within the classroom as crucial to students performance crt is teaching that seeks to empower students educationally and to expand their capabilities in other spheres by incorporating their cultures within the classroom crt requires teachers to make a concerted effort to know their students as people it also requires teachers to take the role of facilitator of not keeper of knowledge furthermore fuglei explained the importance of showing students that their culture and traditions matter and teaching them how to exist within a space that requires codeswitching the ability to adapt ones language and behavior to the whitecentered situation crt is supported in educational research literature and connects to rrtp rrtp includes ways teachers should best address race so young children can develop their own positive racial identity build relationships across races and recognize and stand up to racerelated injustices crt can be used to address race and identity effectively in classrooms university of north carolina at charlotte undergraduate research journal race and culture it benefits all students not just students of color because white students grow in their understanding of the historical impact of racialization similarly multiculturalism is grounded in embracing how varying cultures contribute to diversity teachers need indepth knowledge about ethnic cultures and experiences to integrate ethnic content experiences and points of view into the curriculum multiculturalism argues for the recognition of group differences and offers a positive view of cultural maintenance as an ideology multiculturalism is the foundation of crt recognizing cultural differences and viewing them in an affirming light is key to crt the three core tenets of crt are a student learning and achievement b the affirmation of students cultural competence and c the facilitation of a critical consciousness which encourages students understanding of and critiques against major institutions the lag in application one reason for the disconnect between the development of culturally relevant theories and the application of these theories in public school classrooms is the growing cultural divide between teachers and their students while the publicschool body increases in diversity the teaching population has not kept pace in 2015 the national center for education statistics reported that 80 of teachers were white middleclass monolinguistic women thus teachers are finding themselves increasingly underprepared to teach students whose cultural experiences differ vastly from their own many preservice teachers lack cultural awareness and feel unequipped to productively approach issues of race especially with students of color teachers often fail to recognize their biases which influences their views of culturally andor racially diverse students and can result in labeling students as having deficits based off of unidentified university of north carolina at charlotte undergraduate research journal biases as a result both students and teachers suffer a break in relationships creating an unwelcoming environment not conducive to learning preservice teachers selfefficacy due to the factors highlighted above teacher preparation programs must consider intentional methods to improve preservice teachers selfefficacy in crt recommended best practices include providing preservice teachers with multiple opportunities to engage with authentic crt practices teach diverse students during field experiences and observe crt in action additionally researchers have shown that teachers selfperceptions can impact studentteacher relationships according to jong et al teachers with higher selfefficacy offer their students more support and positive reinforcement than teachers with lower selfefficacy therefore research on preservice teachers selfefficacy for implementing crt is worthwhile the role of educator preparation programs educator preparation programs are a main source of new teachers into the profession within epps many of the teacher educators are white middle class and monolinguistic as well thus we cannot be surprised if epps have difficulty preparing teacher candidates to be culturally responsive if they themselves are not and also have not wrestled with race for themselves or practiced how to teach about race in classroom contexts due to numerous institutional state and professional policies the focus becomes compliance versus preparing teachers to be culturally responsive in their classrooms the tension that exists for teacher education to balance mandates and equity has yet to be resolved and unfortunately both teacher candidates and classroom students lose when they are not exploring race and racism within their classrooms limitations of the background literature within the research synthesized a common limitation was the limited scope of the study samples many researchers only examined the gap between white and black students this is not an accurate representation of the larger student population as other students of color are becoming increasingly prevalent for the few studies that addressed multiple groups the demographics were still limited as they focused on one academic group one implication for research would be addressing performance gaps between nonblack students and their white counterparts as well as gaps between different student groups of color another major limitation in the literature was that studies often focused solely on the way white teachers perceived culture and race more research is needed on the way teachers of color perceptions impact how they respond to cultural diversity in classrooms the present study the current study addressed the preparedness of preservice teachers to educate students from cultures different than their own specifically the study focused on the way preservice teachers perceptions of race diversity and culture impacted their views of crt and rrtp in their classroom understanding preservice teachers perceptions is important because how teachers view culture and diversity could have an impact their curricular practices teachers preparedness perceptions and selfbeliefs have direct impact on the learning environment relationships with students and academic achievement of students of color in particular therefore additional research on university of north carolina at charlotte undergraduate research journal preservice teachers selfefficacy is necessary and could lead to important implications for epps and related education policies research questions this study addressed the following research questions how do preservice teachers perceive their selfefficacy in creating and enacting culturally relevant curriculum and a culturally inclusive classroom environment how do preservice teachers perceptions of race and diversity align with their perceptions of selfefficacy to engage culturally relevant teaching practices the authors chose the frameworks of crt rrtps and multiculturalism as these frameworks center on the convergence of race culture and diversity within the classroom and how those concepts impact both students and teachers method two participants were recruited from the graduating class of an epp at an urban university in the southeastern us maria age 22 was a latina female with strong cultural ties to her heritage she framed her familys socioeconomic status as lower middle class she graduated with a teaching degree but is currently employed as a nanny john age 23 a white cisgendered man from a slightly upper middle class socioeconomic status does not indicate any cultural ties to his personal heritage data sources this study used two modified surveys administered through google forms and an inter the demographic information and teacher questionnaire were necessary to compare how preservice teachers demographics and cultural backgrounds aligned with their selfefficacy to teach in diverse classrooms according to the authors of the survey the major threats to the surveys validity were that the research was conducted by university professors within their own courses but they sought to maintain validity by not tying survey results to grades increasing the likelihood students were comfortable expressing their opinions teaching beliefs and mindset survey the crt selfefficacy section of the teaching beliefs and mindset survey assessed preservice teachers selfefficacy in crt the first author adapted siwatus quantitative survey to be a qualitative openended survey though there were 26 questions in total only eight questions those that related to crt were modified to be used in the interviews these questions assessed preservice teachers perception of their ability to teach diverse students and create a culturally responsive classroom reliability for each section of the survey exceeded 90 as estimated by cronbachs alpha siwatu indicated some inflation in reliability because the original instrument had many questions interview both participants completed a 10to 15minute interview during which they were asked modified questions from both surveys interviews were conducted via zoom platform with cameras off to maintain confidentiality research design this qualitative content analysis evaluated data collected from surveys and interviews administered by the first author a qualitative content analysis is appropriate for analyzing this data as it allows a thematic approach to assessing preservice teachers perceptions procedures to complete this study participant consent was obtained via google forms then each participant was given access to the google form surveys survey responses were collected and compiled into an excel sheet the first author read through survey responses and determined areas of further exploration she then chose questions for the interviews after this was completed consent was obtained again for the individual interviews which were conducted via zoom to protect participant privacy only audio was recorded from each interview cameras were kept off the first author transcribed the recordings transcript data were analyzed to determine codes categories and themes data analysis data were analyzed using a qualitative content analysis as such data analysis was done through thematic coding content analysis uses a directed approach involving two parts first the first author developed initial codes based off predetermined theories and guidance from research findings prior to data collection deductive coding these initial codes were importance of diversity and inclusion importance relationship building with students impact of surrounding influences on perceptions and impact of race on bias the first author began analysis by reading through data and analyzing them against the deductive university of north carolina at charlotte undergraduate research journal codes then she assessed the data responses again sorting them into the initial codes and adding more coding as necessary following initial coding data were reread for any outstanding consistent themes and inductive codes were developed data were then sorted to include the inductive codes as well as the deductive codes all coded data as well as themes and categories were then organized into a codebook first data were sorted into codes these codes were chosen by finding the most commonly repeated motifs within the participants words from there codes were sorted into categories based on commonalities amongst codes these categories were rapport diversity and life experiences trustworthinesspositionality trustworthiness was ensured through three main methods researchers position reflexivity and adequate engagement in data collection i am a black woman in my twenties with politically liberal progressive views regarding race and diversity my identity and beliefs impact my understanding of this topic besides identityrelated biases i also had expectations for the kind of data to garner from the study i worked to guard against confirmation bias in two primary ways first i engaged in careful reflection of potential biases to my perception of data by keeping a bias journal throughout the process and by consulting with my advisor second i spent ample time collecting data to ensure a multitude of potential responses finally i had the third author check the codebook coded data categories and themes to ensure findings were credible and reliable results three inductive themes were uncoveredrapport diversity and life experiences these university of north carolina at charlotte undergraduate research journal three themes are broken into additional subheadings for the main categories rapport repeated patterns surrounding the importance of building rapport with students and families emerged rapport in this case can be defined as efforts towards interaction and meaningful communication with students and families each category for this theme is described in turn relationship building as john indicated knowing ones students and spending time with them is the key to success this concept appeared repeatedly in both participants responses they discussed the importance of building a relationship with students to better understand their culture communication when asked to reflect on the way they internalized relationships and experiences both participants indicated that communicating with others was the best approach both also stated that experiences with people of other cultures helped them be more perceptive to race and culture john indicated that talking with others is the best way for him to internalize and better understand where they are coming from this was also true when the participants were asked about their confidence in communicating with parents while only maria indicated confidence in this ability both emphasized the importance of attempting to communicate with parents they collectively cited the ability to use apps translators or other resources to attempt to communicate with parents of differing languages maria as a spanish speaker indicated more confidence in her ability to communicate with parents particularly parents who speak another language diversity repeatedly topics of race culture language gender identity ethnicity and other concepts of identity diversity came up in both written and verbal responses moreover the participants discussed the importance of multiculturalism and globalism identity identity is at the core of any discussion about race culture and diversity this was true when examining the difference in responses of the two participants when asked how confident they were in incorporating their students cultures maria a lower middleclass latina clearly relied heavily on her experiences living in a culture outside of the dominant one maria said i often like to teach in spanish and english i think if anything the only time i ever get pushback is possibly from my students because i have questions like why are you teaching also in spanish you know and i actually kind of like remind them like hey you know we have other students here who speak more than one language in our classroom and at the same time arent we so blessed that we get to learn new languages and in my morning meetings ill have the students say hello in the many different languages they know so students get to share in different languages and i also try to teach lessons that are globally aware like i had also just taught a lesson on south africa on the xhosa people so that was really something that got the kids motivated to learn more about different cultures in contrast john a white upper middleclass male indicated relying on relationship building to incorporate students cultures and experiences john said i do work especially at the beginning of the year i make a lot of effort to make sure i understand who they are and not to treat like culturalculture is not i dont know what the adjective from monolith is pauses its not all one like its multifaceted so i think that just comes with a lot of relationship building and kind of understanding of the subtle differences that each student brings inclusivity inclusivity is a category that came up repeatedly when talking about multiculturalism both participants cited inclusion as central to the definition of multiculturalism maria argued that multiculturalism is not only the tolerance but the inclusion of different ideas morals religions social classes races ethnicities languages and i would even argue abilities and genders addressing bias the final category that came up under the theme of diversity was addressing bias specifically related to assessment both participants discussed the importance of ensuring that tests assess students learning and not their background knowledge maria also talked about the necessity of consistently consider ing bias and schema when interacting with texts john did not address the importance of analyzing texts within his interview life experiences the impact of life experiences on the answers of the participants was clear both credited their global and cultural awareness to key personal experiences that expanded their perspective these experiences can be divided into the category of academic local and global academic both participants stated that their experiences within their universitys college of education greatly influenced their perspective on culture and race and also their selfefficacy or confidence in being a culturally responsive teacher maria stated that studying in our programs you know they tried to talk to you about other cultures john added that the professors that he had that taught about systemic racism and the different approaches that you can take and kind of working on decentering the dominant culture contributed to his preparation in being a culturally responsive teacher local john said that high school was more diverse and he was able to experience far more cultures and people he shared that this contributed to his selfefficacy in being a more culturally responsive teacher maria did not see her local schools as a major influence on her cultural awareness and therefore did not speak to this topic however another influence for both participants was performing clinicals and student teaching in title i schools global one set of codes that arose specifically for maria was the impact of study abroad on her perspective on teaching diverse students she said my study abroad experiences really did open my outlook to other countries and the importance of globalism john did not have these experiences discussion the findings of this study support the literature suggesting that the factors contributing to selfefficacy of teachers in teaching culturally responsive curriculum to diverse groups of students are multifaceted the first research question addressed how preservice teachers perceive their selfefficacy in creating and enacting culturally relevant curriculum and a culturally inclusive classroom environment these participants portrayed high selfefficacy and confidence in teaching culturally responsive curriculum both participants reported high selfefficacy linked to relationship building which data confirm is the easiest part of crt to implement the participants indicated more confidence as teachers of culturally diverse students when they felt they had a relationship with their students this correlation is supported by literature in fact teachers with higher selfefficacy offer more to their students allowing for a better building of relationships building a stronger relationship can allow for a more conducive classroom environment as well we did not uncover an explicit answer to the impact on curriculum though maria did indicate that analyzing curriculum for bias is important the second research question addressed how preservice teachers perceptions of race and diversity align with their perceptions of selfefficacy to engage crt practices we found that engaging with crt is linked to perceptions of race the racial identity of the participants did influence the way they perceived crt john consistently viewed crt as an important way to show windows into other cultures whereas maria viewed it as a way to celebrate cultures within her classroom as john comes from a whitecentered dominant culture his response still indicates an oppressive power and level of cultural voyeurism ladsonbillings work on crt reiterates the importance of not just viewing other cultures but truly celebrating them she cites that culturally relevant pedagogy must provide a way for students to maintain their cultural integrity while succeeding academically both participants cited efforts to approach bias within their classroom furthermore john relied on relationship building to incorporate students cultures and experiences while maria relied on her personal cultural experience to relate to students both participants also spoke about the importance of multiculturalism in the classroom the importance of multiculturalism is supported by other researchers as well for example dedeoglu and lamme said that by educating preservice teachers about multiculturalism teacher education programs prepare them to become advocates for the many culturally diverse students in our schools limitations one limitation to the study was number of participants data collection for this study coincided with a global pandemic and most people had competing priorities the first author made numerous attempts to recruit participants and converted the study design from the initial plan based on low participation both participants also primarily taught in title i schools with high percentages of minoritized students these experiences influenced the biases these participants held results may have been different if their student teaching experiences had occurred in different settings with a percentage of minoritized students reflected in their hometowns or in predominantly white settings to address this future research should include participants from differing backgrounds who complete their student teaching in more varied settings also data were selfreported and personal perceptions and biases may have impacted their answers conclusion this research may inform how teachers are prepared to address diverse students both participants indicated the importance of the teacher education institution in influencing their selfefficacy in teaching culturally responsive curriculum this research addresses a deficit in current literature as it specifically attempts to address the connection between selfefficacy and culturally responsive curriculum appendix a preservice teacher questionnaire 1 describe your background in terms of class socioeconomic status racial identity culture or religion 2 please provide a detailed explanation of how you were raised including the size of your family type of home you lived in and authority figures 3 describe the demographics of your high school and elementary school for example was it culturallysocioeconomically diverse 4 define multiculturalism to the best of your understanding

faith frayman is a senior in the college of education studying special and elementary education she has minors in both childrens literacy and early childhood studies faith is a levine scholar and an honors education candidate after graduating faith will be teaching english as a second language with a corporation called whales english her service passions include working with organizations such as freedom school partners tan kap vini and wine to water

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introduction attentiondeficit hyperactivity disorder and autism are common neurodevelopmental conditions which first manifest in early childhood and often cooccur 1 both adhd and autism are highly heritable with heritability estimates around 70 for adhd 2 and up to 90 for autism 3 up to 70 of autistic individuals are diagnosed with adhd and around 13 of individuals with adhd receive a diagnosis of autism 4 5 6 furthermore there are many previously reported risk factors associated with adhd and autism related to the child themself pregnancy and delivery complications and to parental factors 27 psychosocial adversity reflecting stress that arises due to adverse life events that an individual experiences has also been associated with neurodevelopmental conditions 8 however few studies have investigated the effect of cumulative psychosocial adversity in the family on neurodevelopmental outcomes and the role of unmeasured confounding a scale for psychosocial adversity created by rutter et al consists of several factors severe marital discord low socioeconomic status large family size paternal criminality maternal mental condition and foster care placement 9 based on rutters index biederman et al found that aggregation of those factors increases the risk for adhd 10 similarly several observational studies and a metaanalysis have shown that the risk for adhd increases with the number of psychosocial adversities 1112 in addition a danish populationbased cohort study that assessed the indicators of adversity in the first year of life reported similar results describing a statistically significant doseresponse effect of psychosocial adversity on risk for adhd among male and female individuals 8 exposure to psychosocial adversity in early childhood is also associated with increased risk of autism however studies on cumulative psychosocial adversity are scarce 1314 when attempting to establish causal associations residual confounding through both genetic and environmental factors must be considered one major limitation of previous studies of psychosocial adversity and neurodevelopmental conditions is that most were unable to adjust for unmeasured familial confounding this is critical because psychosocial adversity 15 as well as diagnosis of adhd and autism are influenced by genetic factors therefore unless unmeasured familial confounding is considered there is a remaining possibility for a spurious association caused by unmeasured residual confounding an english and romanian adoptee study reported on outcomes of romanian children born in the 1980s who stayed in an orphanage with poor conditions for 43 months before adoption while partly accounting for unmeasured confounding 16 those who were exposed to the severe adversity in the institution for longer than 6 months were more likely to be diagnosed with both adhd and autism this highlights the effect of extreme forms of psychosocial adversity during early childhood 16 however further research is needed using genetically sensitive study designs to clarify if less severe forms of cumulative psychosocial adversity have similar effects on adhd and autism after accounting for unmeasured confounding familybased designs is another example of a genetically informative design where differentially exposed groups of relatives are compared 18 for example sibling halfsibling and cousin comparisons an increasingly recognized approach to adjust for unmeasured familial confounding 19 could be used by comparing the risk of neurodevelopmental conditions within family members that are differentially exposed to psychosocial adversity by choosing the first year of life as an exposure period we are minimizing the risk of reverse causation families of children with neurodevelopmental conditions experience higher levels of stress and are more likely to experience psychosocial adversity 20 this is a major limitation of the previous research since most studies concentrate on the preschool and school age there is a possibility for remaining reverse causation 21 moreover adhd and autism often cooccur the rate of adhd in individuals with autism varies from 257 to 70 522 and autism diagnosis is prevalent in up to 1366 of people with adhd 523 findings show that this could be due to partly shared etiology of adhd and autism 24 but the extent to which environmental risk factors have specific or general effects on different neurodevelopmental conditions remains largely unknown 25 more specifically it is currently unclear if psychosocial adversity at an early age is more directly associated with adhd or autism the aim of this study was to investigate the association between cumulative psychosocial adversity in the family during the first year of life and neurodevelopmental conditions in offspring using familybased study designs to control for unmeasured confounding and to assess if psychosocial adversity is specifically associated with adhd or autism materials and methods data sources and study population data for this study were obtained by linking different swedish populationbased registers using personal identity numbers 26 the total population register contains information about all individuals living in sweden since 1968 27 the medical birth register includes information on all deliveries in sweden since 1973 27 the swedish national patient register covers more than 99 of somatic and psychiatric inpatient care records since 1987 and outpatient records from specialist health care since 2001 28 the prescribed drug register covers all filled drug prescriptions from 2005 onwards 29 the longitudinal integrated database for health insurance and labor market studies was established in 1990 and contains information on socioeconomic factors such as education income employment and occupation 30 information on convictions comes from the national crime register and the multigeneration register links different generations through the personal identity number 27 using these registers we identified all individuals born in sweden between 1 january 1990 and 31 december 2009 as well as their parents and followed them until 31 december 2013 we excluded individuals who were stillborn or had major congenital malformations twins everyone who died or migrated during the first year of life and individuals with missing information on their own or their parents personal identity number after exclusion the analytical sample consisted of 1877901 individuals among these we identified subgroups of full siblings for the sibling comparison halfsiblings and full cousins measures exposure several studies have used rutter´s index of psychosocial adversity or its adapted version to assess the association with adhd 8 9 10 we used information from seven specific psychosocial adversities to create an index of cumulative psychosocial adversity in the family during the childs first year of life this index uses the available register data to approximate rutter´s index 9 and has been used in previous studies as well we considered the following dichotomous psychosocial adversity factors parental bereavement defined as any loss of firstdegree relatives of the child´s parents during the childs first year of life based on the total population register parental divorce during the childs first year of life defined as yes if the family situation has changed based on information from lisa the same year parental financial problems during the childs first year of life defined as yes if the family had low economic status based on information from lisa the same year low economic standard was defined as a household disposable income of less than 60 of the median income in the whole population in that particular year 31 parental low education during the child´s first year of life defined as yes if at least one parents highest achieved educational level was less than 9 years of education based on information from lisa the same year any parental psychiatric history during childs first year of life based on icd codes of parental neurodevelopmental and psychiatric conditions identified from npr the same year versus none any parental conviction for violent crime during the child´s first year of life versus none data was obtained through the national crime register the same year large family size defined as 4 or more children in the family at the time of birth of the index person based on information from the medical birth and multigeneration registers all above mentioned psychosocial adversity factors were summarized into a cumulative psychosocial adversity index that was used as exposure varying from 0 to 7 in the analysis we treated this index as both a continuous and categorical variable thus both assuming a linear doseresponse pattern and allowing for deviations from linearity since few individuals were exposed to 4 or more factors we merged these categories resulting in index categories of 0 1 2 3 and 4 or more factors for the categorical analysis outcome the outcome variables were defined as diagnosis of adhd or autism after the age of 3 based on icd9 and icd10 in the npr moreover individuals with adhd were also identified through pdr by anatomical therapeutic chemical codes for adhd medication both adhd and autism were analyzed as timetoevent outcomes covariates we included parental age at childs birth childs year of birth and parents country of origin as covariates and adjusted for them in the analyses statistical analysis the associations between cumulative psychosocial adversity and adhd and autism were assessed with hazard ratios and 95 confidence intervals using cox regression the children were followed from age 3 until migration death end of follow up or a diagnosis of adhdautism whichever occurred first separate analyses were conducted for adhd and autism and for psychosocial adversity as continuous and categorical variables we used nelsonaalen curves to visualize the probability of the outcome at a time interval between different levels of the cumulative exposure first the analyses for crude and adjusted models were conducted at a population level cluster robust standard errors were used in these analyses to account for dependence between individuals in the same family in the whole population to adjust for unmeasured familial confounding we repeated the analysis in different groups of relatives full siblings who share 50 of their genes and all of their shared environment halfsiblings with 25 of shared genes and partly environment and full cousins with 125 shared genes and some of their environment 18 in these analyses we used stratified cox regression where each group of relatives was entered as a separate stratum into the model grouped by the family identification code conceptually the stratified cox regression compares the risk of the outcome for individuals with different exposure levels within the same group of relatives by virtue of the stratification of groups of relatives all factors that are constant within these groups are automatically adjusted for in the supplementary material we provide the number of strata for which there is variation in the exposure and at least one child developed the outcome most of the information about withinstratum associations is derived from these strata sensitivity analyses to investigate if the effect of exposure to psychosocial adversity on adhd was modified by autism we fitted a model where adhd was the outcome and autism was treated as a timevarying covariate by including an interaction term between autism and the exposure in the model conversely to investigate if the effect of exposure to psychosocial adversity on autism was modified by adhd we fitted a model where autism was the outcome and adhd was treated as a timevarying covariate and included an interaction term in this model between adhd and the exposure in both these models we only used the continuous measure of psychosocial adversity to account for diagnostic uncertainty we reran the analyses after having redefined the outcome only those individuals diagnosed with adhd or autism at least twice were considered as diagnosed while individuals with one diagnosis were considered as undiagnosed we also performed sexstratified cox regression on the general population to assess differences between boys and girls furthermore in order to repeat the analysis among individuals with complete follow up from 2001 when information from both outpatient and inpatient care was available we restricted the analysis to individuals turning 3 in 2001 or later data management was performed in sas software figs 1 and2 represent nelsonaalen cumulative hazard estimates of adhd and autism diagnoses given different levels of exposure to cumulative psychosocial adversity adhd in the general population the cumulative psychosocial adversity index was associated with adhd in a doseresponse relationship with adjusted hrs for adhd ranging from 155 to 265 when the index was treated as a continuous variable the hrs for adhd increased 41 with each unit increase in the index when the analyses were repeated in different groups of relatives the hrs of adhd attenuated towards the null with increasing levels of familial relationship autism the association between cumulative psychosocial adversity and autism did not follow any doseresponse trend at a general population level adjusted hrs varied between 119 and 137 for exposure levels 13 adjusted hrs for the most exposed group was 104 which should be interpreted with caution due to lack of power among relatives a similar trend as seen in adhd was observed for autism with estimates attenuated towards 1 sensitivity analysis the association between cumulative psychosocial adversity and adhd was modified by autism the interaction analysis showed that cumulative psychosocial adversity increases the risk of adhd regardless of autism however the effect was stronger in individuals with adhd only compared to those with cooccurring adhd and autism the analysis further showed that cumulative psychosocial adversity increased the risk of autism among those without adhd however there was no such association between cumulative psychosocial adversity and autism for those with cooccurring adhd hrs of getting the diagnosis of adhd or autism were similar among those who have received the diagnosis after 2001 compared to those who were followed the whole time period the sensitivity analysis that aimed to account for the diagnostic uncertainty included only those who received at least 2 diagnoses of adhdautism showed no difference for adhd and autism compared to the main analysis separate analysis with stratification by sex showed that boys and girls had similar risks of developing adhd with the dosedependent effect related to experiencing cumulative psychosocial adversity sexstratified analysis for autism showed that girls had a higher risk of being diagnosed compared to boys discussion the main objective of this populationbased study was to identify whether cumulative exposure to psychosocial adversity early in life increases the risk of adhd and autism in children our findings on the general population level are in line with several previous studies showing that exposure to psychosocial adversities and traumatic events elevate the risk of adhd and autism 10133233 we found a dosedependent effect for adhd but not for autism importantly for both outcomes the estimates were attenuated towards the null with increasing level of familial relatedness indicating that the associations were likely influenced by unmeasured familial confounding moreover cumulative exposure to psychosocial adversity increased the risk of adhd regardless of comorbidity with autism but with a stronger effect among those without autism for autism the risk increase was observed only among individuals without adhd in contrast with our findings at the population level the most recent metaanalysis 25 emphasizes that almost no statistically significant results were found for early life exposure to pregnancyfig 1 the cumulative psychosocial adversity index ranges from 0 to 4 or more factors xaxis followup time from the age of 3 until the diagnosis of adhd death migration or 31 december 2009 yaxis cumulative hazard function the total accumulated risk of being diagnosed with adhd over the followup time fig 2 the cumulative psychosocial adversity index ranges from 0 to 4 or more factors xaxis followup time from the age of 3 until the diagnosis of autism death migration or 31 december 2009 yaxis cumulative hazard function the total accumulated risk of being diagnosed with autismover the followup time related factors and parental characteristics and autism while there were associations between low family income or transient income decline and externalizing behaviors and adhd although that study mostly inspected pregnancyrelated factors however none of the previous studies have taken the cooccurrence between these conditions into account and just a few of them were able to account for unmeasured genetic or environmental confounding given the high heritability of both adhd and autism 734 it is important to consider unmeasured confounding previous studies have shown that in particular for individuals with adhd due to their genetic predisposition they tend to experience more adverse life events over the life span 3536 a norwegian study found that individuals with a higher genetic risk for adhd are at increased risk for adverse life events 36 in order to address this possibility we compared different groups of relatives to account for unmeasured confounding shared between family members this design accounts for unmeasured confounding to different degrees eg comparing full siblings accounts for unmeasured confounding to a larger extent than cousins since they have more environmental and genetic factors in common in line with this our findings showed that the associations between cumulative psychosocial adversity and adhd and autism attenuated with increasing level of familial relatedness indicating that the associations at a general population were likely influenced by unmeasured familial confounding future studies should be performed taking familial confounding into consideration this study has several strengths it is populationbased and includes all children born in sweden over a 20year period we used registerbased data of high quality with coverage of 85 100 depending on the register 2728 the outcome information is retrieved from a register that covers almost all inpatient care records since 1987 and outpatient records since 2001 which would account for half of the follow up time 28 this is the largest study on cumulative psychosocial adversity and adhd and autism to date and the identification of relatives of different levels of kinship allowed us to adjust for unmeasured genetic and shared environmental confounding given that our measures of adhd 37 and autism 38 were based on clinical diagnoses from specialist care the reliability of the data is quite high even though not all cases are reported in the register 38 there are also several limitations to consider information on some of the psychosocial adversity factors included in the study such as parental income and education is based on register data that is updated once a year which makes the timing of exposure somewhat imprecise this might have influenced some sibling pairs where children were born close in time resulting in siblings being concordant on exposure and therefore not contributing substantially to the analysis the information about family situation only reflects those who separated after being married we therefore had no information on separation of cohabiting partners which is a common form of relationship in sweden registerbased data does not allow us to distinguish between symptomology and quantitative traits neither does it allow to explore the level of perception of experienced psychosocial adversity therefore we were not able to disentangle whether some factor had more impact and these factors were equally weighted further studies with more detailed information on both exposure and outcome including eg severity of symptoms are clearly needed the analyses on autism were hampered by the low number of children exposed to 4 or more factors who also had autism therefore we interpreted these results with caution and in view of the overall pattern of results information on diagnoses in outpatient care was only available from 2001 and onwards since we only considered diagnoses after age 3 only individuals born 1999 or later have complete coverage in the outpatient register which might lead to a misclassification of the outcome among those who were born before 1999 however when we restricted the analyses to those who were diagnosed after 2001 the results were similar to the main analysis there is also a possibility of carryover effects where a younger sibling might be more likely to get diagnosed earlier if their older sibling has received a diagnosis of adhd or autism 18 however we found commensurate results in cousins where such an effect should not be prominent clinical significance this study may encourage clinicians and especially general practitioners to pay more attention to families that experience psychosocial adversity if the association between psychosocial adversity and neurodevelopmental conditions is explained by familial confounding the focus should be kept on early detection and intervention this information can be used by policymakers and clinicians on vulnerable groups of children in need of more careful pediatric surveillance and screening for adhd and autism early detection enables timely interventions with the aim to prevent more severe psychiatric problems for children with adhd and autism the importance of familial confounding in this study highlights the need of further research into etiology of adhd and autism to differentiate between the types of familial confounding including genetic and shared environment conclusion this is the first populationbased study investigating the association between cumulative psychosocial adversity and both adhd and autism while accounting for unmeasured familial confounding our findings show that being exposed to cumulative psychosocial adversity in the family during the first year of life is associated with a greater risk of developing adhd and autism associations were weaker among related individuals indicating that they were at least partly explained by unmeasured familial confounding the findings highlight the importance of accounting for unmeasured genetic and shared environmental confounding when studying the effect of psychosocial adversity on neurodevelopmental conditions 3940 we advocate for using familybased designs or other genetically informative designs to account for unmeasured familial confounding when conducting studies on the etiology of adhd and autism disorder from shiretakeda pharmaceuticals and evolan pharma ab all outside the submitted work henrik larsson is editorinchief of jcpp advances funding dr rosenqvist is supported by the jeansons foundation dr rosenqvist is also supported by the swedish research council open access funding provided by karolinska institute competing interests henrik larsson reports receiving grants from shire pharmaceuticals personal fees from and serving as a speaker for medice shiretakeda pharmaceuticals and evolan pharma ab and sponsorship for a conference on attentiondeficithyperactivity additional information supplementary information the online version contains supplementary material available at correspondence and requests for materials should be addressed to aleksandra kanina reprints and permission information is available at reprints publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

cumulative exposure to psychosocial adversity at an early age has been shown to be a risk factor for attentiondeficit hyperactivity disorder adhd and autism that often cooccur however it is not clear if this association reflects a causal effect or familial confounding we aimed to assess whether cumulative psychosocial adversity in the family increases the risk for adhd and autism in offspring while accounting for unmeasured familial confounding we used a populationbased cohort of 1877901 individuals born in sweden between 1990 and 2009 participants were followed from the age of 3 until 2013 with a median follow up time of 138 years we created a cumulative index based on 7 psychosocial adversity factors we used cox regression to estimate the hazard ratios hrs relating neurodevelopmental conditions to cumulative psychosocial adversity to address familial confounding the analyses were repeated in groups of relatives of different kinship siblings and halfsiblings and cousins a doseresponse relationship was observed between cumulative exposure to psychosocial adversity and adhd at a general population level covariate adjusted hrs ahrs with 95 confidence intervals ranged from 155 one adversity 153158 to 265 ≥ 4 adversities 198354 no clear doseresponse relation was seen for autism ahrs ranged from 104 59184 to 137 130145 hrs of adhd and autism decreased with increasing level of kinship in the analysis of relatives cumulative exposure to psychosocial adversity was associated with both adhd and autism in the general population these associations were partly explained by unmeasured familial confounding between relatives this highlights the need for using familybased designs in studies of psychosocial adversity and adhd and autism

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introduction belgium is the highest risk setting for breast cancer in europe with over 10000 new diagnoses in 2015 and 2016 corresponding to a world standardised rate of circa 105 per 100000 person years 1 2 3 4 5 as a country with more than 20 of the population of foreign origin 6 belgium constitutes an interesting study setting for migrant differences in breast cancer breast cancer is caused by multiple risk factors 4 7 8 9 it is mostly postmenopausal disease and is usually hormone dependent with increasing risks due to oral contraceptive use nulliparity late age at first childbearing hormonereplacement therapy and obesity inherited risk is however larger for early breast cancer 10 many risk factors for breast cancer are inversely related to an individuals socioeconomic position usually measured by educational level the associations are especially strong for postmenopausal cancer due to the links between delays in reproduction and higher educational levels 11 research finds lower breast cancer incidence among noneuropean migrants compared to hostcountry natives in westeuropean countries 12 13 14 15 16 this is thought to be attributable to protective reproductive behaviours such as lower age at childbirth higher parity levels and more frequent and longer duration of breastfeeding 12141517 other risk factors that may be unevenly distributed are the use of hrt younger age at menarche and older age at menopause 121415 immigrant daughters risk levels are known to lie between those of firstgeneration migrants and hostcountry native levels as a consequence of shifts to lower numbers of children and later ages at childbearing among sg migrants 1418 the chance of surviving breast cancer is generally high when it is detected at an early stage of the disease over 90 of patients are still alive 5 years after diagnosis 7 this has led to the implementation of early detection programmes in many industrialised countries breast cancer survival is also affected by tumour biology the presence of comorbidities and treatment quality 19 and has improved in most european countries since the mid1990s irrespective of screening 420 in contrast to breast cancer risk survival is higher with increasing sep due to the availability of educational economic and social resources that can be deployed to tackle this disease 14 generally ethnic minorities in the united states and new zealand are at a survival disadvantage compared to the nonhispanic white or caucasian majority populations 19 21 22 23 24 25 26 in europe detrimental outcomes have only been identified for black african women in south east england 27 surinamese women in the netherlands 12 and noneuropean origin groups found to be at low risk of breast cancer in sweden 16 authors point to differences in treatment 16 24 25 26 27 and genetic predisposition to more aggressive tumours as likely causes for the survival disadvantage 1423 additionally various scholars find later stages at diagnosis among some of the origin groups with lower breast cancer survival rates and interpret these as a consequence of lower screening attendance due to limited accessibility of mammographic units and cultural differences in health behaviour 1214162527 such detrimental stage distribution is not invariably observed among origin groups with lower survival however 121417 importantly accessing and navigating a foreign healthcare system can improve with longer spans of life spent in the country as suggested by swedish research identifying higher breastcancerspecific survival among migrants with younger age at migration and longer duration of stay 14 although research considering differences between fg and sg migrants is rare it is crucial to identify effects of growing up in the host country as well as genetic and environmental contributions to differences in breast cancer survival by migrant background 28 notably research has established that risk and prognosis for breast cancer strongly differ by age at diagnosis 71029 raising the possibility that earlyand lateage at onset of breast cancer result in different diseases 10 researchers should therefore design breast cancer studies that allow an assessment of agespecific outcomes 30 nevertheless this approach is rare in migrant research on breast cancer and was mainly adopted in the us the resulting evidence demonstrates a blackwhite crossover in breast cancer risk 10 31 32 33 african american women are at a higher risk of earlyonset but lower risk of lateonset breast cancer than nhw women 3435 european studies point to earlier ages at diagnosis for several migrant background groups 3637 with younger population structures among migrant groups 37 or a higher prevalence of premenopausal breast cancer than among native populations as possible explanations 36 a migrantnative crossover in risk by age at onset of breast cancer has however not been observed to date there are also no clear patterns by migrant background in survival outcomes across eu countries examining premenopausal and postmenopausal breast cancer outcomes separately would allow researchers to identify discrepancies and help to find possible sites for intervention although research from belgium has identified a breastcancer mortality advantage among all large migrant background groups with convergence to native rates by generational status up until now it was impossible to examine whether lower risk or better survival for breast cancer underlies those lower mortality levels 3839 a recent linkage of census data with the belgian cancer registry combines population with diagnostic information thus allowing researchers to study incidence and survival simultaneously and providing an opportunity to delve into the mechanisms underlying previously observed mortality differences using these linked data our study aims to fill many gaps in migrant research on breast cancer first by simultaneously studying incidence and survival by migrant background second by taking the association of reproductive factors with incidence and stage at diagnosis with survival into account while controlling for the contributions of sep to these relationships third by studying incidence and survival separately by menopausal status at diagnosis finally by splitting up the analyses by migrant generational status to explore withingroup differences in outcomes between migrants and migrant offspring materials and methods study design and cohort data from the 2001 population census containing socioeconomic and demographic information were individually linked to the crossroads bank for social security and the standard cancer registration database for incidence years 2004 to 2013 from the bcr cbss data pertained to vital status for whats new foreign and native populations differ in terms of breast cancer outcomes however studies rarely distinguish between migrants of the first and second generation which could shed light on the genetic and environmental factors influencing breast cancer this research fills the gap by investigating patterns in breast cancer incidence and survival in different groups by migrant generational and menopausal status breast cancer incidence was lower among noneuropean migrants compared to belgians accounting for socioeconomic position and known risk factors partly reduced the observed discrepancies a risk convergence between secondgeneration migrants and belgians for the development of premenopausal breast cancer was observed van hemelrijck et al cancer patients until july 1 2017 at the latest the bcr has been collecting nationwide data on cancer diagnosis since 2004 relying on information from the oncological care programmes and laboratories for pathological anatomy 40 all breast cancer diagnoses international classification of diseases 10 code c50 were considered for the incidence analyses and a womans first diagnosis for invasive breast cancer for the survival analyses we selected women from the three largest eu and noneu migrant groups in belgium french italian dutch moroccan turkish and subsaharan african women the country of origin was identified using four variables from the census in the following order nationality at birth of the father nationality at birth of the mother nationality at birth of the woman under study or the current nationality of the woman under investigation 41 the first variable with a value other than belgian yielded the womans origin country the country of birth of women with foreign origin denoted generational status with those belgianborn or moving to belgium before the age of one defined as sg migrants and those born outside of belgium or migrating from the age of one onwards considered to be fg migrants information on the birth country could not be used to determine the country of origin for a large part of the sg migrants because the parents birth country was only known for those still living in the parental household at the time of the census we therefore used a combination of the available nationality variables and birth country to maximise the available information in defining the country origin and generational status we considered women that were 30 or older at the start of the observation period until they reached the age of 70 during followup to be at risk for breast cancer and breast cancer diagnoses in this age range between 2004 and 2013 were examined in survival analyses premenopausal and postmenopausal cancer were studied separately we chose the 50 years cutoff based on the eligibility for the organised breast cancerscreening program in belgium which invites women as of the age of 50 and until the age of 70 to get a screening mammography for early detection of postmenopausal breast cancer analyses for premenopausal breast cancer were repeated with the migrant background split up by migrant generational status we do not report results for postmenopausal breast cancer and the ssa premenopausal group by generation due to small cell counts the age distributions of migrant groups in particular from outside the eu are younger than the belgian decreasing the number of older sg migrants at risk for or diagnosed with postmenopausal breast cancer and limiting opportunities for robust analyses all statistical analyses were generated using sas 94 incidence truncated agestandardised incidence rates and 95 confidence intervals were calculated for belgians and each migrant background group the asrs were computed as the sum of weighted agespecific crude incidence rates per 5year age group the crude rates are the number of new breast tumours diagnosed between 2004 and 2013 in a group divided by the persontime at risk for that group the persontime was calculated as the time spent in followup between the age of 30 and 50 for premenopausal 50 and 70 for postmenopausal breast cancer followup for an individual stopped at the following events occurred breast cancer diagnosis emigration death reaching the age of 50 or 70 or december 31 2013 the complete population in belgium at the start of observation was used as the reference population for the age standardisation the weights in the premenopausal age range equal the agespecific reference population numbers divided by the total reference population between the ages of 30 and 49 for the postmenopausal age group the same method was applied for the reference population between 50 and 69 years old we used poisson regression models with the log of the persontime as the offset variable to compare incidence rates by estimating incidence rate ratios and adjusting them for known breast cancer risk factors such as sep and reproductive behaviour extracted from the census to measure sep we used the highest educational level obtained and home ownership education was divided in primary or less lower secondary upper secondary and tertiary education home ownership was categorised into tenants and owners and is used as a proxy for accumulated wealth 42 reproductive behaviour was operationalised using the number of children born alive and age at first childbirth parity is made up of women with no children one child two children three children four children or five or more children age at first childbirth contains women without children and those aged 1325 2530 3035 3540 and 40 and over for each variable a category for missing information was retained we examined a series of models testing the contribution of educational level home ownership parity and age at first childbirth to irrs adjusted for age at the start of observation we first ran models adding education and home ownership separately and combined to adjust for sep we consequently added parity and age of first childbirth to each of those models home ownership was a borderline significant variable in models that also included educational level and was thus not presented in the incidence results for this paper the models shown are hence adjusted for age at baseline age at baseline with adjustment for educational level and age at baseline educational level parity and age at first childbirth survival survival analyses were performed for patients diagnosed between 2004 and 2013 with vital status provided by the cbss until july 1 2017 we computed 5year relative survival as a proxy for breast cancer net survival eliminating the influence of a different mortality background between population subgroups calculated as the ratio of the observed survival in a patient group and the expected survival in a comparable group from the general population 43 the expected survival was estimated from region sex ageand calendaryearspecific national life tables from statistics belgium 44 using the ederer ii method 45 to compare rs between belgian breast cancer patients and those with a migrant background we modelled the relative excess risk of dying up to 5 years after diagnosis through regression models with a poisson error structure 46 the rer represents the ratio of the excess hazard due to breast cancer vs the belgian population 1246 an rer above one indicates a higher excess risk of dying due to breast cancer of a particular migrant background group as compared to the belgian reference group during the first 5 years after diagnosis information on the disease stage at diagnosis was used to adjust the survival models information on clinical and pathological stage at diagnosis is provided to the bcr and merged into a combined tnm stage the pathological stage prevails over the clinical except for cases diagnosed with clinical stage iv 43 the stage at diagnosis has been used as a marker of timely access to care in research 26 and will be used as such in this paper as well patients diagnosed at stage i or ii and those with stage iii or iv were grouped patients with a missing stage at diagnosis were excluded from the survival analysis the sep variables used for the incidence analyses were added but recategorized into larger groups to avoid small strata primary lower secondary higher secondarytertiary home ownership in missingtenant and owner at the modelling stage we first adjusted the rer for age at diagnosis added stage at diagnosis and subsequently sep we evaluated goodnessoffit by testing the ratio of the model deviance and degrees of freedom with a chisquare significance test as a result we chose to present the following models adjustment for age at diagnosis age and stage at diagnosis and the age and the stage association corrected for educational level and home ownership separately for both incidence and survival we verified the poisson structure models for possible overdispersion by using the method of lindsey 47 and detected no issues ethics authorisation for linkage between the census and belgian cancer registry was granted by the belgian informatieveiligheidscomité previously called privacy commission ethical approval for our data availability the data that support the findings of our study are available in a secured workspace at the belgian cancer registry after permission for use has been obtained from the informatieveiligheidscomité results tables 1 and2 summarise the main characteristics of the population at risk and breast cancer patients tables 345list breast cancer risk and rs by migrant background and menopausal status premenopausal breast cancer outcomes by migrant generational status are given in tables 6 and7 the descriptive table for the population at risk shows young ages at first childbearing for moroccan and turkish women as opposed to most other groups those at risk of premenopausal breast cancer have higher educational levels older ages at first childbearing and higher percentages of nulliparous women compared to the group at risk of postmenopausal breast cancer among patients the mean age at diagnosis was lower for noneuropean than other women supporting information table s1 provides descriptive information for the population at risk or diagnosed with premenopausal breast cancer by generational status incidence table 3 demonstrates lower premenopausal than postmenopausal breast cancer incidence rates for each group noneuropean women were at lower risk than european women for both age groups the relative differences in crude incidence risk obtained through poisson regression are presented in table 4 in general migrant background groups were at lower risk of being diagnosed with invasive breast cancer compared to belgian women with substantial differences between turkish and ssa women compared to belgian ones for premenopausal and all noneuropean groups for postmenopausal breast cancer incidence among turkish women was 43 lower for premenopausal and 57 lower for postmenopausal breast cancer than among belgians adjustment for educational level and reproductive variables attenuated large parts of the risk advantages for turkish and moroccan women and even diminished the slightly lower risk of premenopausal breast cancer for moroccan compared to belgian women upon keeping educational levels constant the italian irr increased to a significantly higher premenopausal breast cancer risk and diminished the risk advantage for postmenopausal breast cancer compared to belgian women parity generally played a more prominent protective role against breast cancer for both age groups than the age at first childbearing examining premenopausal breast cancer by generational status revealed withingroup differences with a significantly lower risk compared to belgians among fg migrants only survival relative survival 5 years after diagnosis was generally high for both age groups at breast cancer diagnosis and in each origin group rer of dying among those diagnosed as represented by rer in table 5 followed a less distinct pattern by migrant background than the irrs for incidence only the premenopausal moroccan group had a survival disadvantage excess risk of dying was 57 higher vs belgian premenopausal breast cancer patients adjusting for the stage at diagnosis reduces this disadvantage further adjustment for education or home ownership further narrows the discrepancy italian premenopausal and postmenopausal patients are characterised by higher chances of surviving their diagnosis with rers of 050 and 048 respectively this advantage hardly changed upon adjusting for the stage at diagnosis or sep and even increased for postmenopausal patients upon adding sep the higher excess risk of dying among premenopausal moroccan breast cancer patients is only observable for the fg again diminishing upon adjusting for the stage at diagnosis the italian survival advantage was identified for the fg after adjustment for the stage at diagnosis but rer for the fg had a wide ci the survival models that take into account educational level or home ownership were presented for larger groupings of european and noneuropean women as model fit by separate origin countries could not be guaranteed discussion in our study we examined breast cancer incidence and survival by the migrant background in belgium simultaneously we aimed to fill essential gaps in migrant research on breast cancer by considering incidence and survival for premenopausal and postmenopausal breast cancer separately and analysing these outcomes for fg and sg migrants our study results attribute the lower breast cancer mortality level in most migrant background groups in belgium 3839 to a lower underlying risk of premenopausal and postmenopausal breast cancer which was particularly pronounced for noneuropean origin groups this lower breast cancer risk was in turn associated with lower educational levels and differences in the reproductive behaviour of groups of noneuropean origin compared to the european origin groups under study for women with noneu backgrounds percentages of nulliparous women are lower and the number of children born per woman is generally higher the observed breast cancer risk pattern corresponds to results for migrant groups in the netherlands england and sweden 12 13 14 15 16 17 36 the remaining breast cancer risk advantage we observed while keeping sep and reproductive behaviour constant is likely to result from risk factors that are unaccounted for in our incidence analyses such as differing breastfeeding customs age at menarche screening attendance physical activity tobacco use obesity hormonereplacement therapy hormonal contraceptive use and genetic exposures 836 the survival analyses revealed an important disadvantage among premenopausal moroccan breast cancer patients that appeared attributable to later stages at diagnosis compared to the native population this finding is in line with prior studies conducted in new zealand 24 25 26 differential tumour biology may underlie later stages at diagnosis and lower survival among premenopausal moroccan women patients of arab descent in belgium have been shown to present with earlier ages at diagnosis and more luminal b breast cancer subtypes than european women 48 the protective role of reproductive behaviour is thought to be smaller for this luminal b subtype and its tumours grow slightly faster and have worse prognoses 49 information about histopathological and molecular subtypes is not part of standardised cancer registration in belgium and could thus not be taken into account in our study but could provide a valuable addition to further research looking to uncover the survival disadvantage among premenopausal moroccan breast cancer patients in contrast to the premenopausal moroccan group both premenopausal and postmenopausal italian patients have a lower excess risk of mortality vs belgian patients considering stage at diagnosis and sep did not explain this italian advantage other valuable resources for those diagnosed with breast cancer such as healthcare navigation skills and strong support from the social network may play a role studies delving into this high survival might consider italian breast cancer patients social contexts and health behaviour our study was one of the first to examine premenopausal and postmenopausal breast cancer by migrant background separately this being crucial since aetiology and prognosis are known to differ between the two our findings demonstrate that migrant patterning in breast cancer outcomes is different according to menopausal status at diagnosis first we observed larger disparities in postmenopausal than premenopausal breast cancer incidence in line with observations in south east england 27 no incidence crossover pattern such as that identified in usbased research 3134 was found for any migrant background group in belgium second survival analyses by menopausal status pointed to premenopausal moroccan patients as vulnerable due to later stage distributions than belgians whereas postmenopausal moroccan patients survival did not significantly differ from that of their belgian counterparts analysing all breast cancer diagnosis combined would not have allowed us to identify this group as being at a particular disadvantage by further examining premenopausal breast cancer by generational status two observations stand out firstly risk advantages were only visible for premenopausal fg migrants second the premenopausal moroccan survival disadvantage did not persist into the sg the incidence finding highlights an early breast cancer risk convergence of sg migrant to belgian levels in line with results from swedish research 14 although the number of patients among sg moroccan women is rather low the premenopausal survival analysis by generational status offers several new insights into the moroccan patients excess risk of mortality it indicates that this groups survival disadvantage is unlikely to be caused by genetic susceptibility to more aggressive breast cancer subtypes among moroccan women an often hypothesised explanation for survival disadvantages among groups of foreign origin in international research 1423 alternatively the lack of a disadvantage among sg moroccan patients may be linked to the differences in reproductive behaviour between the fg and sg namely increasing percentages of nulliparous women and decreasing number of children among sg moroccan women reducing the likelihood of being diagnosed with the more aggressive luminal b breast cancer subtype for the sg 48 another possibility is an improvement in knowledge and navigation of the belgian health system among migrants offspring putting them at an advantage compared to those migrating themselves 50 to the best of our knowledge this is the first article to demonstrate inequalities in breast cancer outcomes by menopausal as well as generational status the convergence in premenopausal breast cancer risk between sg migrants and belgians emphasises the importance of risk awareness and prevention among natives and sg migrants alike worse survival among premenopausal moroccan patients furthermore implies that appropriate risk awareness in women risk assessment in primary care and the provision of timely and highquality care are crucial 2451 despite its contributions our study was subject to some limitations first we used 50 years of age as a surrogate marker for menopausal status information on actual menopausal status could yield more precise patterns additionally research shows that a younger age within the premenopausal group still acts as an adverse prognostic factor 29 which we accounted for by adjusting our rers for age at diagnosis second the bcr has a high coverage rate of belgian breast cancer diagnoses 52 but does not have information on the completeness of cancer registration by migrant background importantly cancer outcome estimates were not thought to be substantially affected by such a phenomenon in other research 36 nor do we think it impacted ours third the crosssectional character of the census limited the information on reproductive behaviour and sep to oneshot measurements even though parity and home ownership were subject to change during followup particularly among premenopausal women a multidisciplinary research agenda that considers clinical social and biological factors and interactions with the environment will allow a better understanding of how differences in breast cancer outcomes arise and how they can be alleviated 53 especially the observed premenopausal survival disadvantage among fg moroccan women represents an interesting subject for further inquiry for example by assessing the underlying differences in tumour biology and by exploring how these women move from helpseeking toward diagnosis and treatment in belgium

foreign and native populations differ in terms of breast cancer outcomes studies rarely distinguish between premenopausal and postmenopausal breast cancer although the risk profile is different nor between migrants of the first and second generation fg and sg which is crucial to examine genetic and environmental influences on breast cancer this research fills these gaps by investigating patterns in breast cancer incidence and survival in different migrant groups by menopausal and migrant generational status taking various risk factors into account to this end individually linked data from the 2001 census the belgian cancer registry and the crossroads bank for social security are used agestandardised incidence rates and incidence rate ratios are calculated by migrant background group stratified according to ages 3050 premenopausal and 5070 postmenopausal incidence rate ratios are examined with and without taking reproductive factors and socioeconomic position sep into account relative survival percentages and relative excess risks of dying among premenopausal and postmenopausal patients are computed with and without controlling for the stage at diagnosis and sep premenopausal breast cancer is further examined by migrant generational status breast cancer incidence is lower among noneuropean migrants compared to belgians keeping sep and known risk factors constant reduces much but not all of the observed discrepancies a risk convergence between sg migrants and belgians for the development of premenopausal breast cancer is observed premenopausal breast cancer survival is worse among moroccan patients due to a higher stage at diagnosis this disadvantage is concentrated in the fg

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introduction citizen science and crowdsourcing projects focus on using the capabilities of paid or unpaid volunteers for data collection and annotation 37994 the internet provides the opportunity to collect or annotate data on a large scale by soliciting volunteers online however this raises concerns regarding data quality 444754 to provide safeguards on data annotations sourced online typically multiple annotations are requested and a minimum level of consensus is expected for an annotation to be accepted ie data is validated by other volunteers 79 a common crowdsourcing task is the classification of data captured through images 39 using project resources such as identification guides and keys 7783 annotations are either accepted independently where users submit their classifications without any collaboration or through a collaborative interface furthermore most of these platforms provide their users a means to share their knowledge and expertise either openly on the classification task or through open discussion forums to support community building and peer learning 43 however there is a lack of understanding on how collaborative design techniques affect users online behaviour and whether these techniques can be effectively utilised to improve data quality as well as engagement and learning around the task this study explores the design of interfaces that allow volunteers to collaborate on classification tasks with their peers specifically we consider differences in the types of feedback and learning processes generated and how these can impact on the formation of more stable citizen science communities we focus on asynchronous collaboration where there is no expectation that online volunteers will all be available at the same time background the usefulness of citizen science for research has been widely highlighted 194871 and citizen science practice has benefitted from advances in digital technologies such as internet and mobile communication 4544 its growing contribution to research is visible in diverse ways from monitoring the environment and biodiversity to promoting questiondriven research and statistical innovations in the handling of variable data sets 11253842 web based citizen science projects have successfully employed volunteer capabilities to accomplish a wide variety of tasks such as digitising biological records 28 predicting protein structures 23 and classifying shapes of galaxies 8 the success of these and numerous other crowdsourcing projects highlights the important roles that volunteers can play in scientific research as well as for the common good 4884 data quality is a common concern for these projects and most include safeguarding mechanisms for data validation 44 for example comprehensive training of volunteers providing guides protocols and tools to support data collection validating collected data samples by experts and building statistical consensus models for classification or object identification tasks 81415778287 human collaboration has been a topic of interest across many disciplines such as psychology social sciences organisational behaviour education and more recently humancomputer interaction 3935555863668197 with the growth of the internet and subsequent rise of online communities such as wikis social media websites citizen science and crowdsourcing platforms online collaboration is utilised for a variety of purposes such as problem solving user learning and engagement consensus building and decisionmaking performance of a group is in general qualitatively and quantitatively superior to the average individual 3555 but typically lower than the best member 45 identifying the best member or utilising the capabilities of high performing individuals can help increase the group performance as they can guide a group of inexperienced members towards better decisionmaking 26 it has also been reported that groups can achieve better performance than even the best individuals for several problemsolving tasks 51 research has also highlighted benefits of collaboration in terms of learning motivation and engagement which in turn can lead to sustained focus and deeper learning 958 collaboration and teamwork have been a regular practice in the scientific domain and scientific discoveries have often been made through collaboration 65 in this article we focus on collaboration amongst nonexpert users for consensus building on a classification task and how digital interfaces can be designed to support this a variety of feedback techniques have been explored for online collaboration to support problem solving decision making and learning in this article we study some of the main techniques and affordances derived from the literature and from citizen science practice with a particular focus on improving learning and data quality 12 feedback processes at the core of collaborative learning dialogism a framework for research into computersupported collaboration 86 provides an effective method for studying interaction and communication between participants mediated by computers especially for tasks which require debate negotiation and coordination among a group 686 supporting collaboration for citizen science activities that require learning new skills and knowledge creation can also be examined using the dialogical framework to understand in the first instance how digital platforms can mediate learning through providing feedback for helping to construct meaning or make sense of a new concept 81 more widely its use can make visible how feedback supporting collaboration in citizen science activities fosters social learning and civic participation enabling a wider range of contexts and experiences to contribute to shaping research agendas 103167 we utilise the concept of feedback 87 in the context of a consensus building task which may progress through divergence and convergence of multiple viewpoints or voices through debate between the participants for problem solving and reaching consensus for successful dialogue to happen it is important to design a dialogic space for presenting multiple viewpoints in the contexts of the collaboration to design and understand such an interactional space we utilise multiple design strategies by drawing on literature on collaboration and feedback in social sciences and education and their applications across citizen science practice 121 social persuasion within an interactive space goal setting has been shown to be a particularly effective strategy for increasing contributions and motivation 9 setting individual and group goals can have a positive effect on group performance by motivating volunteers in accomplishing tasks important to the success of the group 94099 however monitoring own and peer activities via feedback is core to supporting collaborative learning environments for example prompts and visualisations are often used in online communities for problemsolving learning and collective decisionmaking for monitoring progress and activities 40 to build consensus in a group highlighting the level of agreement within the members of the group may act as a persuasive method towards taking a particular course of action as individuals use that information to narrow down on a set of options this feedback is used with success in the commercial sector to influence consumer choices and literature suggests that revealing majority votes 63 and levels of consensus 60 can influence other group members in problemsolving contexts for instance project discovery utilizes this method providing community consensus as a feedback for classification tasks without an expert annotation 53 however it may be limiting to equate consensus simply with agreement uniformity or homogeneity 74 consensusbuilding that relies heavily on individuals dispositions and drivers towards social conformity reinforces habits and behaviours whereby the learning goal is determined a priori it limits the function of collaboration to the transmission and confirmation of existing ideas while discounting evidence that may not fit with the expectations of the individual or the group 98 122 expertisedriven consensus expertise plays an important role for collaboration as members of the group may possess different skills have variable levels of knowledge and experience and show different interests highlighting individual uniqueness and difference can increase contributions from people collaborating online while identifying the expertise of the individuals in the group can be an effective strategy to persuade other members in decisionmaking tasks 94688 user expertise ratings a common method for highlighting individual expertise are ubiquitous in online communities whether it is for ecommerce tourism expert reviews social media or even citizen science 49 more specifically citizen science projects such as ispot 2 and inaturalist 1 make use of user expertise through the use of reputation scores and leaderboards to highlight best performing members of the community both social persuasion and expertiseled consensus are widely utilized in online communities for building consensus however both these methods may generate a conformity effect whereby members of the group may agree with a majority position that may sometimes be incorrect 6193 due to the power of influence exerted by the group or by one of its members 61 online communities also have means to enable anonymous collaboration and this technique is commonly utilised by many users for example in social networking websites to maintain privacy when collaborating on sensitive issues anonymity has shown to be effective for increasing contributions but may also have negative effects such as sharing incorrect information uncivil behaviour or loss of reputation for contributing users 173075 social learning in problemsolving contexts such as citizen science and scientific research it is not only the performance on a problemsolving task that may be affected by the level of expertise of an individual 50 but also how problems may be approached 1876 in such contexts a first level of social learning may occur through modelling followed by reproduction and apprenticeship of a particular way to frame a problem or execute a task for example as novices gain expertise over time or through training they tend to approach the problem more like experts 2076 but a second level of social learning may also entail increased levels of selfregulation and selfefficacy in learners 100 for example any form of collaboration which enables communication and sharing of resources among members of a group can positively affect attention and engagement expanding the number of possible feedbacks on a task increases the possibility for individuals to observe the effects on a product or a course of action thus improving the quality of the work 4096 for instance a form of sequential task editing which enables dialogic interaction where subsequent users edit the input of previous users has been shown to be effective over creative tasks 397 due to the nature of online communication which is largely asynchronous and sequential this technique can be effective for supporting collaboration as each member of a group can utilise the shared inputs of the previous users while providing their contributions following rose et al 1995 we can distinguish between the level of generalised consensus in a scientific community which makes understanding possible and the level of immediate social interaction which draws upon difference of opinions and relies on evidence and argumentation while it is accepted that these two levels are integral to one another both in social and in scientific practice this distinction between levels is particularly useful to citizen science practices as it points to the possibility to overcome the idea of scientific information as a series of mental representations that can be processed and replicated in the heads of individuals such an approach would in factlimit the scope of the citizen science inquiry to wellknown species instead the ability to identify unknown or difficult species may be a quality and feature of a diverse community which incorporates local peoples experiences and could include machines as part of a third level of social learning processes such as those occurring in extended communities of sociomaterial practice 4173 this understanding of social learning is most closely related to the ideas of situated learning 5291 distributed cognition 6970 and activity theory 29 lave and wenger specifically called out the problematic assumption that treats technology as a given instead of focusing on its interrelations with other aspects of a community of practice 52 124 citizen science practice citizen science projects such as inaturalist 64 and ispot 80 rely on creating communities of nature enthusiasts uploading photographs of plant and animal species as well as identifying specimens on photos shared by other members of the community more specifically they i require multiple annotations for producing reliable data ii highlight expertise of the members using user ratings and iii use free text commenting to capture opinions as well as scientific information annotations are usually provided by members of the community using their expertise while additional members can agree or even improve the existing level of annotations 80 however the feedback effect of these techniques on data quality engagement and citizen science learning is largely unknown other citizen science platforms such as zooniverse eyewire project discovery and beewatch recruit volunteers for online tasks that primarily concern processing of data 53598587 with independent classifications being solicited they utilise the principles of goal setting providing shared learning resources such as tools and visualisations and level of agreement to enable collaboration among community members for consensus building zooniverse and eyewire also provide forums for discussion and dialogue which in case of eyewire is in realtime for community building and peer learning 59 zooniverse users utilize a social interface where members of the community can discuss classifications tasks enabling them to learn to identify through practice proxy a peripheral participation strategy that provides feedback to newcomers within a community of practice 5262 however these forums are not directly linked to the classification task and thus might limit opportunities for social agency 41 through collaboration and peerlearning the latter being documented as an important dimension for tasks such as learning to identify species as part of a community of practice 27 additionally opportunities for collaboration among members may also help improve scientific data quality userlearning and engagement dimensions important for citizen science practice 133792 hence the objective here is to look more closely at how identification tasks derive their meaning as social practices for the people involved by taking into account their dependence on the affordances and design of the interfaces for their meaningmaking contributions the overall research aim of this article is to understand the role of feedback strategies for collaboration to support user learning and performance on an online consensus building task we developed online collaboration interfaces operationalising four feedback techniques which were then used by the participants to perform species identification tasks in a citizen science context three of these techniques ie highlighting level of agreement displaying user expertise and providing means of communication through text such as chat boxes or commenting are ubiquitous with respect to the gathering of user data and in supporting online communities dealing with usergenerated content the fourth a natural language generation system is novel and deploys an ai to mediate the task in addition to the feedback techniques we also identified three different situations where there was a lack of consensus on the task thus necessitating intervention through the collaboration interface the citizen science and crowdsourcing literatures have not previously explored the effects of feedback techniques on data quality and citizen science learning in collaborative settings we are also unaware of any studies that have investigated the different types of disagreements identified and studied in this article which are a significant dimension when seeking to widen the reach and potential of citizen science to involve citizens in important issues related to science and society 31 this article adds to the literature by addressing these significant gaps materials and methods we investigated the role of different asynchronous online collaboration techniques in impacting performance learning and engagement within online citizen science communities dataset we used data from the citizen science platform beewatch which provided participants with the option to submit images of bumblebees online as well as to independently identify images submitted by fellow beewatch participants through crowdsourcing 87 the ukbased platform is designed to help users identify photographed specimens to species level as one of 22 possible bumblebee species in general the species can be differentiated on the basis of colour pattern and morphological features there are considerable differences in identification difficulty between species 79 with some being readily identified even by novices and others requiring considerable expertise additionally features may not be visible or harder to detect in photographs adding to the difficulty of accurate species identification specifically we used photos submitted to beewatch for which multiple independent species identifications have previously been obtained from participants but without those leading to agreement the crowdsourcing component of beewatch has received more than 25000 individual identifications for 6500 images submitted the independent species identifications submitted by beewatch participants were used to calculate the level of consensus for each image and when a consensus threshold was reached 79 the species identification was accepted and the original submitter was sent feedback on the species identification each image could accept a maximum of 10 independent identifications from the crowd if there was still a lack of consensus the image needed to be sent to a bumblebee expert for identification a time and effort intensive step that would be useful to minimise such images for which there was lack of consensus within the crowd provided us with a dataset for studying the effects of collaboration for consensus building types of consensus encountered from this dataset three different situations were identified where crowdsourcing did not provide an identification that met the consensus threshold for acceptance all of these situations led to an expert identifier being solicited for authoritative identification of the species we label these situations as three different consensus types • consensus correct if there is an existing majority tending towards the correct identification but not reaching the required threshold for acceptance we label these images as consensus correct images • consensus not correct if there is an existing majority tending towards an incorrect identification but not reaching the required threshold for acceptance we label these images as consensus not correct images • no consensus if there does not exist a majority of at least 5 out of 10 for any single species we label these images as no consensus images we introduced a collaboration step in such situations whereby the participants could review their identifications in the light of new information generated from independent peer annotations we focused on four different types of online collaboration interfaces described below drawn from both literature and practice as summarised in section 12 collaboration interfaces we designed four different collaboration interfaces to investigate their effects on consensus building the interfaces were codesigned with regular inputs from two bumblebee experts who tested them iteratively to improve the design and workflow of the interfaces to be used in our experiment each interface implements one of four types of feedback which impacts the process of collaboration distribution interface to determine whether information on the existing consensus distribution would influence participants into reviewing their identifications possibly towards the majority opinion distribution was used as one of the techniques for persuasion 536063 the first design intervention uses pie chart visualisations of the distribution over species identifications to understand its effect during a consensus building task in computermediated taskbased scenarios due to the nature of communication the social pressures which are reported in facetoface communication may be less influential 95 yet the level of agreement on a task is often utilised in online communities for problem solving and decisionmaking we are interested in whether online participants are persuaded to modify or change their opinion solely based on what other anonymous participants say in this instance feedback will not include the possibility to incorporate specific guidance from others to reduce the number of options and increase selfefficacy as per the second level of social learning that we identified in the literature but will be largely reinforcing existing knowledge and beliefs 98 user ratings interface the second interface was developed to assess the effect of expertise of other participants all 10 species identifications were shown as a list with ratings for the participants that provided them participants own ratings were not displayed in order to prevent comparison of their own expertise with others the identities of participants were anonymized and two user ratings were shown as icons one to represent experience specifically the number of previous identifications by that participant on beewatch and another to represent skill level constructed on the basis of a users historical identification accuracy their identification total number of previous beewatch identifications and accuracy on the previous identifications each row represents a single user with their existing identification number of previous identifications that the user submitted and the existing accuracy of the user on previous identifications accuracy 55 the list was ordered in decreasing order of experience icons rather than real numbers of submissions or percentage accuracy were used to enhance communication values using icons commonly used on digital interfaces representing information ratings of user expertise are widely utilised in both online and citizen science communities and the literature has suggested they are effective for engagement and for improving the performance of a group 946498088 we use user ratings as the second design intervention whereby we highlight the expertise and experience of individual members of the group and study its effect for building consensus in a group for this interface participants own selfreflection is supported by feedback pointing to specific areas of expertise which would to some extent support apprenticeship as per the first level of social learning 2076 social interface sharing of resources and knowledge through communication is important for building communities of practice providing a forum for members of a group to communicate may thus influence task accuracy and consensus 3409697 additionally a knowledge sharing forum may support peer learning an important outcome of citizen science social communitiesbased projects use this method to capture expertise and to provide opportunities for high expertise individuals to guide others 6480 we designed a third social interface whereby members of the group could effectively communicate their knowledge and expertise using anonymous goaldirected comments in the third interface the user was provided with the option to share views motivations underpinning an identification and further relevant experience or contextual information related to an image with others through free text comments in this interface the user was first given textual information highlighting their identification and the alternative identifications provided by their peers the user was then encouraged to leave comments specifically focusing on the features that may help their peers with the identification it was also mentioned that they could read comments left by their peers to see if they might have identified the species incorrectly all comments from users were anonymised for the platform to enable greater scope for dialogic feedback by incorporating the detail of the specific fig 3 social interface with chat boxes this interface firstly highlights the users own submission and provides the alternate submissions by the other users then the interface encourages the user to leave comments that may help other users the interface also encourages the user to read any existing comments which might help in building consensus features that participants considered significant for identification as well as their justifications for the identification made in line with second and third level of social learning 3141100 natural language generation interface artificial intelligence and machine learning algorithms are increasingly being researched and utilised in ecological and citizen science projects 56578790 as more and more projects utilise these technologies humanai interaction in citizen science becomes an important domain of research and practice 16 to add to this relatively new area of research we utilise a natural language generation system to study the role of ai for supporting online collaboration more specifically we use a system which provides machine generated texts highlighting any differences in visual features between the different species independently identified by participants this machinegenerated text concerning comparison was adapted from an existing implementation used to provide feedback to citizens on their submissions on the beewatch platform by explaining what features to focus on 1287 in short when a participants identification is found to be incorrect by an expert the nlg system uses the identification key to identify the visual features that differ between the species selected by the participant and expert and organises these differences into a formative feedback message that explains why the identification is incorrect and what features to focus on to make the correct identification in this work we automatically generated nlg text comparing the participants identification to the existing consensus identification as feedback for reappraising their original identification this enables participants to consider alternatives and support consensusbuilding the use of machinegenerated texts for consensus building may be a suitable method for creating sustainable online citizen science communities where expert knowledge can be presented in a userfriendly manner to promote collaborative learning between community members this interface was designed to determine whether the formulated differences in visual features between bumblebee species which are machinegenerated and presented in the form of natural language texts would be useful to build consensus this interface used automatically generated texts to identify the features that distinguish the users identification from those of other users we first automatically generated text that highlighted the features of a users existing identification fig 4 natural language generation interface showing machine generated texts this interface firstly highlights the users own identification together with nlg text which highlights specific features of that species then the interface displays comparison nlg texts for all other species submitted by other users so that these could be compared against the submitted image next we automatically generated text that reported the differences between the users identification and each of the conflicting identifications notably with reference to our theoretical framework focused on feedback in social learning this fourth interface focused more on the affordances of the machine rather than the strength of the social environment that was generated thus further decoupling the social from the material in the identification task as we will discuss in the data analysis that follows this aspect was important in order to probe our understanding of the effect of feedback on learning in sociomaterial interactions 41 procedure based on previous experience with employing beewatch data for user performance studies we sought at least 50 participants for the study and 15 images for each of the four interfaces we eventually decided upon working with 72 photographs from beewatch which were randomly selected from a total of 497 images that had not reached the required threshold for acceptance of the 72 images 36 had consensus of at least 510 identifications for the correct species 16 had consensus of at least 510 identifications but for a species that was not correct and 20 had no consensus of at least 510 identifications for any species all 72 images had an expert identification which was used for evaluating accuracy of participants identifications before and after the collaboration step participants who had provided an identification for any of the selected photographs were contacted via email and invited to participate in a study to review their previously submitted identifications each participant viewed different numbers as well as types of interfaces depending upon the number of images in this studys sample which they had previously identified hence some of the participants saw all interfaces while others saw only one two or three the email contained the information about the study as well as the link to a webpage after clicking on the link provided participants were shown the consent form for participation and upon agreeing to participate they were shown a list of images allocated to them for review when selecting an image the user was directed to the collaboration interface associated with that image together with review and do not review buttons at the bottom of the page in addition to comparing accuracy before and after collaboration information regarding the reasons why the participants clicked on review or do not review during the process was also collected participants were not obliged to respond in the not reviewing popup window a radio button was provided saying my existing identification is correct as well as a free text option when clicking on review users were directed to a page where they were shown the image and collaboration interface together with the guide used previously to derive at the identification on this page they could submit their new identification which could be the same as the original one or a different identification after submitting the new identification participants could also provide their reasoning for reviewing their identification fig 5 popups for collecting reasoning information when a user clicked review or do not review the top popup box provides a text box for the user to provide specific information on why they reviewed their existing identification if the user selected the same species after reviewing the popup displayed a note to the user as shown in the figure the bottom popup was shown if the user did not review their identification after seeing one of the collaboration interface this popup provides two options one where the user can indicate that their existing identification was correct and another to make clear any other reason why they did not review their identification through the above processes of reviewing and reasoning participants were engaged in dialogic interactions with information provided from other participants interaction with the interfaces and process of reviewing these interactions may have supported divergence and convergence of participants opinions and the reasoning information from these interactions were hence utilised to assess how participants may have engaged with the collaborative interfaces for consensus building the qualitative results thus provide a summary of engagement across each interface assessed from the reasoning provided by the participants participants and responses a total of 61 out of 114 invited beewatch users participated in the study and completed a total of 373 out of 720 possible identifications of the total of 72 images the mean number of responses for each image was 58 with a minimum of 2 and a maximum of 9 responses per image the interfaces received a similar number of responses and the interaction of interface type and consensus type and the anova function from the car package was then used to test for significance to test interface effect by consensus type hypothesis testing of count data was done using the fischer test due to the presence of cells with low counts results we focused on how participants responded to different forms of online collaboration techniques which were designed to support peerlearning and improve user performance during species identification tasks we compared the four different collaboration interfaces in terms of their effectiveness for consensus building on the task of species identification and their potential to introduce or reinforce bias for the latter we considered whether there was already a level of consensus for any species and if so whether it was already for the correct species our expectations were that user accuracy would improve through reviewing their classification with any interface where there was an existing consensus the distribution and user rating interfaces would persuade participants to revise their identification to that consensus whether or not it was correct the social and nlg interfaces by focusing on the identification skills rather than the peer responses would outperform the two majoritarian interfaces for images where there was no existing consensus and also where the existing consensus was for an incorrect identification change in consensus the majority of images 96 out of 117 reviewed for which participants clicked review were initially incorrectly identified by that participant and the majority of images 151 out of 256 not reviewed for which participants clicked not review were initially correctly identified by the participant this indicated that incorrect identifications were more likely to be reviewed during collaboration however for the incorrect images which were not reviewed participants mostly selected my identification is correct as the reasoning this suggested that the information provided through the interfaces may have been either lacking or not persuasive enough to review the original identifications figure 6 shows the percentage of identifications changed and reviewed across interfaces highlighting that user ratings interface may have been the most persuasive followed by social and nlg using the distribution interface resulted into lowest percentage of identifications reviewed and changed the results in fig 7 show that the level of consensus changed from before to after collaboration for many of the 72 images worked with consensus was defined as proportion of the group that selected the mostselected species and was different from accuracy where each individual identification was evaluated as correct or wrong by comparing to a gold standard expert identification and then averaged the results illustrate that there was an increase in consensus after reviewing as the average consensus increased from 582 to 676 overall according to consensus type when the original consensus was correct the increase was from 634 to 759 for incorrect consensus images it increased from 629 to 639 and for no consensus images from 451 to 556 moreover the greatest gains were when consensus was initially relatively low and where consensus was already high reviewing frequently reduced the level of consensus effect of interface and consensus type significant variation in new accuracy was explained by the effects of old accuracy interface type and consensus type while the number of interfaces used by each participant and the interaction of interface type and consensus type did not significantly affect new accuracy average increase in accuracy after reviewing was 42 for the distribution interface 125 for the user ratings interface 186 for the social interface and 119 for the nlg interface indicating that the social interface design led to the largest average increase in accuracy when taking consensus type into consideration we found that when the initial consensus was towards the correct species the increase in accuracy differed significantly by interface suggesting the usefulness of the user ratings interface for this category of images to enable participants to review their identifications where consensus was towards the incorrect species however no significant difference of interface type was found finally for images where there was no consensus towards a particular species differences across interface type were again significant of all interfaces user ratings were most sensitive to consensus type improving accuracy markedly for the consensus correct images but leading to no improvements in accuracy for other image types highlighting the potential negative effect it may have in such cases across all consensus types the social type achieved greatest accuracy followed by the nlg interface both contrasting sharply with the low level effect of the distribution interface qualitative results on engagement 331 distribution for the distribution interface participants who did not review their identifications mostly selected the my identification is correct option as previously highlighted although they might have been unsure if indeed their identification was correct due to the limited information provided by the interface comments showing the reasoning from some of the participants highlighted that the distribution information may have been insufficient for them to either change their existing identification for example because they were not given any new information about how to identify tricky photographs this was evident also for consensus not correct and no consensus images participants who did review their identifications did not mention influence of the interface information explicitly and confidence in their new identifications appeared often rather limited the distribution interface was least effective in making participants review their incorrect identifications across all consensus types while this interface gives information about the existing disagreement within a group it offers limited opportunities to engage in a dialogic interaction with the groupinterface 686 in line with the theorisation of feedback via persuasion 6193 the interface relies on the participants selfmotivation and own prior knowledge to carefully review their existing identification though some of the participants were motivated to review this was a small number compared to other interfaces in line with it offering limited impetus to participants to review their identification for those who did modify their identification their comments highlighted the limited use of the interface in helping them revisit their species identification thus preventing selfregulation and selfefficacy user ratings for the user ratings interface some of the participants who reviewed their identifications explicitly mentioned that they were persuaded by other users analysing the reviewed identifications we found that more experienced users were indeed usually correct more importantly the reasons for reviewing indicated that some participants were not just mimicking or agreeing with the top user but also validated the features which they might have missed previously these observations highlight that firstly the user ratings were persuasive for participants which led them to review their identifications using the identification tool as the participants were not aware of their own ratings the interface emphasises how the perception of expertise can be used to improve engagement although featurebased information was not provided on this interface participants tried to pay attention to features different from those considered for their original identification however this may be argued to be only true if the existing consensus was correct as the interface may lead to negative performance when the consensus is incorrect or in the cases where there is no consensus social the social interface led to a consistent increase in accuracy across each consensus type and overall outperformed the others in this interface the types of comments left mainly concerned reasons behind participants changing their identification in total there were 28 comments left for the 18 social images and only 2 out of them did not have any comment however the new information was only available after someone had commented on this interface the types of comments centered around two themes a key features this theme included comments mainly highlighting features that could help other participants with identifying the specimen some participants also commented on the reasons why their identification may be correct compared to other options the highlighting of features as well as comparison with other species was persuasive for other users for reviewing the identifications as was evident from the reasoning provided after using the social interface through reasoning popups b contextual information this theme included comments related to the contextual information which might affect the identification such as image quality visibility of features and angle in some cases others seem to agree with the reasoning information that was present in the social interface this is not a bumblebee a discoloured red mason bee is correct 6269 while in other cases participants did not agree with the reasoning information hence using the social interface participants could provide reasoning behind their identifications as well as learn from others including if they had overlooked certain features that might have led to different identifications the comments left also suggested higher engagement with the overall process of identification using this interface participants were willing to comment on the contextual information such as image quality or angle of the bumblebee that would be difficult to capture using other interfaces and may be relevant for identification the interface promotes dialogic interactions between the participants by adding information andor possibilities to view the same object from different angles the information provided during these interactions enabled convergence of thinking thus leading to improvements in accuracy and consensus building however lack of comments for some images as well information only available after someone left a comment may have limited the collaboration and interactions between participants nevertheless the interface consistently enhanced engagement on the task as compared to other interfaces with participants willing to revisit their existing identifications and utilising the new information to improve accuracy natural language generation the nlg interface improved consensus across all image types the comments from participants also indicated how they may have used the information provided by the interface the comments often focused on the features that were clearly visible in the image and may have directed attention of other participants towards those features contributing to increase in accuracy for example participant 5347 while identifying a consensus correct image commented hairy ab and that probably is pollen baskets and not just long hairs cannot tell if wings are clear or dark which highlights information from the nlg texts to focus on the relevant feature to change the identification similarly for consensus not correct image participant 6269 commented either garden or heath but in one picture it looks like the face is not that long so heath again describing the feature information that was used to change the identification the nlg texts were designed to provide a comparison of identification features of species and the texts may arguably simulate a dialogic interaction that assisted participants to derive at better species identifications discussion we investigated how participants involved in a citizen science project concerning online species identification responded to different forms of feedback in order to better understand online collaboration and inform the design of toots that support peerlearning and improve task performance to address this we designed four collaboration interfaces implementing different feedback mechanisms within asynchronous collaborative online interactions to support consensusbuilding the interfaces underpinned by collaboration literature and citizen science practice allowed for studying the role of majority vote user expertise communication and sharing of resources through social interactions and automatically generated texts representing expert knowledge highlighting level of agreement in the form of visualisations is a widely utilised technique in online communities and is suggested as a persuasive method in literature 60 for supporting collaboration however we found it to have little effect on user accuracy and engagement in our study although the visualisation to communicate level of agreement may have helped users in monitoring and progressing on the identification task 40 it generally lacked persuasiveness due to the absence of any species identification knowledge or connection therewith thus preventing to reconsider the initial species identification made validating prior literature 9464988 user expertise influenced participants to carefully reconsider their choices making it a persuasive method to support collaboration even though this interface also lacked communication of species identification knowledge the conformity effect 93 discussed in section 12 may have been elicited by this interface leading to increased accuracy when the consensus was correct but no enhanced accuracy due to participants being driven towards the incorrect answer 61 the fact that there was no decrease in accuracy when the majority vote was incorrect or when there was no consensus indicates that the conformity effect of the interface was not fully blinding participants were more likely to conform with outcomes that seemed right than with those that seemed wrong or ambiguous thus as participants utilised the identification key while reviewing their identifications they also looked at reasoning behind reviewing their identifications which limited social conforming effects and bias this may not be the case in online communities where such keys or learning resources are not provided or readily accessible hence usage of expert ratings to support collaboration should be approached with caution the social interface which promotes knowledge sharing and communication between members of the group was most effective in improving user performance the results provided evidence of participants being persuaded to review their observations in light of the comments posted by others facilitating peerlearning 24 comments posted were anonymised to prevent any effects associated with the users personal profile 17 the interface with the goal setting instructions may have acted as a rules for interaction for the group members 4099 leading to comments with detailed reasoning and preventing general commenting behaviour as is the case with many online communities as this method of online collaboration is widely used in citizen science be it in various ways the results of this study may further inform the design of social collaboration for citizen science 598085 results from the analysis of the social interface also indicated that this kind of taskfocused annotation appeared the most effective in motivating participants to review their initial submissions deliberately compare features across species and types of images and thus simulate the experiential feedback loops underpinning learning in the field and as part of a community of practice 2753 the effect of ai in mediating the collaboration task using the nlg interface revealed that it was on average as effective as the user ratings interface in improving user performance more importantly however the effect was consistent across all consensus types showing that this technology can be a useful intervention for supporting social collaboration in citizen science this is an important finding as this technology provides the same amount of information for every image and is not dependent on the participating user the social and nlg interfaces were found to also help with creating consensus in situations where there is no consensus which make them suitable methods for building consensus in webbased citizen science the distinct capabilities of the interfaces also highlight their potential for use in combination with supporting online collaboration some of these are already utilised across online communities such as reddit and stack overflow where some of the comments and posts are uploaded by members of the community 24 additionally citizen science platforms such as ispot show the level of agreement on a species the user ratings and allow for comments around the identifications thus using a combination of social user ratings and distribution interfaces 80 we havent explored these dimensions within our study but our results highlight the potential for utilizing machinegenerated content to support and promote contributions from community members for example the nlg texts can be used to support and strengthen discussions initiated by citizens on a social platform all four feedback techniques provided insights into how collaboration can assist consensus building online while supporting peerlearning for citizen science strengthening some of the findings from the collaboration literature 926405155 the study also provides some novel insights such as the limited effects of the distribution interface context specific effect of the user ratings interface and value of machinegenerated texts for consensus building projects on citizen science platforms rely on independent validation of datasets from multiple users which is an important criterion for scientific analysis and removing biases an arguably yet more important finding given how central data quality learning and engagement are to online citizen science 43444754 is what online collaboration can bring more generally strong and persistent concerns about data quality have driven many citizen science projects to seek independent validation routes 53598387 whilst sensible and required for scientific data analysis this may lead to missed opportunities for collaboration and peerlearning the results from our study show that careful collaboration design such as the social interface which provides a platform for knowledge sharing and communication may help to improve scientific data quality as well as foster userlearning and engagement 59 this is an important finding that can support greater integration of citizen science in formal and informal science education contexts and can enable members of the public not only to contribute but also to potentially influence scientific research agendas with novel targets and questions that will emerge from shared experiences in their local contexts this is a notable contribution particularly for citizen science and policymaking practice in contexts which demand greater sensitivity to historical linguistic and contextual dimensions of specific environmental or developmental problems 34 machine learning and ai algorithms are being explored increasingly for automated species identification and for some species groups the algorithms are very efficient 2257 nevertheless for noisy data and difficult species such as bumblebees ai performance is still inadequate therefore requiring human expertise for data validation and emphasizing the need for training of volunteers through learning resources such as the collaborative technologies explored in our study 3336 more importantly developing identification technologies may help in engaging the wider public around environmental issues such as climate change and biodiversity loss through positive citizen action 78 finally our research has wider implications in multiple disciplines including taxonomic research into developing novel species identification technologies vital for ecological and conservation activities 89 and the domains of hci and humanai interaction for the development of aimediated collaborative learning environments future research can investigate how annotations from automated image identification can be incorporated into such online environments to support collaborative learning this study shows that collaborative interfaces can be used to help novices perform complex species identification tasks therefore citizen science projects that provide such interfaces can facilitate novices in contributing valuable scientific information as well as acquiring scientific skills 77 importantly our study corroborates the value of the sociomaterial frame to make sense of learning through feedback 768 within a system or assemblage which may include humans and nonhuman expertise this is an important finding which suggests that the value of digital interfaces lies beyond their use as a novelty or repository of factual information indeed by shifting emphasis from the passive acquisition of expert knowledge to generating interest and motivation amongst participants significantly a kind of hot function that is related to socialaffective engagement appears to be present due to the newly established social interactions and collaboration on a cognitively demanding task which the participants were intrinsically motivated to perform leading to a common goal 32 this emotional social and cognitive engagement emerges as intrinsic to the process of learning enabling participants to achieve the more immediate and practical goal of reaching the correct identification in addition our findings also showed that for successful outcomes computational devices supported together two aspects of the identification process representational practices and relational practices representational practices included writing verbal descriptions including contextual information and estimating shapes and sizes converting one form of information into another which were made available to other users as textual sketches relational practices were visible as interactional exchanges mediated by simple language the way in which team members communicated with one another often reelaborating complex information into accessible descriptions influenced the level of engagement and collaboration this finding opens up exciting new avenues in citizen science research looking at the integration of technology in the development of hybrid communities of practice which can help bring together the visual precision of the expert with more varied forms of encounter with nature 27 including contextual aesthetic affective and embodied features underpinning environmental consciousness 21 further research could focus on the design of social learning interfaces supporting more extended fieldbased investigations with the potential to widen participation and inclusion in citizen science initiatives in different cultural and geographical contexts and by a variety of different groups conclusions the primary aim of the study reported in this article was to explore the use of different types of feedback within collaborative interfaces for building consensus on species identification tasks collaborative interfaces such as the ones studied here are ubiquitous in online communities we report that interfaces which support logical reasoning for problem solving such as the developed social and nlg interfaces are more effective than the ones which only display consensus and user expertise and that the latter is context specific we found the social interface to be most effective however the usercomments may need to be goaldirected to foster meaningful outcomes additionally we also found machinemediated consensus building using nlg to bring value across different consensus types highlighting the potential of this technology for consensus building a2 user workflow for the review process consensus building in online citizen science 43425 a appendices a1 email text for participation dear beewatch user we would like to invite you to participate in an online study on the beewatch website which is part of ongoing research which focuses on collaboratively building consensus of species identifications participation to this study is voluntary and you can withdraw any time all the data you provide will be anonymised and your identities wont be disclosed to anyone outside the research team we have selected a few images for which there is lack of agreement among beewatch users and our records indicate that one or more of these images were identified by you we are investigating ways to improve consensus among users in order to get a reliable identification for the difficult photos when you click on the link below you will be redirected to an experiment webpage which shows a list of the image that you had already identified and where a consensus has not been reached when you click on the individual images on the experiment webpage you will be presented with a different interface which provides information about how other beewatch users identified the image as well as options to review your identification if

a number of initiatives invite members of the public to perform online classification tasks such as identifying objects in images these tasks are crucial to numerous largescale citizen science projects in different disciplines with volunteers using their knowledge and online support tools to for example identify species of wildlife or classify galaxies by their shapes however for complex classification tasks such as this case study on identifying species of bumblebee reaching an agreement between volunteers or even between expertsmay require consensusbuilding processes collaboration and teamwork approaches to problem solving and decisionmaking have been widely documented to improve both task performance and user learning in the real world most of these processes and projects are mediated online through feedback delivered in an asynchronous manner and this article thus addresses a central research question how do participants involved in species identification tasks respond to different forms of feedback provided in online collaboration designed to support peerlearning and improve task performance we tested four different approaches to feedback within a collaboration task where participants reviewed their previously annotated data based on information curated from their peers on a long running online citizen science initiative the selected interfaces have a strong foundation in social science and psychology literature and can be applied to citizen science practices as well as other online communities results showed that while all four approaches increased accuracy there were differences based on the types of consensus that existed before collaboration such differences highlight the usefulness of different forms of feedback during collaboration for increasing data accuracy of identification and furthering users expertise on identification tasks we found that anonymised and goaldirected free text comments posted on social learning interfaces were most effective in improving data accuracy as well as creating opportunities for peerlearning particularly where the species identification task was more difficult this study has significant implications for extending the practice of citizen science across formal and informal learning environments and reaching out to a variety of users ccs concepts • humancentered computing → computer supported cooperative work empirical studies in collaborative and social computing

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introduction although some researchers have resisted using film because of its roots in popular culture others have valued its potential to trouble the contours of the familiar deeming it to be as conventional and artful as any written text where film and video have been used in classroom ethnography in the uk this has generally been from within a realist perspective video recording is predominantly deployed as merely one more device for capturing classroom realities by developing deconstructive film video and textual strategies within this paper i hope to disturb habitualised ways we spectate 1 children and by doing so interrupt something of the metastories surrounding childhood that service uk government crusades media editorialising and prevailing educational visions of the child …the enemy is a mode of seeing which thinks it knows in advance what is worth looking at and what is not against that the image presents the constant surprise of things seen for the first time… as an untrustworthy antagonist my intention is to reflect upon ways ethnographers wle comfortably with what is worth looking at when studying children by edging into entangled cinemaethnographic 2 gazes i want to untidy what is thought to be known in advance by undertaking spectator work around childhood posing the question how can a consideration of the interstices between filmand classroomspectatorship usefully contribute to an ethnography of representation the process of wling comfortably with what is worth looking at is intended to agitate ways that 1 the term spectate is used here to denote the spectator and actor roles that are entangled within the participatory process of watching and the spectacle of looking 2 the neologism cinemaethnographic refers to an entangled process that brings cinematographic and ethnographic processes in relationship with one another of how we observe children i will discuss how the experience of reading a film might trouble habitual acts of observation and in doing so reimage ways to consider what is worth looking at and experience what is worth looking at in different ways the aim of this paper is to reflect on a performance of film spectatorship to consider the potential of becoming continually embroiled in but simultaneously violated by already inscribed discursive readings of our own possessions interruptive orientation to the performance of identity documentary ethnographic surrealist and documentary ethnography films according to ellis and mclane documentary film is one of three basic creative modes in film the other two being narrative fiction and experimental avantgarde the term has its roots in the word document or the latin docere rotha suggests this narrows the scope of documentary films into fields that engage with being naturalist newsreel propagandist and continental realist the naturalist tradition includes the films of flaherty for example nanook of the north which is generally cited as the first featurelength documentary despite flahertys commitment to knowing something more of inuit culture he has been heavily criticised for distorting and tampering with the events he filmed flaherty himself suggests sometimes you have to lie one often has to distort a thing to catch its true spirit the emergence of ethnographic films saw what might now be considered a culture of voyeurism or imperialism played out in the johnsons very foreign peoples and flahertys nanook of the north debates about voyeurism distortion imperialism and the subordination sentimentalising exoticising of marginalised cultures have often shaped critical and public reception of ethnographic film loizos suggestion that ethnographic films are a subset of documentary films… inspires a brief with ryan near a canal that runs through town james accidentally knocks ryan into deeper water and he drowns james is too scared to tell anyone but the incident weighs heavily on him adding further tension to an already strained relationship with his alcoholic father overview of the developments in these entangled filmic styles according to ellis and mclane the 1920s saw a number of what were variously described as documentary and ethnographic films being produced these included vertovs kino pravda a series of news reportage films that foreshadows both later newsreels and later documentary styles including cinéma vérité propogandist films largely grew out of the revolutionary theory developed by marx and became a primary concern of lenin however according to ruby there is little interest in the impact of social and political films and the degree to which a film can produce desired political action is debatable as lenin suggests film may not be a costeffective tool for social a political change rotha suggests that the continental realist documentary films emerged as part of the avantgarde of the 1920s various european and american experimental filmmakers began to work in styles that incorporated avantgarde cinematic filming and editing techniques and abstract narratives to create impressionistic highly poetic and quasidocumentary works these experimental works that explore the transactional juxtapositioning of viewer and film include various city films such as ruttmanns berlin a symphony of a great city and cavalcantis rien que les heures surrealism and ethnography share a partially overlapping history clifford traces their interconnections in 1930s france when surrealists and ethnographers shared an interest in the realities that were repressed by the taxonomic orders of western rationality and looked to primitive cultures and to the unconscious as sources of disruptive energy ethnographic surrealism as defined by clifford values fragments curious collections and unexpected juxtapositions putting these to work to provoke manifestations of extraordinary realities drawn from the domain of the erotic the exotic and the unconscious surrealist films with a specifically ethnographic aspect include kildea andleachs trobriand cricket andjennings spare time according to dallasta surrealist cinemaethnographic spectatorship 7 cinema sought to conjure a kind of parallel universe that lay sunk in the folds of the real world breaking with the conventions of linear narrative in favour of fragmentary assemblages of dissonant images in the attempt to represent the workings of the subconscious filmakers such as dalí and buñuel used techniques of cutting superimposing blending manipulating images and irrational plot sequences to create jarring juxtapositions according to chanan ethnographic filmmaking changed radically at the start of the 1960s perhaps with the technical breakthrough of the 16mm portable cameras able to be synchronised with portable tape recorders the term observation was used to denote a particular sort of ethnographic filmmaking that first appeared in an article by sandall for the british journal sight and sound sandall noted interesting attempts made by some observational filmmakers to record moments of cultural life that tried to represent the complex dynamics and intricacies of relationships despite the inclination to fragment their films worked to resist what sandall refers to as interpretation engaging with the debate around fact and fiction as portrayed in the ethnographic and observational film genres young contested that observational filmmaking involved an invisible camera the ideal was never to pretend that the camera was not there the ideal was to try to photograph and record normal behaviour ruby suggests that filmmaking emerging within the realist documentary ethnography tradition required a cooperative collaborative and subjectgenerated focus where the social political and epistemological implications of filmmaking share or relinquish their power moments when filmmakers and ethnographers work together such as in the meo the collaboration tries to convey subjects and ideas that have outreach and staying power the dramatic narrative logic of realist documentary ethnographies might reach different audiences and bring additional information into films that otherwise might absent the ethnographic gaze for example the process of ethnographically building long relationships with individuals and communities can help disrupt cinemaethnographic spectatorship 8 more traditional documentary filmmaking practices in order to move the film subjects filmmakers and spectators into fluid spaces of participation and collaboration offering different ideas to work on the visual narrative according to chanan morin and berman rosenheimer and aviad other later documentary ethnography filmmakers such as dick and kofman began more deliberately to exploit moments of psychoanalytic ideas within film such as scopophilia and voyeurism while on the side of the subject there is narcissism and sometimes exhibitionism this could be understood as the documentary ethnography working to represent subjects for example in derrida the subject of the film himself discusses with the camera what is happening in the process of the documentary filmmaking according to chanan this is not to say that the result is fiction as both the subject and the filmmaker tend to become invested in their relationship with each other nevertheless the increasing complexity and fluidity the playing with representation and the visibility of the camera have all contributed to a critique that is energised by questioning and provocation mass observation art house film and contemporary artist moving imagery the 1930s saw another encounter between surrealism and social science with the inauguration of mass observation in the uk created by a group of leftwing intellectuals mass observation aimed to document the everyday life of the people of england in their own words the political aim was to forge a polity more expressive of the collective wish than the socialist imaginaries of the time for humphrey jennings and david gascoyne the two surrealists among the founders the aim was to free the energies of the collective unconscious by tapping into the fears and fascinations aroused by public events buildings customs and objects jennings film spare time assembled clips strange rituals to document the leisure pursuits of working class communities the democratising and defamiliarising aims of the early mass observation filmmakers photographers and writers foregrounded their commitment to representing multiplicities of voices against a historical background that plays with cinemaethnographic spectatorship 9 distortion fragmentation juxtapositioning and contested notions of truths the 20 th and early 21 st centuries have witnessed a proliferation of filmic works that play with distinctions of fact and fiction truth and fakery art and social science education and entertainment the emergence of independent or art house films as well as contemporary artist films also mark out significant moves to disrupt the classical cinematic narrative the roots of independent film can be traced back to filmmakers in the 1900s who resisted the control of a trust called the motion picture patents company or edison trust these typically lowbudget films could afford to take risks and explore new artistic territory influenced by foreign art house directors exploitation shockers and those who walked the line between a number of young film makers began to experiment with transgression not as a boxoffice draw but as an artistic act directors such as waters and lynch would make a name for themselves by the early 70s for the bizarre and often disturbing imagery which characterised their films curtis notes the preeminence of film and video work on the contemporary british art scene for instance deller gordon mcqueen and wearing vitali suggests that the status of truth reality and identity has become even more contested for film and documentary makers working within postmodern conditions of fluidity multiplicity and fragmentation the cinematic gaze the place of lack displacement and desire debates that connect film and cinematic genres with the process of spectatorship often engage with the cinematic gaze aaron suggests that the spectator is the target of the films address but at the same time althussers imagined relations render the narrative and cinematic mechanisms as working to conceal this by allowing the subject an illusionary sense of himherself as the producer of meaning this allperceiving spectator who is absent from the screen yet always present ties into lacanian readings of the screen as the spectators mirror becoming a complex site of recognition fuelled by the racial and masculine gaze as analysed in the work of hall russell zavarzadeh cinemaethnographic spectatorship 10 mulvey and later williams cook and johnston and rich russells conceptualisation of the dominant gaze attempts to bring together the complexity of mulveys masculine with halls critical racial gaze in order to reiterate the pleasure or desire of the one who is looking and the one who is looked at as split between activemalewhite and passivefemalenonwhite she suggests that the dominant gaze subtly entangles the spectator in identification and objectification processes within its visual representations as natural universal and beyond challenge it works to fortify its own legitimacy in defining narratives and images zavarzadeh argues that the distortive messages conveyed in films and documentaries have a hegemonic effect on popular culture precisely because they create the space in which the daily is negotiated the racial masculine gaze consumes lacans insatiable notions of desire displacement and lack the gaze is therefore the object that is eluded by all forms of representation and vision it is the lack that is inscribed into the phenomenology of consciousness… according to aaron spectatorship represents a desirefuelled but anxietyridden relation to the screen but the lack that is being worked out or played out by cinema is the lack of the nondominant gaze and the fretful reality that it represents to the intricate workings of the dominant gaze within the context of more recent feminist and postcolonial work perhaps we need to consider halls negotiated gaze which seems to entangle cook and johnstons reading against the grain in order to resist succumbing to colonial and patriarchal prescriptions perhaps here multiple complex and much more fluid notions of identification might become provocative within cinematic structures of looking critical and performance ethnography art and anthropology anthropology has itself undergone processes of diversification fragmentation textual experimentation and critical reexamination in the wake of postcolonial critiques of cultural and linguistic imperialism and doubts about the relation between world and text inaugurated by the crisis of representation torship 11 1997 atkinson coffey 1995 pignatelli proposes that a critical ethnography should aim to move people to see themselves and their relation to a set of circumstances differently and recommends cliffords ethnographic surrealism as a set of defamiliarising practices capable of placing the possibility of comparison …in unmediated tension with sheer incongruity and leaving visible the cuts and sutures of the research process denzin locates performance ethnography as a genre within critical postmodern ethnography formulations of performance ethnography that seek to disrupt notions of the real continue to interrogate the boundaries of self and other autobiography and culture in the search for a reflexive ethnography conquergood invokes a pedagogical borderland in the spaces where rhetoric politics parody pastiche performance ethnography and critical cultural studies come together discussions around the edgy relationship between art ethnography and anthropology have been circulating for some years from benedict who presented whole cultures as collective artists or read them as aesthetic patterns of symbolic practices and benjamins call for artists to side with the proletariat to criticisms of clifford who was thought to have artistenvy to more recently an emerging ethnographerenvy where the prestige of anthropology rages in contemporary art according to foster these practices of envy seem to conflate in particular configurations of the landscapes that both fields seem to share for example according to foster both fields grapple with alterity they take culture as their object they are considered contextual and arbitrate the interdisciplinary and they invite reflexivity vying for authority across the fields of art and anthropology seems to have preoccupied many yet the potential in resisting any sense of authority within either field seems to open up opportunities for interesting bordercrossings anzaldúas la coatlicue existing in a hybrid or inbetween state fluidly shifting…always a path to something else with such historical and more contemporary moves to interrupt realist filmic narrative playing along the edges of fiction nonfiction real and fantasy film genres and qualitative research methodologies continue cinemaethnographic spectatorship 12 to diversify and offer opportunities to challenge and question received and homogenised cinematic narratives here i want to introduce a different aspect to interruptive techniques that might also contribute to antirealist practices of representation by turning to film spectatorship as an ethnographic collage by pulling through and playing with ideas that inspire ethnographic and surrealist films art house cinema and performance ethnography the second part of this paper will reflect upon ways researchers spectated the film ratcatcher in order to disrupt their habitual practices of looking frames of familiarity ryan and kenny live on a poor workingclass estate in glasgow uk jamies story lies in a leafy suburb in manchester uk6 discursive framings could be understood as mechanisms that hold still these two disparate stories for example i would suggest that terms associated with children such as working class and classroom evoke familiar and particular sets of discursive framings in the uk new labours political rhetoric seems to frame aspects of working class as particular types of families and specific kinds of insufficient or incomplete children … children and families constructed as being in deficit andor expressing aspects of otherness inscribed in the dialogue and visual language deployed in the opening encounter between ryan and his mother in ratcatcher i find metonymic signifiers of traditional working class caricatures that discursively frame and designate as particular placeholders through which the individual can be revealed in language… opening depictions of ryans broken family the harsh slap to the head that ryans receives the use of colloquialisms the highrise innercity council flats situated amongst a grey concrete landscape together with the unfolding struggles between a mother and her son all seem to be visual triggers that lean on stereotypes of working class cultures ratcatcher estate glasgow copyright © pathé pictures and bbc films 1999 ratcatcher for gods sake look at the state of my curtain it is interesting to consider how characterisations in ratcatcher and in classroom observations rely on tropes associated with familiar framings of childhood cultures of disaffection they seem to evoke familiar representations that are wellrehearsed in the form of stereotypical objectification of children and their social circumstances given these framings and their tacit familiarity maclure suggests that our ways of seeing young children in are so deeply ingrained with discursive familiarity and mythic immediacy that we are moreorless insulated from shock for the spectator of children whether that is the politician the ethnographer the film audience or the teacher this mythic immediacy could be construed as entangled amongst a complex of subliminal strategies that inscribe and impoverish children with layers of fixed and reductive correspondences for benjamin as for surrealist writers such as breton and aragon disruptive moments that might interrupt these inscriptions were to be found in the defamiliarisation of discarded commoditites familiar places and mundane events of everyday life i would suggest that both the process of going to the cinema and going into the classroom have become a means to commodify by discarding places and peoples in particular and wellrehearsed ways by discard i am suggesting that in our engagements with children we continue to overdetermine them within discursive parameters that possess the child in simplified and banal ways cinemaethnographic spectatorship 15 across the domains of research policy and practice cannella burman dahlberg moss and pence propose that children continue to be impoverished by definitions and judgements that bind and fix them in normalising and proper ways obscuring the intricacies of the cultural social and economic conditions enriching their complex and enigmatic lives in order to disturb uncomplicated versions of the child we might attempt to make mundane encounters strange whereby we engage with unpredictable moments that spark from the clash of incompatible realities and momentarily jolt people out of the slumber induced by ideology to push towards a trangressive jolt that comes from an encounter with a demented form of the familiar i imagine entangled and negotiated cinemaethnographic gazes as processes that might read against the grain by defamiliarising children in order to pursue the fantasies these processes allow us perhaps the interstices between film and the classroom offer occasions to disturb buffered versions of possession in order to revitalise ideas around children that are too discontinuous to be appreciated amongst more plausible or real landscapes the archaeological process of oblique photography is used to rupture and penetrate incongruous landscapes in order to know something more about surfaces layers and curious undulations considered worthy of closer observation osullivan suggests that ratcatcher plays with …the layers beneath every surface… noticing materials in conjunction with each other flesh beneath curtain fabric… spectacles beneath water these textures dont cancel each other out they just add mystery blurring our perceptions… ideas around layers and surfaces being worth looking at but contingent on processes of rupturing and penetrating seems to covet what entangled and negotiated cinemaethnographic gazes may illicit as moments of furtive unfamiliarity unexpected displacements antagonistic positions i want to probe at how we might look more obliquely at children and how our practices of looking could become obscured by penetrating tendencies to simultaneously possess and dispossess cinemaethnographic spectatorship 16 leaning to contaminate edges in order to probe at discrete versions of filmic and classroom ethnographic spectatorship perhaps a more interesting question would be how could we elude revoking one position for the other by conjuring mystery and negotiation and thereby blurring our perceptions rather than falling into familiar framing devices that serve to embrace some and prohibit other ways of seeing perhaps our entangled gazes could become ways to incite antagonistic play on the edges of possession and dispossession in ways that stronach describes as …necessary adjacencies they are leanto concepts … they only stand up by leaning against each other… they do not border each other so much as they invest the heart of the other with its parodic opposite … neither story … holds still with the other… across the empty span of their connection they insist on being with and also against the other in acts of mapping and spacing… if we were to imagine the complex leanto mechanisms that discursively frame the ways we read film and the classroom the idea of possessions seems to straddle those inhabited spaces films around childhood may stand up by leaning against the audiences willingness to be seduced by parody and pastiche inciting a more stable cinematic gaze whilst allowing affective responses to possess the cinematic narrative in intricately biographical ways the classroom seems to conjure different leanto devices where the ethnographer is conditioned by the surge of discursive educational narratives that somehow entangle her in cogent and possessed versions of the child these intriguing leanto devices allow us to go about our differentiated acts of spectatorship in uncomplicated ways secure in the knowledge that authoritatively we can appropriate our performances resiliently holding each still but my question here remains how can we edge into entangled and negotiated cinemaethnographic gazes that cinemaethnographic spectatorship 17 map and space these leanto mechanisms so as to ensure neither holds still with the other how can we rupture different framing devices as the processes of film and classroom spectatorship insist on being with and also against each other with a persistent menacing of each and both perhaps the possibility of putting both workingclass and classroom into play with one another we find imaginary spaces to push at linguistic and performative enervations to evoke a sense of interruption to those discarded commodities or correspondences i began this disruptive process by inviting a group of researchers to join me in spectating the opening scene of ratcatcher in order to consider how we might lean to particular practices of looking the opening scene has the soundtrack absent and is focused on the slowly turning image of young boy ryan standing in front of a window wrapping himself tighter and tighter into a set of white lace curtains suddenly a hand comes from offscreen and slaps the boy across his head which has the effect of jolting the spectators into the reality of the moment ryans mother insists that he stop playing around and go with her to visit his dad this scene is filmed in choppy slowmotion the image of the boy in the curtain is both beautiful and foretelling ryan wrapped in the curtains copyright © pathé pictures and bbc films 1999 ratcatcher on spectating the opening scene we responded what i thought was interesting about this image… was that i conjured all kinds of things… like hostages being wrapped up and i found it terrifying the swirling… you know reminiscent of something captured… visceral terms used here such as hostages and captured are interesting moments that rendered the spectating experience somewhat different to undertaking classroom observations ryan is possessed by the lace the narrative the ravaging processes of spectatorship the tragedies of working class life his relationship with his mother and the fate that awaits him his face and body are enclosed in a delicate but simultaneously violent rush of metaphorical rapture …flesh beneath curtain fabric… our reflections conjured and were reminiscent in terrifying and sinister ways reflecting back upon some classroom data we note how our observations seem starkly disparate from our filmic preoccupations jamie came into reception when i was in year 2 we were told we were getting a deaf child when he first came but we soon realised that we had to lock all the doors he was very wild they cant control him at home he takes his hearing cinemaethnographic spectatorship 19 jamie in the playground 7documentation of the teachers thoughts of jamie alongside observations of jamie in the playground render his behaviours somewhat pathologised the observer is drawn to the oddness of his behaviour seemingly oblivious to the furore of other children playing the position of his feet close together his refusal to join in with other childrens games instead looking at their feet and occasional shaking his body with excitement are all noted as though these behaviours are developmentally inappropriate and somehow justify his pathologised condition it seems curious that we read jamies behaviour from within familiar normalising educational narratives more cleanly and unemotionally pathologised yet ryans evokes a dirtier less familiar rendition peppered with memories traces of sinister happenings and apprehension jamie becomes coveted in diagnosis wrought with observations that shrewdly dispossess him of the colourful and emotive moments that engaged us with ryan in pursuit of disruptive moments found in the defamiliarisation of mundane events of everyday life i am interested in how jamie remained familiar yet odd in the data whereas ryans behaviour evoked less familiar and more visceral responses our focus around the classroom data and in particular how representations of children might become less familiar moved into an analysis of our practices of objectification i think we did get that sense of strangeness when we came back carrying the school data and then related what wed observed… perhaps its when you take it out of the frame in which it was observed… does it become unfamiliar then… quite bizarre… is it that it kind of opens up a space… a space from within which you can get some distance from it… see it as a kind of object… objectifying it perhaps if we saw a child swirling in the curtains in the classroom it would be seen as play… or theyd be told to stop it… spaces for example between the classroom and the university between the observers documentation and more open public discussions of the data served to carry data from inside across to outside particular discursive frames which perhaps rendered the data and jamie objectified …across the empty span of their connection… these carrying spaces created a distance from how the classroom was being observed perhaps these spaces ruptured a symbiotic relationship causing interruptions to the fluidity that might capture the observer and those being observed within a particular set of discursive frames nevertheless this connection manages to hold the different stories still rather than them being with and also against each other perhaps ethically we are with jamie in trying to disturb pathologised interpretations of his behaviour but simultaneously against any antirealist readings of the system and practices that frame and fix him in particular ways when spectating the film although other discursive frames might be in circulation perhaps we permitted ourselves more license to take risks within our practices of looking as we seem more willing to abandon familiarity and wellrehearsed narratives for example returning to our responses to the opening of ratcatcher we were moved into childhood collections of swirling in curtains cinemaethnographic spectatorship 21 and film does deliberately work on the emotional… visceral… you bring feelings thoughts to the image and to the sounds … you immediately get a montage… that layering stuff for me i immediately had that sense of well ive done that as a child but i remember what my feeling was… and immediately you respond to that sense of turning and having that thing around you and how that felt… something about seeing it up close and so slowed down makes you remember it yourself… i could smell the curtains… you mean a kind of embodied feeling yes i think so here we brought feelings and collections to our looking we made connections with processes of montage layering and remembering as well as describing feelings as embodied there is a very different response that disturbs any sense of a straightforward reading of the images perhaps we are with ryan in the curtains collecting similar childhood experiences but simultaneously against any realist tendencies to look uncomplicatedly at the character wrapped in the curtain there seemed to be no linear inscriptions within the visual narratives which perhaps allowed waves of images metaphors and juxtapositionings to elaborate the visual encounter ambivalent lenses and hybrid identities the seemingly disparate worlds of film spectatorship and classroom observation each bring interesting challenges to the idea of the child rather than straightforwardly carrying one set of practices of looking over to the other context my intentions are to aggravate and menace each and both contexts in order to forge renewed ways of seeing within both scenarios i sense impoverished practices of looking film evoking emotions collections and biography the classroom rendering us rational connected and somewhat unreflexive in attempts to blur perceptions conjure mystery and obscure these contextual boundaries i would suggest the pursuit of conceptual spaces inhabited by ambivalent narratives and cinemaethnographic spectatorship 22 ideological predicament used as discursive lenses for contextually transgressive data analysis perhaps by using the idea of ambivalence across particular paradigmatic lenses to deconstruct visual and textual data aspects of film and the classroom could become both with and against the other which might allow for tensions and contradictions to be played out across these different contexts for example if i were to open up the idea of colonialism as both a filmic and classroom trait it is rendered ambivalent as it captures something of the early ethnographic films culture of the voyeuristic masculine and racialised gaze imperialism and the exoticising of marginalized cultures as well as inciting the …discomfort of postcolonial ideology in dealing with its colonial past which spills over into its present… by turning to this idea i could probe at its relational tensions between that which enacts the affective content of colonised ideas places peoples and the discourses that might circulate amongst the colonial critique through which the ambivalence pushes and overflows by reaching across dissonant texts and subtexts where the colonizing gaze circulates amongst visual landscapes the process of reading filmic and classroom data could negotiate epistemological meanings that are brought about by the interplay of an obvious communicating utterance and the different utterance which is anterior to the obvious communicative gesture the interconnections of surrealism and ethnography sharing interests in the realities that were repressed by the taxonomic orders of western rationality become interestingly drawn into kristevas idea of communicating utterances and different utterances the interstices of film and the classroom become our surrealist primitive cultures used as a source of disruptive energy rupturing something of the ways we frame children by using inbetweenness as a broker of ethnographic spectatorship the colonial encounter kenny and the mouse look its a rat aitken suggests this dialogue from ratcatcher evokes the … brutality of peer pressure… contrasted with the beauty of james kindness and protection of kenny ambivalent colonial readings of this narrative extract might suggest that kenny is being used to reconfirm or stabilise the other boys own hierarchical status their raison dêtre as colonisersinthemaking understood as enacting the spectacle of stereotypical working class cultures with a menacing resemblance of kennys compassion an older boy reassures kenny ah thats lovely which could be read as an attempt to seduce him persuading him that he can trust the older boy by appealing to his gentleness weakening his resistance to subversive colonising practices here the obvious communicative utterance could be read as kenny performing the indigenous noble savage an uncorrupted child untainted by the processes of working class civilisation as rousseau suggests of the noble savage …the peacefulness of their passions and their ignorance of vice keep them from doing ill… perhaps kennys gentleness led others to feel permitted and responsible for cultivating his appropriately brutal behaviours a beguiling goad into the homogeny of working class youth culture in tension with this reading lies the subtext or the different utterance… anterior to… the obvious communicative gesture perhaps in his colonised status as terra nullius kenny is mistakenly read as tabula rasa which performs a useful distraction from more sinister workings of the colonial project and for the other boys vying struggles for working class notability and growing understandings of their own working class performances kenny is being looked at and colonised by the colonisers who paradoxically need him to reaffirm their own brutalities and performances of domination when kenny is encouraged by being told that he is one of the boys he looks to james and asks am i james seeking reassurance and affirmation unsure of their motives kenny momentarily questions the premise on which the older boys brutalities are founded kennys question am i does not seem to express a sense of relief or hope of accession but perhaps looks to james in a moment of his own ideological predicament the older boys cinemaethnographic spectatorship 25 use of seduction to cajole kenny into working class youth culture suddenly becomes a demented form of the familiar kenny presents a disorientation or ontological stammering in which normal sense including sense of himself and the other boys is fractured amongst the colonial relationships at play here i detect the discomfort of what chadha might describe as colonial workings being enacted in postcolonial landscapes an ironical crevice in postcolonial narratives propagated in the films different utterance where ambivalent meanings of the working class child are located tunbridge and ashworth discuss how most colonial heritage in the postcolony landscape can be subsumed under the taxonomic grasp of dissonant heritage and kenny seems to occupy a space of conflicting emotions and indeterminate meanings that seem to be a clear reminder of ongoing yet complexly possessed occupation within the ambivalent narratives of colonial critique we could also reimage the workings of restless hybridity within the film the idea of stories being with and against each other is used here to describe the ways we are trying to straddle the film and the classroom as sources of ethnographic data as complex and fluid acts of spectatorship as ways to read characters in the film and the classroom and as a way to use ambivalent critiques to push at the edges of discourse and narratives according to bolatagici hybridity can reveal elements of contradiction and conflict within cultures and individuals as sakamoto explains g iving up the desire for a pure origin hybridity retains a sense of difference and tension between two cultures… a new form of identity … … this new form of identity could be understood as bhabhas third space a liminal space embracing betwixt and between sonn and green suggest that …an inbetween or hybrid identity can only manifest itself through boundaries it … redefines them… kennys hybrid identity retains a difference and tension between two cultures that of the older boys wellrehearsed brutality and his own leanings towards compassion which is eventually played out cinemaethnographic spectatorship 26 when he succumbs to a form of protest … hes going to the moon… perhaps against his own uncomfortable compassion this act of distorted benevolence seems to evoke a demented form of the familiar as kenny sanctions the cruel intentions of the older boys and perhaps even shocks them into a reconsideration of their own expressions of brutality earning the status … hes a fuckin psycho… but does this within his own fantasy of mouse liberation the colonial classroom jamies restless hybridity returning to extracts classroom data children were called out in their groups to line up by the door good boy jamie good boy said nathaniel stroking jamies head nathaniel tried to hold jamies hand as they go to line up at the door jamie pulls his hand away marcus says ill help jamie and takes jamie by the hand ill wash his hands too because im very helpful to jamie miss keith responds you are arent you marcus and jamie walk handinhand out of the classroom here jamie like kenny is subjected to disparaging treatment as both nathaniel and marcus enact the colonising ways they have observed adults behaving with him their resembling of the adults behaviour towards jamie is uncomfortable to observe as it serves to further pathologise jamie however jamies hybridity enacts a complex digression where his behaviours permit the other childrens colonial undertakings whilst simultaneously denying access to other knowledges that might reframe the ways both the observer and other children are able to understand him perhaps the observers documentation becomes the mediator whereupon different kinds of observations of jamie could potentially enable other denied knowledges to resist something of the dominant discourse here i am reminded of mass cinemaethnographic spectatorship 27 observations commitment to representing multiplicities of voices against a historical background that plays with distortion fragmentation and contested notions of truths mass observations aim was to document the everyday life of the people in their own words perhaps here the observers text could become disruptive whereupon different kinds of negotiated observations of jamie could begin to consider what the familiar grain might look like in order to find ways to think about negotiating other denied voices by attempting to challenge the prevailing ingrained discourse and estrange the basis of its authority we could make the structure of meaning and reference a more ambivalent process returning to another extract of classroom data i notice how jamies restlessness and resistance to being known definitively finds a way of jolting the observer out of her ideological slumber jamie comes over to my camera and is intrigued by the little viewing screen he is watching through the screen what i am recording i turn the screen around and pointed the camera at him so he could see watch himself he quickly turns his back on the camera so i move it away as i feel he wasnt comfortable with that experience he seems to want to watch other children on the screen and returns to stand behind the camera he sits on my knee and watches the screen as i film his peers again i explained to the teacher what hed done when i turned the screen to face him she said they said as part of his autism that he wouldnt recognise himself in photos or on video i am replaying some of the footage to show the teacher what he did jamie comes over and when he sees himself he points and smiles although his gestures of selfrecognition could also be construed as jamie merely enjoying something in the images being played back to him he also unsettles us in a moment of abjection a moment of cognitive dissonance which leaves a sense of discomfort amongst our uncomplicated diagnostic leanings that possessed something of his pathologised behaviours whether he recognised himself or not he momentarily questions the assumptions that were continuing to colonise him in ways that rendered him so autistically familiar so how do the ideas of colonialism and hybrid identities enable us to interrupt cinemaethnographic spectatorship 28 our familiar and impoverished practices of looking at children how do they engage us with halls enemy so as not to possess worthiness as we curate our gaze so readily how does the ambivalent lens of colonialism enable us to incite play on the edges of possession and dispossession perhaps here we could lean to bhabhas notion of how the ambivalence of colonial rule also enables a capacity for resistance within the performance of lacans mimicry … the effect of mimicry is camouflage… it is not a question of harmonizing with the background but against a mottled background of becoming mottled exactly like the technique of camouflage practised in human warfare… reflecting upon ratcatcher aitken suggests that … the boys profanity… like all other peer relations in the film… suggests an edge along which violence may flow at any moment… this menacing edge that might or might not lead to violence lends itself to lacans thoughts around mimicry as camouflage we question how we might possess something of the older boys who seem to resemble and perform the familiarity of the camouflage that evokes working class disaffected youth on the edges of violence which we might expect all younger boys to mimic however we might also dispossess moments where the mimicry becomes menace in our sentimentalising of marginalised cultures as kenny dements what has become so familiar to the older boys he enacts hybrid identities that camouflage and disturb as he moves inbetween mimicking and rejecting the mottled background on occasions classroom data also seems to possess something of jamies mimicry his acceptable or expected classroom performances become mottled against a mottled background but simultaneously his hybridity seems to become compliant and threatening creating moments of classroom dispossession jamie is taken to the glue and tissue paper area mrs collinge is using a combination of actions gestures and simplified language to tell him what cinemaethnographic spectatorship 29 to do jamie stick he seems reluctant to do this activity intermittently he puts glue on the paper and sticks paper onto glue whilst looking at the shadows created on the window blinds from the wind moving the trees outside this seems far more interesting to him mrs collinge keeps trying to refocus him on the sticking activity mrs collinge is standing over jamie and starts showing him how to apply the glue o the paper and then sticking tissue paper over his glue he stops gluing and she crouches down next to him and tries to encourage his fuller rather than intermittent participation jamie being shown how to glue 8 jamies resistance is characterised in the data by his fleeting digressions moments of wandering towards the shadows of trees outside discussing data taussigs writing around montage resonates with jamies performative transgressions … alterations cracks displacements and swerves… the sudden interruptions in a battering of wave after wave of interruptedness… stopping the song in midflight to yell at the dogs to stop barking… and in the cracks and the swerves a universe opens out… the surface itself in a state of continually interrupted and fragmented construction… the actors create the surface by rendering their own representations while at the same time commenting upon this thereby gliding between representation and representationasdigression… similar to mimicry perhaps hybridity and possession must continually produce their slippage their lack their excess their dispossession expressed through the film and classroom characters the slippages rupture any sense of the colonisers or spectators victory narrative as jamie and kenny slip in and out of being camouflaged remaining incomplete to class9 conformity through the slippages they refuse to keep the stories of the classroom or of the film or of the processes of ethnographic spectatorship still as they resist straightforward readings instead their stories contaminate spaces that were previously bounded and fixed which is suggestive of the porosity of colonial boundaries bhabha proposes that the discourse of colonialism as a site of hybridisation offers resistance waged from … the interstices of an unstable boundary that desires to discriminate the subject from the nonsubject such unstable boundaries that inscribe something of being working class or being an autistic pupil in a classroom have become porous allowing readings that are against the grain and negotiated both with and against the mythic immediacy of such framing devices according to bakhtin the language of hybridity becomes a means for critique and resistance to the monological language of authority so interestingly if colonising colonised groups are characterised by dominance and resistance yet boundaries can become unstable do kenny and jamie authoritatively trouble the familiar binaries of coloniser dominance and colonised resistance in their menacing mimcry perhaps the spectator needs to reconsider what is worth looking at and what is not and experience what is worth looking at in different ways as jamie and kenny no longer remain straightforwardly knowable in any uncomplicated sense perhaps the possibility of the image presenting the constant surprise of things seen for the first time affords them a powerful enigma amongst colonial readings is their porosity a powerful menace that is both alluring and resistant to different spectator readings if so how does their disruption of the unspeakable slash that juxtaposes dominanceresistance colonisingcolonised menace our reluctance to read them as complicated how are kennys and jamies performative acts of dominance contradictory as they both deconstruct and reinscribe the hierarchical world of colonisers and colonised they seem to resist complying and becoming assimilated which focuses the spectator on their vibrant textures and foregrounds their differences kenny or rather the processes of spectating the classroom and the film no longer seem to exist in isolation as stories that hold still across the empty span of their connection perhaps my tentative explorations around ambivalent narratives ideological predicament colonialism and restless hybridities have performed a sense of savage anthropology borne from a curiousness around that which seems unfamiliar misplaced and illfitting the processes of spectatorship have helped define something different of jamie and kenny as well as foregrounded my struggles with desires to covet and cleanse via practices that implicitly and straightforwardly seem to colonise them as knowable the role of the spectator in and amongst this savage anthropology remains somewhat menacingly voyeuristic moving into the complexity of the cinemaethnographic gaze and notions of lack and displacement i get a sense of the filmic and classroom characters belonging and displacement which might be conceptualised as colonial spaces being substantiated in the fluid relationships between the class and the spectators with their rhetorics discursive practices and memories perhaps the class could be understood as a site of complex displacement restless hybridity and cultural eclecticism where for example jamies and kennys belonging and displacement could be contrasted with the cultural competences of those who are seemingly assimilated the possessive processes of assimilation might also include the spectators but the class spaces marked with precise and determined functions all regulatory also seem to render them and the masculinised racialized gazes contingent similarly to saids discussion around realist novels i could construct the spectator as protagonist engaged in highly regulated plot mechanisms and entire systems of social referencing that depend on the existing and traditional institutions of colonialist societies with authority and power however i could also suggest that kennys and jamies restless hybridity have jolted me into conceptual spaces that question the social referencing on which my practices of looking are based for the children on one level they could still be understood to stabilise the spectators accession to reconfirmed identity we are able to watch them in particular ways because we assume they are interestingly different cinemaethnographic spectatorship 33 unconventionally predictable yet always already inscribed within discrete discursive framings however by transgressing via the interstices of film and the classroom i feel that kenny and jamie have forced a reverse spectatorship they have begun to call upon the actor the spectator as participant to mark herself to become intricately embroiled in their discursive transgressions the complexities of the different utterances and denied voices in the data foucault writes of velásquezs las meñinas the action of representation consists in bringing one of these two forms of invisibility the painter who paints the king who is not in the picture into the place of the other in an unstable superimposition and in rendering them both at the same moment at the extremity of the picture the mirror provides the metathesis of visibility learn about myself as possessive spectator within the stories i have told and will go on to tell the multiplicity of spaces created within this act of telling a story about other stories has become an engagement in the erotics of my own playful language games yet there are possibilities to reflect upon this morass of semantic playfulness with some sense of purpose also discussing velásquezs cinemaethnographic spectatorship 34 las meñinas stronach garratt pearce and piper suggest how the painter … sweeps himself into the picture in an act of perfect reflexivity …it is the instability of these perspectives that animates the picture by forcing the onlooker into reflective and reflexive action she has to work out what is going on… i feel as though i have been swept into jamies and kennys stories by ideological jolts that momentarily provoked ontological stammering abjection and cognitive dissonance in my knowing of children the paper has permitted moments of what bhabha describes as the emergence of interstices the overlap and displacement of domains of difference or inbetween spaces provide the terrain for elaborating strategies of selfhood that initiate new signs of identity and innovative sites of collaboration and contestation i have begun reconsider what i might have previously left behind dismissed possessed deemed worthy of my gaze as participatory spectator entangled within the process of watching and the spectacle of looking at children i have attempted to move amongst the cinemaethnographic gaze as an inbetween space the classroom as an active space of collaboration and the characters of jamie and kenny as participating in the enactment of their own hybrid identities perhaps these have become innovative sites of collaboration and participation that disturb something of our comfortable gaze but a cautionary note would be that perhaps they simultaneously conspire to reenframe and rearticulate once again the bounded ways we have available to us to practice our looking and ways of seeing children perhaps it is the idea of engaging with the deflections and fractious moments of recognition contemplating the intricacies of representation and representationasdigression that becomes useful within the cinemaethnographic stories i have begun to image

holmes r 2010 cinemaethnographic specta c torship discursive readings of what we choose to dis possess cultural studies critical methodologies 10 3 pp 221237

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introduction great efforts have been made during the past two decades to improve access to and the utilization of prenatal care in lowincome countries while over threequarters of pregnant women seek at least one prenatal care visit from a health professional only 39 of women benefit from the minimum recommended four prenatal visits there also remain substantial disparities in prenatal care attendance and the frequency of use both between and within lowincome countries while the benefits of routine prenatal care are still debated some elements of prenatal care have clearly been shown to reduce complications and improve birth outcomes prenatal care attendance offers multiple opportunities to reach expectant mothers with information on any risks related to labour and delivery and as a way of promoting delivery with the assistance of a skilled healthcare provider timely and adequate prenatal care has also been found to be important for the health of newborns in addition prenatal care can be an entry point for the prevention of hiv transmission from mother to children prenatal care attendance can also especially in rural settings facilitate womens access to medical care for future needs although there is a substantive literature on the determinants of prenatal care attendance in lowincome countries comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating decisions regarding any use of prenatal care and the frequency of use in particular moreover most of the existing studies are countryspecific and it is unclear whether the influence of the main determinants of any prenatal care use and the frequency of visits vary in magnitude across geographical regions crosscounty studies have their own usefulness in terms of capturing broad patterns and trends in utilization of maternal healthcare services at the global level that could be used as an input into formulating overall policy strategies the primary objectives of this article are twofold first the article seeks to extend the range and scope of the existing literature by comparing the strength of a wide range of individual household and community risk factors on both prenatal attendance and the frequency of visits for 32 lowincome countries from asia subsaharan africa and latin america while controlling for unobserved communitylevel factors second the article aims at assessing the differential influence of the observed individual household and community factors on both prenatal attendance and the number of visits across the three world regions these are achieved using demographic and health survey data for 32 lowincome countries across asia subsaharan africa and latin america and a twopart model a wide range of empirical studies have examined the utilization of maternal health services in lowincome countries however some of these studies only examined the factors associated with the use of prenatal care attendants fewer studies have empirically assessed the determinants of the frequency and timings of visits comparatively little is known whether there are separate processes generating decisions regarding any use of prenatal care and the frequency of use in particular data and methodology data this article uses the most recent data from the dhs for 32 lowincome countries from the regions of asia subsaharan africa and latin america since the survey years vary by country only those countries whose per capita income was below the world bank cutoff point for lowincome status during the survey year were selected 1 the appendix to this article provides a list of countries by survey year and region the dhs are largescale household surveys that use a multistage cluster sample design to collect nationally representative samples of women of reproductive age using the same methodology dhs collect among other things detailed information on the use of prenatal care the number of prenatal visits as well as data on respondents various socioeconomic characteristics such as age education and employment status the total sample in this study consists of 200 417 women who had their last baby born alive in the 5 years preceding the survey 2 methodology the utilization of prenatal care can be disaggregated onto two broad measures of access the use of prenatal care which takes the value of one if an individual uses prenatal care during the pregnancy of her last baby born alive and zero if an individual does not use prenatal care and the number of prenatal visits this disaggregation allows us to more clearly identify the factors that motivate what is essentially a twopart decision given this twopart attribute a womans decision on the utilization of prenatal care is best modelled using a hurdle or twopart model in the context of our analysis in the first stage the expectant mother decides whether or not to use prenatal care in the second stage the healthcare provider together with the expectant mother decides on the number of visits underlying the tpm is the assumption that separate processes may govern the decisions to use the service and the frequency of use the tpm is often interpreted in a principalagent type framework in which the physician partly determines utilization on behalf of patient once initial contact has been made a tpm is also considered to be conceptually more appropriate for modelling healthcare utilization where the number of visits made by an expectant mother during her pregnancy meets the underlying single illness spell assumption of the tpm both the use and the frequency of use constitute two components of a single episode of care 3 in the first stage our dependent variable is binary and therefore the probability of using care or not is modelled using a binary logistic regression in the second stage our dependent variable is a count variable measuring the number of prenatal contacts the two commonly used methods for modelling truncated count data are the truncated poisson and the negative binomial models the negative binomial model is generally considered to be superior to the poisson model which restricts the conditional variance of the dependent variable to being equal to its conditional mean thus in our hurdle specification the first part of the likelihood function is the binary process defined over the total sample and the second product is the likelihood of a truncated at zero negative binomial model defined over the sample of woman who had at least one prenatal contact to the extent that womens decisions to use prenatal care and the frequency of its use are influenced by the unobserved characteristics of the community such as the availability and accessibility of health services the prevailing health beliefs and practice surrounding reproduction health and birth the likelihood of women using prenatal care is likely to be correlated among the community members in this case the application of standard binary regression models such as a logistic model leads to bias instead we have used a twolevel random intercept logistic model to control for the influence of health risks associated with social structures and community ecologies that influence utilization of prenatal care to assess the overall degree of homogeneity in the utilization of prenatal care among women within an enumeration area 4 we at first estimate a twolevel random intercept logistic regression model for the utilization of prenatal care and a twolevel random intercept poisson regression model for the frequency of prenatal care use without including the observed covariates and then calculate the intracluster correlation 5 the estimated is 033 for seeking prenatal care and 007 for frequency of prenatal use the later correlation becomes very small once the model controls for all observed individual householdand communitylevel characteristics we thus control for unobserved communitylevel attributes only in modelling the decision to access prenatal care the use of multilevel modelling strategy for any use of prenatal care accommodates the clustered or hierarchical nature of the dhs data and corrects standard errors of the estimated coefficients for intracluster correlation standard errors of the estimated coefficients are also corrected for intracluster correlation in the estimation of the frequency of prenatal use stata version 91 was used for all data analysis study variables the theoretical and empirical literature suggest that the utilization of maternal healthcare services is influenced by a wide range of observed individual householdand communitylevel variables as well as unobserved communitylevel variables such as perceived benefits of care attitudes towards health and healthrelated behaviours variations in habit persistence organization advice seeking the ability to use the available resources and the prevailing health beliefs and practices surrounding pregnancy and birth the individuallevel variables include maternal educational attainment maternal age at last live birth marital status employment status the desire for the pregnancy and the parity level the observed householdlevel variables include household economic status and household size the observed communitylevel variables included in this study are the place of residence and a regional poverty indicator place of residence highlights the differences in the availability and accessibility of services among urban and rural areas a countrys region is classified as poor if the share of the poor and nearpoor households in the total population of the region exceeds the national average by one standard deviation poorest regions reflect remoteness poor road and health infrastructure limited access to information and strong adherence to traditional values the poorregion dummy may act not only as a proxy for the state of regions physical infrastructure and health service environment but also as a proxy for ethnicity ethnicity is closely linked to place of residence with ethnic minority groups typically accounting for a disproportionately high share of a countrys poor and residents of remote areas other potential communitylevel variables such as physical infrastructure and health service environment indicators are excluded from the determinants of prenatal care use analysis due to the lack of data dhs provide data on problems posed by transportation and distance to the nearest health facilities when respondents are seeking outpatient care for themselves however these data are available for 25 countries we have used these data to assess the robustness of our results table 1 provides definitions and summary statistics for the dependent and each type of independent variables used in the estimation of the tpm for three regions and for all countries combined results descriptive analysis table 2 reports prenatal care attendance and the number of prenatal visits by wealth quintile the level of maternal education and the place of residence the percentage of pregnant women using prenatal care varies from 765 in asia to 885 in latin america among those who sought any prenatal care the average number of visits varies from 42 in subsaharan africa to 56 in latin america these averages mask wide variations in the utilization of prenatal care within and across the three regions in terms of the economic status the level of maternal education and the place of residence these disparities are more marked for the number of prenatal visits than the use of any prenatal care and in asia than in other two regions in the case of asia pregnant women from the richest wealth quintile are 17 times more likely to use prenatal care and have 23 times more visits than those from the poorest wealth quintile the education gradient is also more pronounced in asia where 95 and 982 of women with the secondary and postsecondary education respectively sought prenatal care compared with 613 for those with no education those with secondary and postsecondary education also had on average respectively 6 and 73 visits vs 32 for those with no education as shown in table 2 the incremental influence of maternal education on utilization of prenatal care beyond the primary level is also more pronounced in asia than in the other two regions multivariate results allcountry sample the regression results obtained from the tpm for all countries combined are presented in table 3 the likelihood ratio test clearly rejects the null hypothesis that the standard deviation of the random intercept term is zero and hence favours a random intercept logistic model over an ordinary logistic model the intracluster correlation and the estimated values of the variance of the random intercept term are also shown in the table the high value of even after controlling for all observed individual householdand communitylevel covariates suggests that there are some unobserved covariates in the primary sampling units that affect womens decision to use prenatal care regarding the second part of the tpm the estimated measure of dispersion is positive and small and the lr test clearly rejects the truncated poisson model in favour of the truncated negative binomial model to facilitate interpretation the estimated coefficients of the logistic model are converted to odds ratios for the truncated negative binomial model the estimated coefficient of a dummy variable indicates the proportionate increase in the dependent variable when the explanatory dummy variable takes the value of one rather than zero the coefficients of the explanatory variables other than dummies can similarly be interpreted to control for the unobserved countryspecific factors we have included one dummy for each country in the sample due to space limitation the coefficient estimates of the 31 countryspecific dummies are not reported in table 3 regarding the results for all countries combined all explanatory variables have their expected signs and they are statistically significant at the 1 level with the exception of household size in the decision to use care and employment status in the frequency of visits the likelihood of prenatal care attendance and the frequency of use are both positively influenced by the level of maternal education age marital status household wealth and the place of residence the influence of education is more pronounced for seeking prenatal care than the number of visits compared with those with no education women with completed primary school education are twice as likely to use any prenatal care and those with secondary and post secondary education are 3 and 63 times more likely to use any care respectively by contrast women with secondary and postsecondary education are likely to have only 24 and 37 more visits respectively than those with no education prenatal care attendance and the frequency of use also vary positively with maternal age with adolescents being the most disadvantaged age group married women are almost one and half times more likely to use prenatal care than the unmarried women and are also more likely to have a higher number of prenatal visits the likelihood of seeking any prenatal care and the number of prenatal contacts increases monotonically with household wealth pregnant women from the top fourth and fifth wealth quintiles of households are 14 and 32 times respectively more likely to use prenatal care than those from the lowest wealth quintiles on the other hand women with a higher number of child births are less likely to use any prenatal care and have fewer visits pregnant women are less likely to use any prenatal care and have fewer visits for unwanted pregnancies compared with pregnancies that are wanted 6 as might be expected residents of the poor regions are 46 less likely to use any prenatal care and have fewer visits when they use care to assess the effect of the place of residence on prenatal care attendance and the frequency of contacts at various levels of wealth an interaction term combining urban and wealth quintile is added to the list of explanatory variables 78 the urbanrural differences in using care become larger as we climbed the wealth gradient urban women from the richest wealth quintile of households are 13 times more likely to seek prenatal care than their counterparts vs 45 for women from the lowest wealth quintiles of households by contrast there is no difference in the number of prenatal visits between the rich and poor and near poor urbanrural residents allcountry sample with interaction terms to assess the differential influence of the significant individual household and community indicators on the utilization and frequency of use of prenatal care across the three world regions the regression model for all countries was extended by including three sets of interaction terms the results for the interaction terms are reported in table 4 9 the first set of interaction terms combines the individuallevel factors with each of the three world regions allowing us to compare and test directly for the differential influence if any of the individual level factors on both prenatal attendance and number of visits among the world three regions the second set of interaction terms combines household wealth with each of the world three regions while the third set of interactions combines the place of residence and the poor region variable with each of the three world regions overall the results indicate remarkable consistency among regions in the association of individual household and community indicators with prenatal care utilization notable exceptions are maternal employment the place of residence and regional poverty employment has a negative and significant effect on the number of visits in asia while it has a significant and positive effect in subsaharan africa urban residence also has a positive influence on prenatal care utilization in both asia and subsaharan africa while it has a negative influence in latin america by contrast living in a poor region of a country has a negative influence on prenatal care utilization in asia and subsaharan africa while it has a positive influence in latin america however the incremental influence of the individual household and community factors on the utilization of prenatal care varies greatly for many predictors across the three world regions regarding individual level factors regional differences are particularly more noticeable for maternal age marital status and parity the incremental influence of maternal age beyond 30 on the odds of using prenatal care varies across regions with the age gradient being steeper in subsaharan africa and latin america than in asia however the regional differences are only statistically significant for older women compared with adolescents older women in latin america and subsaharan africa are 77 and 56 more likely to use any prenatal care respectively vs 16 in asia by contrast there are no significant regional differences in the incremental influence of maternal age on the number of visits among older women pregnant women in asia are relatively more disadvantaged if they are unmarried especially in terms of the frequency of prenatal care use compared with unmarried women married women in asia are likely to have as many as 41 more visits vs only 16 and 11 more visits for women in latin america and subsaharan africa respectively while the parity gradient is almost flat for latin america it declines steadily both for asia and subsaharan africa and more sharply for asia than for subsaharan africa as one moves up the parity gradient compared with the first parity the second parity reduces the likelihood of prenatal attendance in subsaharan africa by 28 and by as much as 50 for women with the fifth and higher parity in asia the fifth and higher parity reduces the likelihood of prenatal attendance by as much as 70 similarly the fifth and higher parity reduces the number of prenatal visits by as much as 45 in asia vs 13 for subsaharan africa regarding other individual level factors the influence of primary education on prenatal attendance is stronger in subsaharan africa than in other two regions compared with those with no education women with primary education are 58 more likely to use prenatal care in subsaharan africa vs 38 for latin america and asia the regional differences in the use of prenatal care are not statistically significant for the secondary and higher education on the other hand the incremental influence of education beyond primary schooling on the frequency of visits is significantly different across the three world regions with the education gradient being steeper in asia than it is in other two regions compared with women with no education women with secondary and higher education in asia are likely to have 22 and 30 respectively more visits the negative influence of the desirability of a pregnancy on prenatal care attendance is not significantly different across the three world regions while its influence on the frequency of visits is greater for asia than for other two regions in asia women with unwanted pregnancies are likely to have 12 fewer visits vs 2 in subsaharan africa regarding the householdlevel factors the household wealth gradient is more pronounced in asia and subsaharan africa than in latin america where there is no significant difference in the incremental influence of household wealth among women from the nonpoor households the odds of seeking prenatal care increases sharply in both asia and subsaharan africa as one moves up from middle wealth quintile households to the richest wealth quintile of households compared with the women from the poorest wealth households women from the top wealthiest quintile of households in asia and subsaharan africa are 38 and 31 times respectively more likely to use any prenatal care the wealth gradient is particularly more pronounced for the number of visits in asia where women from the top two wealth quintiles of households are likely to have 62 and 43 more visits respectively than women from the poorest wealth quintile of households the results for the interaction terms combining the place of residence and each of the three world regions suggest that living in urban areas increases the odds of using any prenatal care in both asia and subsaharan africa and reduces the odds in latin america the urbanrural disparities in prenatal utilization also vary positively with household wealth with these disparities being more pronounced for prenatal care attendance than for the frequency of visits in the case of prenatal attendance the disparities are more marked for subsaharan africa than for asia and latin america urban women from the lowest three wealth quintiles and the richest wealth quintile in subsaharan africa are 68 and 172 times respectively more likely to use prenatal care than their rural counterparts in contrast there are little urbanrural disparities in the number of visits in subsaharan africa and they are modest in both asia and latin america the influence of regional poverty on any use of prenatal care is also more negative in subsaharan africa than in asia but surprisingly it is positive in latin america women from the poor regions in asia and subsaharan africa are 45 and 59 less likely respectively to use any prenatal care than their counterparts in the nonpoor regions the results for latin america are driven by a small number of regional outliers with a relatively high rate of prenatal care attendance and poverty and hence the results should be interpreted with caution with respect to the number of visits urbanrural disparities are relatively small and significant only for asia and latin america discussion and conclusions the results of this investigation indicate that though both the utilization of prenatal care and the number of prenatal visits are influenced by a range of observed individual householdand communitylevel characteristics both the set of relevant variables and the magnitude of the effects vary across the two decisions in the first instance unobserved communitylevel variables have been shown to have an effect on the utilization of prenatal care but not on the number of visits second several variables that affect prenatal attendance appear to have no influence on the number of visits third even when the same variable appears to influence both the use and frequency of prenatal care decisions the magnitudes of its effect is quite different across the two decisions finally despite remarkable consistency among regions in association of individual household and community indicators with prenatal care utilization the estimated coefficients of the risk factors vary greatly across the three world regions consistent with the general findings of earlier studies the likelihood of using any prenatal care and the frequency of its use are both strongly influenced by the level of maternal education and maternal age however the influence of education is more pronounced for using prenatal care than the number of visits which may partly reflect the fact that nonattendees who are mostly disadvantaged women with no education are not in the second model 10 the positive effect of education on healthcare utilization has been attributed to increased autonomy and decisionmaking power greater control over resources greater ability in accessing and processing new information and being more efficient in the production of health 11 similarly the positive association between maternal age at the time of birth and the use of prenatal care may reflect older womens greater experience in using health services more control over household decision making and higher biological risks on the other hand women are less likely to access prenatal services and use these services more sparingly as birth order increases several possible explanations exist for this effect including the knowledge and confidence gained from past experiences difficulty in accessing prenatal services due to the lack of adequate child care fort and birth attendants negative comments the positive influence of marital status may reflect the stigmatization faced by single expectant mothers since childbearing in most communities is perceived as the purview of those who are married on the other hand the finding that the desirability of a pregnancy has a negative influence on the use of prenatal care accords with the argument that woman with an unplanned pregnancy may delay prenatal care use as they go through a period of denial or as they contemplate an abortion the influence of both marital status and the desirability of pregnancy are stronger on using prenatal care than on frequency of visits suggesting that once the decision is made to seek care womens behaviour is much closer to the norm the findings that a womans employment status has little effect on her use of prenatal care in asia and latin america while it has a positive effect in subsaharan africa points to the potential for multiple pathways through which a womans working status can influence the use of prenatal care seeking employment outside the home may encourage women to use more care by providing them with an increased range of movement better access to information more resources as well as greater confidence and ability to plan for the future however employment may not necessarily be associated with greater use of maternity care if women have little control over their earnings employment is largely povertyinduced and reflects resource constraints and employment is seasonal and poorly remunerated moreover to the extent to which participation in incomegenerating work increases womens paid and unpaid work load they may have little time available for seeking prenatal care in general and for repeated visits in particular consistent with previous research household wealth is an important predictor of both prenatal care attendance and the repeated visits which point to financial barriers including both direct and indirect costs of accessing prenatal care although facility fees are less a barrier to seeking prenatal care compared with delivery care households often face significant costs in accessing prenatal care including travel costs and the time spent away from productive activity 12 the low utilization among poor households may also reflect the aversion to investment in maternity care due to low perceived benefits or perception of poor quality of care and the higher work burden of the poor in terms of both paid and unpaid work our results on place of residence and interaction with household wealth quintiles may reflect greater physical barriers especially transportation faced by rural women in general and the rural poor and nearpoor in particular an urban centre no doubt provides greater awareness and exposure to a wide range of providers and services but only to those who can afford them lack of stable and regular sources of income and pressures to work long hours in ad hoc trading jobs to meet basic household needs often leave the urban poor and nearpoor with little time to use care even when care is provided free of charge moreover weaker family support networks in urban areas compared with the rural areas also leaves many urban poor women without support of the extended family in providing childcare the results that women living in the poorest regions of a country are less likely to access prenatal care than those living in the nonpoor regions may reflect remoteness poor road and health infrastructure limited access to information poor access to health services and strong adherence to traditional values the findings that the responsiveness of both the use and frequency of visits to certain individual household and community attributes varies across regions may reflect regional variations in overall levels of development availability and the quality of care modes of delivery of services and cultural norms and practices surrounding birth in many resourcepoor settings both the shortage and competency of healthcare providers are important barriers and a birthing woman may not necessarily receive competent care even if she uses a formal health facility subsaharan africa is the poorest of the three regions and not surprisingly the urbanrural divide is strongest in that region the finding that the urbanrural gap in the utilization of prenatal care increases rather than decreases as household wealth increases may reflect the regions poor rural infrastructure including healthcare services roads and transport by contrast the weaker effect of urban residence and the level of regional poverty in latin america may reflect the higher level of development of the region and greater overall access to facilities in general moreover many nongovernmental organizations have targeted latin americas poorer nations to promote the use of prenatal care by implementing and expanding maternal health programmes particularly in those areas with a poor health infrastructure or suffering from extreme poverty private provision of healthcare services is more developed in asia than in other two regions almost 45 of the women who sought prenatal care in asia used private facilities as compared with 16 in subsaharan africa and 10 in latin america the importance of private care in asia may explain the greater wealth effect on both the utilization of prenatal care and the number of visits as well as the more pronounced education and maternal age effect on the number of visits in the latter case both age and education may allow women to better assess the cost and benefits of additional visits also the stronger influence of marital status on the decision to use care in asia may be reflective of a greater cultural bias against premarital births in that region some caveats are in order while the quality of dhs data is quite high for lowincome countries common data limitations remain the data on the utilization of maternal services are subject to recall errors and the wealth index as a measurement of household socioeconomic status has been criticized for being too urban in the construction of the household wealth index moreover the study does not adequately control for the availability and quality of prenatal care services the problem is further compounded by the lack of a supportive infrastructure including the lack of drugs and equipment ineffective supervision poor attitudes towards patients and an uncoordinated care process using enumeration areas as proxies for communities may conceal a category of much greater complexity however enumeration areas are considered to be a more accurate representation of the community environment for some settings than the sampling strata the estimated coefficients of the determinants of frequency of prenatal visits may be subject to selectivity bias if there are unobserved factors such as complications during the previous pregnancy and previous exposure to maternal healthcare services influencing both the use and the frequency of the prenatal care however controlling for unobserved communitylevel factors through the use of multilevel estimation probably mitigates this problem but it does not remove it entirely these findings have important policy implications for the utilization of prenatal care in lowincome countries the strong influence of household wealth education and regional poverty on prenatal care use suggests that safe motherhood programmes need to explore effective ways of increasing service utilization among poor and less educated pregnant women as well as those living in the poorest regions of a country similarly the existence of large urbanrural disparities in the use of any prenatal care and repeated visits in africa and asia emphasizes the importance of developing appropriate maternal healthcare delivery systems in rural areas to ensure greater and timely access to quality maternal health services interventions that could be delivered by primary health in community settings allowing community female fieldworkers to identify pregnant women for antenatal care have proved important in utilization of antenatal care in some resourcepoor settings over the longer term the objectives of safe motherhood programmes can be linked with those of social development programmes such as poverty reduction enhancing the status of women and increasing primary and secondary school enrolment rate among girls the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to seek prenatal care and have fewer visits especially in asia suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy since teenage birthing mothers are more likely to experience premarital and unintended births than older pregnant women coupled with their more precarious socioeconomic positions it makes them a particular subgroup of concern finally the importance of unobserved communitylevel factors on womens decision to use any prenatal care suggests the need to contextualize policy efforts aimed at increasing the use of prenatal care in lowincome countries clearly additional research especially qualitative remains to be done to understand the unseen communitylevel determinants of utilization of prenatal care and how any barriers which may exist can be reduced in socially and culturally appropriate ways number of visits were missing respectively among the latter there were no differences in their age and education profile though they were more urban 3 pregnancy is of course not an illness however in terms of the need for healthcare services it has similar attributes and can be considered under the rubric of single illness spell 4 community boundaries are defined by enumeration areas the primary sampling units used by dhs 5 suppose the likelihood of accessing prenatal services for ith individual in the jth cluster or community is given by logitfprðy ij ¼ 1jx ij j þg ¼ þ 0 x ij þ jð1þ where is the constant or intercept b is a vector of regression coefficients corresponding to observed individual householdand communitylevel covariates x ij and j is a random intercept the random intercept represents the combined effect of all omitted community level covariates that cause some pregnant women within a cluster to choose to access prenatal care the random intercept is assumed to be normally distributed with a zero mean and variance the degree of dependence or correlation between observed responses on two pregnant women i and i from the same cluster can be quantified in terms of the intracluster correlation as ¼ þ 2 3 the ratio of the clusterlevel variance to the total variance provides an estimate of the intracluster correlation the higher the degree of dependence among the observed responses within a cluster the higher would be the proportion of the total variance that is between clusters 6 the model was initially estimated using three categories unwanted wanted later and wanted as a measure of the desirability of pregnancy with wanted being a reference category the estimated coefficient of wanted pregnancy was found to be not significantly different from the estimated coefficient of wantedlater and hence both categories were aggregated into a single category wanted 7 testing for equality of the coefficients on the interaction terms between wealth quintiles and urban suggested that certain interaction terms could be aggregated as shown in table 3 8 we have run the model with and without interaction terms the likelihood ratio test for using any prenatal care is 7278 and for number of visits is 1157 this suggests that adding interaction terms results in a statistically significant improvement in model fit 9 complete results for all explanatory variables are available from the authors upon request 10 eighteen percent of the pregnant women did not seek any prenatal care of which almost twothirds belong to the bottom two wealth quintiles only 376 of the pregnant women had no education when it comes to using any prenatal care as well as the number of visits 11 since the model does not control for the partners education the estimated coefficients of maternal education dummies are likely to be biased upward reestimating the model for a subset of the sample for which data on partners education is available suggests that the size of bias is rather small for the frequency of visits and between 11 and 36 for the prenatal care attendance 12 waiting time costs are found to be substantial in a poor region of tanzania accounting for 97 of the total costs borne by maternity users at the hospital the average waiting time for the consultation was found to vary from 73 minutes at hospital to 65 minutes at health centers and to 28 minutes at dispensaries endnotes appendix

while much has been written on the determinants of prenatal care attendance in lowincome countries comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating the decisions to use prenatal care and the frequency of use using the demographic and health surveys data for 32 lowincome countries across asia subsaharan africa and latin america and appropriate twopart and multilevel models this article empirically assesses the influence of a wide array of observed individual householdand communitylevel characteristics on a womans decision to use prenatal care and the frequency of that use while controlling for unobserved community level factors the results suggest that though both the decision to use care and the number of prenatal visits are influenced by a range of observed individual householdand communitylevel characteristics the influence of these determinants vary in magnitude for prenatal care attendance and the frequency of prenatal visits despite remarkable consistency among regions in the association of individual household and community indicators with prenatal care utilization the estimated coefficients of the risk factors vary greatly across the three world regions the strong influence of household wealth education and regional poverty on the use of prenatal care suggests that safe motherhood programmes should be linked with the objectives of social development programmes such as poverty reduction enhancing the status of women and increasing primary and secondary school enrolment rate among girls finally the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to use prenatal care and have fewer visits suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy

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background disability may be defined as negative interactions between the functional impairments of people and their environment with problematic consequences 1 people with disabilities often experience difficulties in their daily lives and are limited in their activities and social participation and comprise 15 of the global population with a minimum estimated 1 billion 2 the number of people with disabilities increased every year in taiwan from 38 in 2003 to 46 in 2011 3 for decades the definition of disability remained unclear and debated among experts in the medical and social sciences 1 however two major advances have occurred in disability research recently the international classification of functioning disability and health and the united nations convention on the rights of persons with disabilities the first is the promulgation of the icf in 2001 by the world health organization 4 traditionally disabled people have been viewed from a medical perspective disability had been narrowly equated with the health condition impairment or capacity limitations of people this overly medicalized view fails to address the social factors discrimination prejudice and barrier of environmental factors that prevent the full participation of people with disabilities and unable to describe the factors such as assistive technology that contribute to the overall disability experience 45 the icf framework was developed by the who to describe health and disability at both the individual and societal level the icf framework assists in examining an individual functioning at the physical personal and societal levels and provides definitions to conduct operational assessments the icf system provides a universal framework for assessing the functioning of any person the icf classifications are based on the understanding that for any person various factors interact and all these factors must be considered to perform a proper assessment hence several components are included such as body function and structure activities and participation and environmental and personal factors the icf system provides an excellent scientific approach to collecting reliable statistics on disabled populations in japan italy and australia and portugal the icficfchildren and youth version framework has been used to guide clinical measurements and evaluations of people requiring rehabilitation home care elderly adult care special education and disability support 4 6 7 8 second the un crpd was adopted by the united nations in december 2006 and it became effective in may 2008 people with disabilities often require special support in various areas such as education housing work and social benefits to assist them to live and participate in their community the crpd states that all mainstream health services are inclusive of people with disabilities especially for older adults women and people with a low economic status since 1980 the taiwanese government enacted certain legislative procedures to create and revise categories regarding disabilities a person who fulfills the eligibility criteria for disability benefits may be granted financial aid and inkind benefits from the government however the criteria for disability evaluation were mainly based on the medical model that considered disability as a physical and mental impairment before 2007 thus physicians identified candidates for disability benefits based mainly on their severity of body impairment but without a sufficient evaluation of their daily activity participation and environmental factors in 2007 taiwan legislated a constitutional amendment known as the people with disabilities rights protection act 9 since july 2012 the act has mandated that the assessment of individual eligibility for disability benefits should be based on the icf framework the purpose of this new nationallevel model is to form links among disability evaluation needs assessment and social welfare services in order to promote the participation of people with disabilities to prepare the new disability eligibility system the taiwanese government authorized professionals to form a taiwanese icf taskforce the taskforce missions were to develop standardized measures and regulations of disability evaluation and to monitor the impacts of the new eligibility system the specific aims of this study were to 1 design the evaluation tools for disability eligibility system based on the icf and icfchild and youth 2 compare the differences of disability grades between the old and new systems 3 analyse the outcome of the new disability evaluation system methods the preparation for the reformation of the disability system began in 2007 by taiwan authorities of health and social welfare in collaboration with researchers and social welfare groups the activities of three main phases to reach the specific aims are shown in figure 3 and described in the following sections we applied to the registration system minister of interior taiwan and got this anonymized data the joint institutional review board at the taipei medical university approved this study phase i evaluation tools development we formed an implementation taskforce for this reform to survey existing resources and measures tools for people with disabilities to review the literature to design measurement items based on the selected icficfcy categories and to conduct a smallscale field trial to examine the feasibility of the developed evaluation tools step 1 taskforce building and meeting from june 2007 to december 2009 the health team facilitated 16 focus groups that were attended by 199 professional experts these members included physicians dentists nurses physical therapists occupational therapists social workers psychologists special education teachers vocational assessment workers public health scholars and representatives of welfare groups for people with disabilities all of them were familiar with the icf andor with disability assessments eight groups focused on the icf components of body functions and body structures and 8 groups focused on the icf components of activities and participation and environmental factors each focus group included 5 to 10 experts and meetings were held periodically a leader was appointed in each group to lead the discussions and assist the group in reaching an agreement through a consensus or by a vote several leader group meetings were also held to decide on the following principles measure items are designed based on second level categories of icficfcy both icf and icfcy categories should be considered scale of each item is designed based on generic qualifiers for b s and d categories and binary scale for e categories assessment should be based on existing tools with sound psychometrics such as the wechsler adult intelligence scale third edition for intelligence assessment and the berg balance scale for balance evaluation for the needs assessment of social welfare services the social welfare authority assembled another professional group simultaneously the group was tasked to develop the needs assessment tool for people with disabilities to check the services at the local government for stakeholders take and to develop the training materials for testers to conduct needs assessments based on references related to the icficfcy step 2 developing assessment tools for medical and functional assessments in the 8 focus groups on body functions and body structures each group selected categories for disability evaluation through the participation of several medical associations by numerous meeting and electronic mails the standardized examination methods for each category including the rating scale to assign qualifiers were also determined and adjusted through the physicians previous disability evaluation and clinical experiences consensus meetings and empirical data analyses of pilot studies in the 8 focus groups on activities and participation and environmental factors measures for the 137 categories that were selected from the icf checklist by consensus meeting were designed for the trial version of functional assessment 1011 an operation manual of the trial version which included standardized testing methods and qualifiers rating was drafted however due to practical reasons and the lengthy time required to administer the trial version the de focus groups later decided to adopt the 36item version of the who disability assessment schedule 20 12 instead of the trial version 1011 in the performance dimension of the functioning scale of the disability evaluation systemadult version the advantage of the whodas 20 is that it can be used crossculturally and has been tested in more than 10 countries 13 between 2007 and 2012 all of the groups held 57 meetings to discuss the disability evaluation 19 meetings were for the group leaders and 75 meetings focused on the icfcy version the meetings were held across taiwan step 3 developing measurement tools for needs assessment for understanding the profile of welfare resources and developing the needs assessment tool a resource checklist and a structured questionnaire were mailed to the administrators in charge of welfare services in every city in taiwan the needs assessment tool was also based on the icf d component and the possible environmental barriers step 4 a smallscale field trial a smallscale field trial was conducted in 2009 to test the feasibility of the trial version of disability evaluation several testers were trained by 4 training programs in two cities and two counties to collect data a total of 500 persons with disabilities in those 4 cities or counties participated in this trial phase ii evaluation tools refinement and validation step 5 refine evaluation tools after the smallscale field trial the 18 focus groups for bsd continued to refine the tools throughout the meetings according to previous trial experiences and data analyses for the bs assessment and functional assessment tools the first priority was to develop a core set for disability evaluation the main references for the core set included the manuals of the icf 4 icfcy 5 the whodas 20 and the child and family followup survey 1415 in addition we translated the whodas 20 and the cffs into chinese which were then backtranslated into english the needs assessment tools were also refined based on the icf checklist and the icfcy and its reliability was examined in this step step 6 a nationwide study we collected nationwide data and compared them with those obtained from the old system the sample was 7329 persons with 16 types of disabilities of the old system including 7098 adults and 231 children for most subjects one physician and one of the following professionals physical therapists occupational therapists speech pathologists social workers or nurses in every authorized hospital were enrolled to conduct the disability evaluations after being trained after disability evaluation a social worker conducted needs assessments with the individual family and caregivers all the evaluations were conducted using facetoface interviews with the individuals with disabilities or their familiescaregivers and by directly testing the individuals with disabilities step 7 verify the evaluation procedure health and social welfare government officials health professionals and hospital administrative staff met regularly to discuss the appropriate evaluation procedure to assist the people with disabilities in obtaining social welfare services several procedures were proposed to meet the different needs and characteristics of those individuals an information system framework was established and all data were managed through this information system and tables containing crucial information were generated automatically to be monitored by the responsible authorities 16 one dataset of the information system including 7098 disabled persons aged 18 years or older was used to compare the differences between the old and the new system phase iii implementation of the new system and impact analysis step 8 collaboration and monitor the new system at this stage we regularly monitored the results of the new system by looking into the tables that were generated automatically every month by the information system 16 central and local government officials also met regularly to discuss issues and collaborate to solve problems the data of 168052 persons who applied for disability services were used to investigate the impact of the new system the central government of taiwan also formed five counselling groups to assist local governments and authorized assessment hospitals since march 2013 these groups consisted of multidisciplinary experts government officials scholars and representatives of nongovernment social welfare organizations they are tasked to monitor the procedures and outcomes of the disability evaluations and provisional statuses of the social welfare services results development of the measures of the core set for disability evaluation this study used delphi technique to develop the bs core set for the disability assessment 17 18 19 fortythree bs categories were included in the core set most items were secondlevel categories of the icf and icfcy however to provide greater detail certain items were fourth level categories for the icf d components we designed two scales to measure the functional status of two age groups they were the fundesadult for people aged 18 years and above and the fundeschild version for children and youth 2021 the two fundes were designed based on the whodas 20 and the cffs respectively the fundesadult includes 94 items with performance and capability dimensions in domains 1 to 6 and capability and capacity dimensions in domain 8 domain 7 includes items that measure the perceived environmental barriers that people might encounter in the 2011 nationwide study 7098 adults with disabilities received the functional assessment fundesadult the indicators of performance and capability for internal consistency were between 093 and 099 factor analysis revealed a twolevel hierarchical structure the factor loadings of confirmatory factor analysis for the indicators of performance were between 08 and 089 and the capability was between 080 and 090 21 the fundeschild had 58 items which covered four parts physical and emotional health participation the child and adolescent factors inventory and the child and adolescent scale of environment the participation part includes items for measuring independence and frequency of participation and was derived from the child and adolescent scale of participation 141520 other parts measured health conditions impairment of body functions and environmental factors of the icfcy the participation part had four domains home participation neighbourhood and community participation school participation and home and community living activities the psychometric properties of the casptraditional chinese version have been found to be valid and reliable 20 development of evaluation tools for needs assessment evaluation tools for needs assessment were modified three times and 81 items were included at the end each item has capacity and performance dimensions people were also asked about their history of welfare applications family support and environmental factors the assessment was conducted with facetoface interviews with the persons or their families among the 7098 persons in 2011 6114 persons were used to examine the reliabilities of the needs assessment the internal consistency of the needs assessment was between cronbachs α 087 and 099 procedures for disability evaluation and welfare services the procedures for disability evaluation and welfare services are depicted in figure 5 in most situations one physician gives the icd9cm diagnosis codes and performs the bs assessments one qualified tester assesses the de components and the fundes after the two assessments at the authorized hospital a medical evaluation report with the information of disability determination type of disability and grade of disability will be sent to the local social welfare bureau to arrange a needs assessment for that applicant after the thorough evaluation of the needs assessment by another qualified tester the eligibility for disability benefits is determined and finalized and the disability identification will be issued to the applicant so that persons needs for state support and services can be provided there are several types of social welfare services including parking permit for the disabled personal support and care caregiver support financial support and others thus the process for a disability evaluation requires at least three authorized specialists for each person with disabilities due to the multiple services qualified testers of fundes should be professionals who have experience of providing service to people with disabilities for at least 1 year in their field and have passed the required qualification tests between 2010 and 2012 we trained more than 6000 fundes testers nationwide to perform the new disability evaluation in taiwan 22 differences between the old and new systems to compare the differences of disability grades between the old and new systems the data of 7098 disabled persons aged 18 years or older were used in this study 3869 men and 3229 women with an average age of 574 ± 176 and 601 ± 187 years respectively the causes of disability included visual impairment hearing impairment speech dysfunction motor dysfunction mental intellectual impairments vital organ impairment facial damage dementia autism chronic mental disease and rare disease the three leading types of disability were motor dysfunction chronic intellectual impairments and hearing impairment the proportion of impairment types of this sample was similar to the national population with disabilities the results showed a 497 agreement of disability grades between the old and new systems impacts of the new system a total of 168052 persons applied for services through the new system and 110667 persons were eligible for disability benefits and received the needed social welfare services to enhance their social participation discussion the icf system was unanimously accepted by the world health assembly in 2001 4 it provides a robust classification system for collecting statistics on populations with disabilities although the icf framework has been implemented in numerous countries few documentation currently exists on using the icf system to classify people with disabilities on a nationwide basis 7 23 24 25 this study demonstrated that disability eligibility system based on the icf could provide a common language between disability evaluation needs assessment and welfare services this is crucial when social welfare resources are limited by linking disability evaluations and needs assessments we can reallocate social welfare resources and provide more resources to people in need this study demonstrates a practical model for integrating the medical model with a biopsychosocial model based on the icf the estimated prevalence of disability differs across nations the reported prevalence ranges from less than 1 in kenya and 5 in south africa and bangladesh to 20 in new zealand 2627 in taiwan the disability prevalence was 47 in 2012 3 differences in the estimated prevalence among countries may arise through several factors including different cutoff values for eligibility for disability benefits different methodologies and data collection and variations in the quality of the study design a vital factor that influences the reported prevalence rate is the purpose of disability evaluation in taiwan the purpose of disability evaluation is mostly for the subsequent allocation of welfare services and allowances 28 thats why the prevalence rate of disability is lower than that of most the other countries the icf model conceptualizes disability as arising from the interaction between the health condition of a person with hisher physical cultural and policy environments 2930 if the environmental factors were designed to accommodate the full range of human functioning and were to incorporate appropriate services and support people with functioning problem would not be disabled and would be able to participate fully in society services and supports are thus not only emphasized at the individual level but also focused at the societal level 31 thus the taiwanese government selected the icf as the preferred model to assist with the reformation of disability evaluation in the country 32 in taiwan the disability assessment consists of 32 bodily functions 11 body structures and 94 items of fundes for adult 58 items for child respectively all of these codes and items were adopted from the icf checklist 33 icfcy whodas 20 and cffs however only five bodily functions and 15 activity participation codes are used to evaluate person eligibility for social security in europe 34 whether too many categories for disability assessment were used in taiwan needs to be further investigated in its old disability service system taiwan adopted a residual welfare model 35 every person with disabilities had the similar benefits from the government for example everyone had disability parking permits and assistive device allowances besides in the old system the government allocated the benefits mainly depending on the severity instead of on the basis of needs such support might be not able to enhance the participation of persons with disabilities after reformation with the new system only 469 had disabled parking permits and 237 gained assistive device allowances besides the government provided services according to results in the functional and needs assessments based on taiwans experiences of disability evaluation using the icf the following guiding principles are suggested for countries that might use icf in their disability evaluation for hospitals and other medical providers a multidisciplinary team approach will be required to complete the evaluations and the number of testers and rooms for testing must be expanded for local government the budget for disability assessments should be increased than the traditional medical model and more collaboration and information sharing among different sectors and disability groups to resolve case disputes for the central government quality of professionals for the disability evaluation should be regulated and that the diverse resources and delivery system should be organized effectively to meet the various needs of people with disabilities and the results of the disability evaluation should be integrated with other social welfare system such as longterm care or medical care to decrease redundant evaluations for people with disabilities and their families some might be affected by a change in the new system such as pension might be less however the services related to social participation would be enhanced limitations the final determination of the disability grade was obtained from a summary of assessment however no empirical evidence or nationwide data currently exist for justifying the use of certain cutoff values for disability evaluation the validity of the cutoff values to determine the disability grade has yet to be established and needs further research instruments and methods require further testing and validation conclusions this study demonstrated that disability evaluation system based on the icf could provide a common language between disability assessment needs assessment and provision of welfare services we implemented a new system to assess a persons eligibility for disability benefits at a national level however the proposed procedure and tools require additional testing and validation abbreviations icf international classification of functioning disability and health who world health organization crpd convention on the rights of persons with disabilities whodas 20 who disability assessment schedule 20 version cffs child and family followup survey waisiii wechsler adult intelligence scale third edition fundesadult functioning scale of disability evaluation system adult version fundeschild functioning scale of disability evaluation systemchild version casp child and adolescent scale of participation hcla home and community living activities competing interests the authors declare that they have no competing interests authors contributions wtc and thl participated in the design of the study cfy swt and wcc contributed to acquisition of the data hfl khc and yhw perform the statistical analysis and interpretation of the data wtc cfy swt hfl and thl drafted the manuscript khc and yhw revised the manuscript critically all authors read and approved the final manuscript

background before 2007 the disability evaluation was based on the medical model in taiwan according to the people with disabilities rights protection act from 2012 the assessment of a persons eligibility for disability benefits has to be determined based on the international classification of functioning disability and health icf framework nationwide the purposes of this study were to 1 design the evaluation tools for disability eligibility system based on the icficfchildren and youth 2 compare the differences of grades of disability between the old and new evaluation systems 3 analyse the outcome of the new disability evaluation system methods to develop evaluation tools and procedure for disability determination we formed an implementation taskforce including 199 professional experts and conducted a smallscale field trial to examine the feasibility of evaluation tools in phase i to refine the evaluation tools and process and to compare the difference of the grades of disability between new and old systems 7329 persons with disabilities were randomly recruited in a national populationbased study in phase ii to implement the new system smoothly and understand the impact of the new system the collaboration mechanism was established and data of 168052 persons who applied for the disability benefits was extracted from the information system and analysed in phase iii results the measures of the 43 categories for body functionstructure components the functioning scale of disability evaluation system for activitiesparticipation components and the needs assessment have been developed and used in the field after several revisions in phase ii there was 497 agreement of disability grades between the old and new systems in phase iii 110667 persons with a disability received their welfare services through the new system among them 77 received basic social welfare support 89 financial support 24 allowance for assistive technology 7 caregiver support 8 nursing care and rehabilitation services at home and 47 were issued parking permits for persons with disabilitythis study demonstrated that disability evaluation system based on the icf could provide a common language between disability assessment needs assessment and welfare services however the proposed assessment protocol and tools require additional testing and validation

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background health is unequally distributed across society evidence reveals social class gradients in health outcomes at every stage of the life course with disadvantaged populations faring worse with regards to noncommunicable disease risk prevalence and correspondingly life expectancy 1 many health behaviours are socially and economically patterned playing a central role in shaping inequalities in population health outcomes through affecting the development of disease and overall quality of life 23 in developed and many developing countries differences in physical activity behaviour across subgroups contribute to existing health inequalities including stark socially graded differences in obesity prevalent across populations 4 the benefits of engaging in regular physical activity during childhood and adolescence are well established playing a critical role in promoting health and reducing future disease risk and mortality 5 however despite the breadth of welldocumented health benefits 6 7 8 9 most children and adolescents do not meet global recommendations for physical activity and are not active enough to benefit their health 1011 following significant declines during the transition from childhood into adolescence physical activity further declines into adulthood 12 with levels tracking across the lifespan 13 14 15 thus differences in physical activity behaviour between subgroups of the adult population may develop during childhood accordingly childhood is a critical time to intervene and change behaviour before patterns become entrenched for life 16 the development of effective and sustainable interventions to increase physical activity in children has been identified by many governments and public health agencies as a key research priority for improving health outcomes 17 however the equity impacts of these interventions are unclear with concern being raised regarding the possibility that even where interventions successfully improve overall behaviour across a population they also may inadvertently increase inequalities by not equally benefiting subgroups of individuals within the population 1819 differential effectiveness frequently termed intervention generated inequalities ensue when interventions provide greater benefit to one population group over another 20 such an effect is concerning when an intervention provides greater benefit to advantaged than disadvantaged groups evidence from evaluations of childrens physical activity interventions have revealed that inequalities are generated at multiple points throughout the intervention process including by differential provision of and access to interventions and resources 21 variation in uptake 22 differential intervention efficacy 2324 differential long term compliance 25 and differential response in evaluation 26 while these evaluations of individual trials provide an indication of the potential for equity generating effects within childrens physical activity interventions across the wider literature there is not a coherent overall understanding of the direction and size of effect across equity factors despite the frequent use of systematic reviews for decision making very few analyse or report equity effects 27 multiple recent reviews have investigated the effectiveness of childrens physical activity interventions across varying settings 28 29 30 31 32 33 34 35 yet there is limited consideration for the differential effects of the included interventions this has resulted in a lack of understanding of the characteristics and features of interventions that generate or reduce inequalities in childrens physical activity behaviour across population subgroups in addition it is possible our understanding of equity effects is biased due to underreporting of differential effects when statistical significance is not achieved it is currently unknown whether there is sufficient consideration of differential effects across individual interventions to enable a full systematic review and furthermore whether trials report appropriate data to allow for retrospective analysis of the question given this lack of clarity we conducted this review in a scoping manner to map out the existing state of the literature the purpose of this scoping review was to assess the availability of evidence for differential effects of childrens physical activity interventions and investigate the characteristics of interventions that study differential effectiveness the collation of evidence through this systematic scoping review will be valuable in providing an overview of the literature with an aim of identifying where evidence gaps exist to direct future research methods with an aim of identifying research gaps and mapping out the existing literature by examining the extent and nature of research this review was conducted as a scoping review a literature search was conducted to identify relevant published controlled trials designed to promote physical activity in children 618 years of age in school community home or healthcare based settings searches were conducted in six electronic databases in may 2016 all sources were searched with a prepiloted search strategy with no restrictions by publication year geographic location ethnicity or other sociodemographic indicators searches were limited to manuscripts available in english the search strategy as used in medline is included in additional file 1 file s1 the review protocol was registered with prospero inclusion criteria the search strategy was designed to retrieve controlled trials of single or multicomponent interventions in the school home healthcare or community environment aimed at increasing schoolaged children and adolescents levels of physical activity with a minimum intervention or normal control group and objectively assessed physical activity at baseline and followup the full inclusion and exclusion criteria are outlined in table 1 these inclusion criteria were based on existing knowledge of the literature base demonstrating the presence of numerous controlled trials 33 using objective forms of physical activity measurement 32 within the population of interest as selfreported activity is also likely to be differentially biased 36 we established restrictive inclusion criteria while conducting the review in a scoping manner to map out the availability of evidence contained within the trials intervention screening and selection primary article titles identified following deduplication of the initial search were manually screened and those clearly outside the review criteria discarded the abstracts of the remaining citations that passed the initial title screening were independently reviewed and compared to the inclusion criteria to determine if retrieval of the full primary study was needed for further examination the initial literature searches and scanning stages were conducted by one reviewer a 15 random sample was double checked at each stage the full text screening was performed in duplicate by two authors at the full text phase related and preidentified reviews on the same topic were scanned for missing trials 29 31 32 33 all discrepancies were resolved through discussion amongst the research team supplementary searches for associated publications for each trial that met the inclusion criteria steps were taken to retrieve all associated publications to ensure that equity analyses reported separately to the main intervention effect paper were captured to find associated publications for each included trial subsequent searches were performed using trial names and registration numbers additionally forward citation tracking on google scholar was used to screen and identify additional trial publications that referenced the main effect paper included in this review data extraction for each trial that met the inclusion criteria intervention characteristics and covariates were extracted using a preestablished data extraction form and microsoft excel at each stage of the review process all data was managed using mendeley reference manager data extraction was performed in duplicate the extracted data included trial name journal of main intervention effect paper and year of publication study population and size setting baseline descriptive data equity data collected at baseline intervention type intervention targeting ethnicity socioeconomic status place of residence and religion intervention effects across all outcomes differential effect analyses and the methods utilized to investigate differential effects subgroup analyses were classified as the evaluation of treatment effects by subgroups of participants defined at baseline by an equity characteristic while interaction analyses were identified as the use of an overall statistical test to directly compare differences in intervention effects across subgroups 37 equity data and analyses were considered across progressplus a framework created to ensure explicit consideration for the multiple intersecting factors that affect health equity within research and intervention design 38 differential effects were considered across all factors outlined by the progressplus framework applicable to a child population gender socioeconomic status ethnicity place of residence and religion 39 ses data and analyses were further classified by whether ses had been measured at the family school or community level to give an indication of how ses was conceptualised in this context in addition bmi was included as an additional equity factor of particular relevance in the context of physical activity interventions in consideration of substantial evidence indicating it is patterned by ses geographic area and ethnicity 40 41 42 other factors included in the progressplus framework were not considered relevant within a child population and excluded all discrepancies in data extraction were resolved through discussion amongst the research team as per standard practice for scoping reviews methodological quality assessment of included interventions was not performed 43 analysis graphical and narrative methods were used to summarize the results subsequently logistic regressions analyses were performed to determine if certain intervention or study characteristics influenced the likelihood of reporting of differential effects intervention and study characteristics of interest included as exposure variables in logistic regression models were journal impact factor country of origin intervention setting participants ages sample size and whether or not positive main intervention effects were reported outcomes comprised of whether or not any equity effects were studied and whether or not gender equity effects were studied no other equity characteristics were considered frequently enough to allow for further analysis univariable models were run for each exposureoutcome pair results figure 1 outlines the search and screening process the database search resulted in the identification and retrieval of 13052 records including 7963 unique records after removal of duplicates following title and abstract scanning 241 potentially relevant articles were screened in full text ensuing assessment against the inclusion criteria led to inclusion of 125 publications representing 113 intervention trials citation and trial registration number searches identified an additional 92 associated publications of which 39 had appeared in the original database search the reference lists of included trials and associated publications are included as additional files characteristics of included interventions the characteristics of included trials are outlined in table 2 the majority of the 113 included trials were conducted in europe followed by north america and australasia of the remaining 5 4 were conducted in asia and 2 in south america only 3 were conducted in low and middle income countries fortytwo percent of trials were targeted solely at physical activity behaviour change while 58 were targeted at multiple health behaviours primarily a combination of diet and physical activity of the included trials 74 had intervention components that took place in schoolbased settings 56 in homebased settings 30 in communitybased settings and 3 in healthcarebased settings the mean sample size of included trials was 267 ranging from 18 to 3010 participants the average age of participants at baseline ranged from 6 to 165 years of age with a mean of 103 years of the 113 included interventions 21 were targeted specifically by gender while 19 were targeted by bmi and 17 by ethnic groups in addition a number of interventions were targeted by school and community level ses of all included trials 90 reported a main intervention effect on any outcome while 66 reported a main intervention effect on objectively measured physical activity differential effect analyses figure 2 presents the number of included trials that captured equity data at baseline and the number that subsequently conducted equity analyses of the 98 interventions not targeted by gender all reported gender data with 45 of the 98 exploring differential effects by gender through subgroup or interaction analysis across the remaining equity characteristics differential effects were explored substantially less frequently of the 86 included interventions with reported bmi data 16 reported differential effects only 7 of the 60 trials with reported ses data 1 of the 49 with reported ethnicity data and 1 of 3 with reported place of residence data documented exploration of differential effects of the 70 equity analyses reported most were performed by subgroup analysis with considerably fewer by interaction analysis factors predicting differential analyses table 3 highlights the characteristics of differential effect analyses by each equity characteristic logistic regression models indicated that significantly more is known about equity in the context of schoolbased interventions in comparison to other contexts studies investigating schoolbased interventions were 29 times more likely to report differential effects by any factor and 45 times more likely to report differential effects by gender as expected due to differences in statistical power an increase in sample size was associated with an increased odds ratio of conducting differential effect analysis country of origin intervention type age and journal impact factor were not significantly associated with reporting of differential effects regression models indicated that a main intervention effect on objectively measured physical activity was associated with subsequent exploration of differential effects by equity subgroups when restricted to exploration of differential effects by gender this likelihood increased to a odds ratio of 36 discussion to the best of our knowledge this is the first review to provide a comprehensive overview of available evidence on consideration of equity effects in the childrens physical activity literature we have revealed a scarcity of consideration for equity despite all included trials collecting at least one equity characteristic of interest at baseline a limited number reported investigating analyses of differential effectiveness when reported differential effect analyses were primarily concentrated on gender with substantially fewer focusing on bmi ses ethnicity place of residence or religion the failure of authors to report equity analyses reinforces a lack of understanding of and importance given to intervention generated inequalities the wider health literature supports these findings with reviews of both smoking interventions and universal schoolbased behavioural interventions indicating similar rates of equity analyses with accompanying calls for more routine testing of differential effects 4748 similar to these results analyses within the adult physical activity intervention literature have found that despite researchers commonly measuring equity characteristics at baseline differential effect analyses are infrequently reported in trial evaluations 4950 likewise when reported analyses are mostly confined to gender with considerably less attention given to other equity characteristics the lack of equity focus identified in this review is surprising considering the widespread public health policy focus on inequality 275152 despite overarching policy goals in practice we have a very limited understanding of the potential for inequality generating effects from current intervention efforts as a research community we are not accumulating the evidence policy makers need to deliver on objectives and targets for the development and implementation of interventions that effectively reduce health inequalities considering the state of the evidence and paucity of data we recommend and echo prior calls for the conduct and reporting of differential effect analyses 50 however we acknowledge the financial and resource requirements of running sufficiently large trials powered to detect a main intervention effect let alone differential effects between subgroups to tackle these critical questions we encourage a coordinated effort towards fewer highquality large trials adequately powered to address questions of differential effectiveness continuing to amass evidence solely to address the question of overall effectiveness will only propagate our current level of understanding and limit the evidence base from progressing we acknowledge the potential generation of false negative results as a consequence of subgroup and interaction analyses with inadequate statistical power 53 54 55 while it is encouraging that included interventions with a larger sample size were more likely to perform differential effect analyses we do not specifically know what proportion of the 70 differential effect analyses were adequately powered considering that many trials focus on recruiting sufficient participants to detect differences in effect between intervention arms 56 it is crucial that each analysis is interpreted sensibly and the credibility of the analyses carefully scrutinized independently against established criteria 37 57 58 59 guidelines categories marked with a a are not mutually exclusive generally advise conducting a small number of differential effect analyses that are prespecified and based on strong theory adjustment for multiple testing is considered and that reporting indicates if analyses were preplanned or performed posthoc unfortunately previous evidence has indicated that differential effect investigations by subgroup analyses are often not prespecified in protocols and even when they are 90 deviate from the described plan 60 when possible interaction analyses should be preferentially performed as these provide a more direct test of differences in effect 61 considering the possibility that reporting of differential effect analyses is dependent on the achievement of statistical significance at a p ≤ 005 level we need to continue moving towards required prespecification in protocols and analyses plans and the enforcement of reporting of any deviations and accompanying rationales in trial publications by reviewers and journals alongside this evidence is the proposition that authors may be particularly likely to explore subgroup analyses if they did not find a main intervention effect encouragingly this hypothesis was not supported within this review with trials that found a main intervention effect being significantly more likely to conduct differential effect analyses in comparison to those that did not girls are well known to be on average less active then boys 6263 this observation is likely influencing the focus on assessment of differential intervention effects by gender moreover compared to gender ses and ethnicity are challenging to accurately measure within populations of children and adolescents evidence has shown difficulties in the conceptualization of ses and inconsistencies in the relevance of tangible measures of education occupation and income in relation to childrens perceived ses 64 additionally when parental questionnaires are utilized to help overcome these differences new challenges arise evaluations indicate that the completion of parental questionnaires and consent forms is socially patterned with factors including poor literacy levels among low income parents affecting the return of signed consent forms 65 furthermore gender is generally equally distributed across participant samples and study groups in comparison ethnicity and ses often end up considerably skewed towards the majority within that specific context since intervention trials are frequently implemented within a restricted region of schools and neighbourhoods these differences in distributions may result in an increased likelihood of gender being adequately powered for differential effect analyses in comparison to the remaining equity characteristics it is likely that these issues contribute to the differences and patterns identified in these analyses there is growing evidence that certain subgroups such as girls children with disabilities and those from minority ethnic groups and low ses families or neighbourhoods have lower levels of physical activity than their counterparts 63 66 67 68 69 70 71 72 which contribute to associated and apparent health inequalities 73 in response a multitude of interventions tailored to the characteristics of highrisk subgroups have been developed 31 as evidenced in this review with more than a third of included trials targeted by at least one equity factor and a subset of these targeted by multiple equity characteristics the comparative effectiveness of targeted vs nontargeted interventions is largely unknown as the interventions evaluated differ substantially although fig 2 total number of trials that reported each equity characteristic of interest at baseline and number of which reported differential analyses by subgroup and interaction analysis trials targeted by each equity characteristic are not included in the figure subgroups of highrisk children may benefit from an intervention targeted directly at them public health benefits in terms of physical activity and health outcomes may be limited in the absence of a population approach roses theory of disease prevention suggests that it is more efficient to utilize a universal program approach that works to shift the entire population distribution of a risk factor then focus exclusively on a highrisk subgroup through a targeted intervention 74 analyses of differential effects in response to one universal intervention revealed greater benefits to girls and inactive children but also significant benefits to boys and those already active 75 this suggests that a gendertargeted approach in this case may have disregarded a subgroup also able to benefit while it is likely that the optimum population preventative strategy incorporates a tiered combination of both targeted and universal approaches the optimal balance for the greatest impact on behaviours and disease risk at maximal costeffectiveness is unclear given this state of the evidence we highlight the concurrent need for research of the comparative effectiveness of interventions targeted specifically at population subgroups and those that are universally targeted it is critical these efforts work to understand the comparative effectiveness while considering the lack of effect within the nontargeted subgroup this scoping review has multiple strengths including the systematic searches duplicate review methods and the consideration of a wide range of evidence as is inherent within a review this work is limited by reporting and quality within the included primary studies due to the nature of the review as a scoping exercise to map out available evidence we did not look at the reporting and analysis of interaction and subgroup effects in a detailed manner we also recognize the limitations inherent in combining a heterogeneous set of intervention studies with varying aims and implemented across a variety of settings we further acknowledge the intrinsic challenges in the use of ses due to the fact it is measured at multiple levels with each captured by numerous indicators as appropriate for a scoping review we are unable to draw conclusions regarding the extent of differential effectiveness in childrens physical activity promotion efforts however the results indicate that there may be sufficient data available for a more indepth exploration of differential effectiveness either through metaanalyses or pooling of primary data this may need to be performed within a more homogeneous subset of studies and take the operationalization of varying indicators into consideration conclusion there is a widespread lack of knowledge of the equity effects of childrens physical activity interventions despite often collecting relevant information at baseline most controlled trials do not report analyses of differences in intervention effect more evidence is needed to effectively understand how current intervention efforts are affecting existing behavioural inequalities across population subgroups of children while being mindful of the tension with statistical constraints understanding the characteristics of interventions that generate differential effects has important implications for directing future research and intervention development as governments and international health organizations increasingly advocate the need for equity focused evidence to inform population interventions addressing health inequalities there needs to be action to ensure that intervention evaluations and systematic reviews consider and address these equity effects additional file authors contributions rl evs and ja designed the study rl performed the literature searches rl and evs conducted the title abstract and full text screening rl and ja conducted data extraction rl drafted the manuscript all authors contributed to the interpretation of the results and critically reviewed the manuscript all authors read and approved the final manuscript ethics approval and consent to participate not applicable competing interests all authors declare that they have no competing interests

background differential effects of physical activity pa interventions across population subgroups may contribute to inequalities in health this systematic scoping review explored the state of the evidence on equity effects in response to interventions targeting childrens pa promotion the aims were to assess and summarise the availability of evidence on differential intervention effects of childrens pa interventions across gender body mass index socioeconomic status ethnicity place of residence and religion methods using a prepiloted search strategy six electronic databases were searched for controlled intervention trials aiming to increase pa in children 618 years of age that used objective forms of measurement screening and data extraction were conducted in duplicate reporting of analyses of differential effects were summarized for each equity characteristic and logistic regression analyses run to investigate intervention characteristics associated with the reporting of equity analyses results the literature search identified 13052 publications and 7963 unique records following a duplicate screening process 125 publications representing 113 unique intervention trials were included although the majority of trials collected equity characteristics at baseline few reported differential effects analyses across the equity factors of interest all 113 included interventions reported gender at baseline with 46 of nongender targeted interventions reporting differential effect analyses by gender respective figures were considerably smaller for body mass index socioeconomic status ethnicity place of residence and religion there was an increased likelihood of studying differential effects in school based interventions or 29 1272 in comparison to interventions in other settings larger studies per increase in 100 participants 12 10 14 and where a main intervention effect on objectively measured pa was reported 30 1368 conclusions despite regularly collecting relevant information at baseline most controlled trials of pa interventions in children do not report analyses of differences in intervention effect across outlined equity characteristics consequently there is a scarcity of evidence concerning the equity effects of these interventions particularly beyond gender and a lack of understanding of subgroups that may benefit from or be disadvantaged by current intervention efforts further evidence synthesis and primary research is needed to effectively understand the impact of pa interventions on existing behavioural inequalities within population subgroups of children trial registration prospero prospero 2016 crd42016034020

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china has a rapidly aging population that comprises an increasing proportion of the overall population by 2020 the number of people 60 years old and older is projected to grow to 2439 million or 17 of the total population however china lacks a mature social infrastructure such as a social security system and health care program to meet the demands of its aging residents health and health care costs have become a major concern among older adults in china encouraging participation in productive activities has become a viable way to help older chinese adults remain healthy and active in recent years many national programs such as silver aging action have been established to engage older adults in productive activities in urban cities nonetheless research on productive aging in china is still in the early phase of development and has focused mainly on the prevalence of productive activities and predictors of participation in these activities by older adults moreover most previous studies on productive aging used regional samples making it difficult to generalize the results to a broader population in mainland china to the best of our knowledge no study has been conducted to examine the relationship between productive aging activities and health among older adults in china a productive aging activity refers to any activity performed by an older individual that produces socially valued goods or services whether paid for or not or that develops the capacity to produce such goods or services paid employment providing assistance to families and volunteering are three major categories of such productive activities research has generally shown that engagement in these productive activities is associated with favorable health outcomes such as lower levels of morbidity mortality and depression in later life however previous research on productive aging has mainly focused on volunteering and its effect on health resulting in an incomplete understanding of the effects of other productive activities moreover these studies were conducted mostly in western countries with welldeveloped income support programs and health care systems thus providing limited information on cultural variations in the relationship between productive activities and health in lessdeveloped countries this study intended to address these gaps by investigating the effects of different productive activities on health among older adults in china a developing country with a vastly different cultural and social context paid employment and health china has a mandatory retirement age of 60 for men and 55 for women such a policy has curtailed the careers of many youngold adults who are still in their productive years it has also unintentionally legitimized the practice of discrimination against women in the labor market however continuing to work and maintaining financial security after retirement age has become a necessity for many especially older adults with lower education levels or without wealth or economic assets many adults seek reemployment after they retire however most often jobs available to them in private market are contract jobs with little or no benefits whether continuing to work during old age renders any health benefit is unclear one study examined crosssectional baseline data from the korean longitudinal study of aging and found that employment status was not associated with mental health among older koreans whereas another study using crosssectional national data from the sample survey of older adults in urban and rural china found that continuing to work in old age was associated with better selfreported health among older chinese adults attention needs to be paid to those in poor health who tend to exit the labor market early research has shown that those with a poor work environment and health complaints before retirement experienced improved health after retirement regardless of gender and occupational grades and such improvement lasted for 810 years previous studies also noted unemployed older men tend to report worse mental health than unemployed older women assisting family and health china has been characterized as a familyoriented collectivist society in which reciprocity among family members and across generations is expected and often practiced cultural and conventional expectations of caring for grandchildren and doing housework have tended to fall upon women more than men older adults provide a wide range of assistance to their adult children with tasks such as house cleaning cooking and raising grandchildren providing assistance to family members can differ widely in terms of level of involvement and intensity we limited our review of the literature to homemaking and caring for grandchildren considering their relevance to our study variable in a crosssectional study caring for grandchildren was negatively associated with selfrated health among those widowed longer compared with those married or widowed more recently suggesting an exacerbated effect of caregiving on a disadvantaged senior group in the same study helping with household chores was associated with a lower likelihood of reporting good selfreported health chen and liu examined six waves of data from the china health and nutrition survey and found that providing highintensity care to younger grandchildren accelerated health declines among coresiding grandparents whereas a less intense level of care had a protective effect on health these results suggested that providing assistance to family members is associated with health condition but how family assistance is related to depression or functional limitation needs further exploration volunteering and health volunteering by older adults has been heavily promoted via several national policy guidelines since 2000 national programs such as silver aging action have mobilized large number of seniors to volunteer to the best of our knowledge no study has been conducted to examine the effect of volunteering on health among chinese individuals studies conducted in western societies have produced less equivocal evidence that volunteering in later life is related to improved wellbeing one study used three waves of data from the americans changing lives study and found that older adults who volunteered and engaged in more hours of volunteering reported better selfrated health less depression and improved functional health independent of gender and race volunteering was associated with lower cumulative odds of frailty in a study using two waves of data from the macarthur study of successful aging it was also associated with fewer depressive symptoms and functional limitations in another study in which older adults participated in the experience corps a highcommitment us volunteer program for 2 years in general volunteering has been shown to have mental and physical benefits for both older men and women given chinas vastly different social contextin which national retirement policies create discrimination against older women in the labor market caregiving roles are traditionally held by women and the volunteer sector is mainly run using a topdown approachit is important to study how relationships between productive activities and health vary among older men and women in urban areas using data from a nationally representative sample we examined whether involvement in productive activities is correlated with health outcomes and whether such relationships differ by gender we asked the following specific questions to what extent do older chinese adults participate in productive activities such as paid work caring for family members or volunteering does participation in productive activities vary according to gender is participation in productive activities related to better health outcomes how does this relationship vary by gender how does the effect of each type of activity vary methods data source and participants the data used in the current study came from the sample survey on aged population in urbanrural china conducted in 2006 by the china research center on aging to ensure all geographical regions were appropriately represented the crca selected 20 divisions from all provinciallevel administrative divisions throughout china provinciallevel administrative divisions included provinces autonomous regions metropolises and special administrative regions the number of sample divisions allocated to each region was approximately proportional to its population the survey was based on a stratified multistage quota sample design first 20 divisions were selected second within each division four cities and four counties were selected using the same measure of size third 16 blocks and 16 rural townships were selected within each division all urban residential communities within the 16 blocks and all the villages in the 16 townships were listed together fourth a quota sample of 50 urban residential committees was selected with equal probability within each province fifth 50 urban residential communities and 50 rural villages were selected at random from the list in the case of households with more than one person aged 60 years or older one individual was selected at random this resulted in a sample of approximately 500 urban and 500 rural older adults in each province the sampling method and data collection have been described in more detail elsewhere potential participants were contacted and asked for informed consent unavailable subjects were replaced by older adults in the households next to those originally chosen based on the kish table provincial or county committees on aging recruited interviewers who conducted interviews using a structured questionnaire after receiving intensive standardized training from crca officials a proxy was used for individuals who had difficulty answering interview questions to ensure the quality of interviews crca researchers and personnel from the bureau of statistics and the bureau of civil affairs supervised the interview process upon completion questionnaires were examined onsite by interviewers and offsite by their supervisors to ensure completion of the questionnaires to minimize missing data all valid questionnaires were returned to the crca for further review and data entry more details regarding the procedure can be found elsewhere the final sample included 19947 individuals with a response rate of 971 given our focus on productive activity which is a concept less recognized and less common among rural older adults particularly in terms of paid employment and volunteering the present study focused on urban participants only for this analysis 10016 individuals aged 60 years or older were included measures health outcomeswe considered multiple aspects of health to gain a more comprehensive understanding of the effects of productive aging on health both physical health and mental health were included selfrated health was measured using a 5point likert scale ranging from 1 very bad to 5 very good depression was measured using a short form of the geriatric depression scale which consisted of 15 items the gds15 was used to determine the degree to which participants experienced depressive symptoms during the previous week this scale has been extensively used with chinese populations in mainland china hong kong and the united states and has been confirmed as crossculturally reliable and valid of the 15 items 10 indicated the presence of depression when answered positively whereas the remaining 5 items indicated depression when answered negatively respondents answered whether they experienced each symptom during the past week after reverse coding the 5 items that indicated depression when answered negatively a sum score was calculated with higher scores indicating a higher level of depression the reliability coefficient for the scale was 078 functional health was measured using activities of daily living and instrumental activities of daily living adls refer to the ability to perform basic activities such as eating dressing using the restroom getting in and out of bed mobility locomotion at home and bathing similarly iadls include meal preparation laundry sweeping carrying 10kg objects and walking 152 km adl and iadl scores were the sum of six adl and five iadl items all adl and iadl items were rated on a 3point likert scale 1 not difficult at all 2 a little bit difficult and 3 unable to perform the task the internal consistencies of the adl and iadl measures were 87 and 88 respectively sum scores for functional health were calculated with a range of 1133 higher cumulative scores indicated more limited functional ability productive activitiesmorrowhowell and colleagues notion of productive aging was used as our framework for understanding productive activities in old age this framework is a useful umbrella under which to consider the wide range of involvement of older adults in productive activities and the relationship between such productive activities and health paid work was defined as maintaining a paid job after age 60 including both fulltime and parttime work this dichotomous variable was measured by asking the respondents do you have a paid job at the time of the survey providing assistance to family was measured by asking the participants have you helped your family with the following activities looking after the house helping with chores and caring for grandchildren this item was dichotomized as either helping with any of the three activities or not volunteering was measured by asking the respondents have you participated in the following activities neighborhood watch voluntary labor mutual aid group mentoring youth and other volunteer activities this item was dichotomized as either participating in any type of volunteer work or not control variablessociodemographic and health variables including age gender education marital status selfrated financial condition and chronic conditions were included as control variables in this study based on a review of health outcomes literature among chinese populations age was measured as an intervallevel variable and entered as a continuous variable in the multivariate models it was also recoded based on 5year age groups and used in the descriptive analyses gender was a dichotomous variable education was measured with four categories 1 no formal education 2 primary school 3 high school and 4 college and above marital status was dichotomized as married or not married selfrated financial condition was measured using a 5point likert scale 1 having a surplus 2 just enough 3 soso 4 difficult and 5 very difficult chronic illness was measured by asking older adults whether they suffered from any chronic disease at the time of the survey data analysis the analysis included examining the rates of participation in productive activities among men and women overall as well as by age education marital status financial condition and health status next the relationships between participation and selfrated health depression and functional health were modeled using linear regression general regressions were first conducted with interaction terms between gender and the three productive activities then the regression models were run separately for men and women the regressions were first adjusted for control variables of age education marital status financial condition and health conditions in model 1 then each activity was added in model 2 all analyses were performed using spss 150 results table 1 displays the demographic characteristics of urban older adults in this study the average age of respondents was 71 years and approximately half were women many participants reported receiving a high school education or higher and approximately two thirds were married they reported an average score of 313 regarding financial strain on a 5point likert scale a majority reported having at least one chronic health condition at the time of the survey average selfrated health was 305 on a 5point likert scale the mean level of depression was 479 on a scale that ranged from 0 to 15 because a score of 58 indicates mild depression this study showed a relatively mild level of depression among older urban chinese adults these participants also had few functional limitations with a mean score of 1337 regarding participation in productive activities only 52 of older adults in our sample had a paid job at the time of the survey most of them helped family members in one way or another nearly half of the respondents participated in some type of volunteer activity the statistics presented in table 1 are consistent with other national surveys and census data table 2 shows levels of participation in each productive activity for both men and women by age education marital status financial strain and chronic illness there were significant differences in participation in paid work between men and women with 77 of men and 27 of women reporting paid employment there were also significant gender differences in providing help to family members with women more likely to provide assistance to family than men however there was no significant difference between men and women in terms of volunteering in general the only significant difference between sexes was found in the category of mentoring youth when we examined specific age groups our results indicated that participation in paid work decreased dramatically with age particularly for women compared with men helping family members and engaging in volunteer activities also significantly decreased with age older adults who were married or had higher education levels regardless of gender were more likely to participate in all three types of productive activities participants with no chronic illnesses were more likely to participate in productive activities additionally assisting family and volunteering increased among those with better financial status regardless of gender men with better financial status were more likely to participate in paid work whereas financial status had no influence on paid employment for women table 3 shows the results of regression analyses regarding the relationship between each productive activity and health outcomes after controlling for sociodemographic factors the results showed that paid employment was significantly associated with fewer depressive symptoms better functional health and better selfrated health providing assistance to family and volunteer work were also found to be significantly related to fewer depressive symptoms better functional health as well as better selfrated health to test gender differences we entered three interaction terms in the model the interaction term of female × paid employment was statistically significant suggesting the effect of paid employment on depression differed by gender a similar level of significance was found for female × family assistance on functional health but not for female × volunteer interaction the results indicated that gender moderated the relationship between paid employment and depression as well as between assisting family and functional health figure 1 displays the effects of paid employment on depressive symptoms after controlling for sociodemographic variables as shown having paid employment was associated with fewer depressive symptoms for older men but not older women similarly figure 2 indicates that providing family assistance was related to fewer functional health limitations and this effect was more prominent for older women to further examine the magnitude of the relationship between each productive activity and health outcomes by gender and compare the effects of each type of activity on health separate regression analyses were further conducted the results indicated that having a paid job was significantly associated with decreased depression for men but not for women helping family members and volunteering were associated with lower levels of depression fewer functional limitations and better selfrated health for both men and women statistical tests were further conducted to examine whether the coefficients of each productive activity on health outcomes are statistically different in size between men and women the results showed that the coefficient of paid work on depression among men was significantly different from that among women and the coefficient of family assistance on functional health among men was significantly different from that among women there were no significant differences in size between men and women on coefficients of volunteering on health outcomes when the effects of three productive activities on health outcomes were compared we found that volunteering had a consistently greater effect on depression functional health and selfrated health among women compared with the two other activities for men volunteering had a similar effect on depression and functional health but paid employment exerted a slightly greater influence on selfrated health compared with the other activities discussion and conclusion using representative national data this study examined participation in productive activities and its association with multiple health outcomes among older adults in urban china the results showed that older chinese adults in urban cities had a low participation rate in paid employment but high participation in assisting family and volunteering participation in these activities was generally associated with positive health outcomes but the effects varied the effects of paid employment on depression and family assistance on functional health differed significantly between genders similarities and differences exist between our findings and those reported for western populations in terms of participation in productive activities we found that men and women participated in productive activities to a certain extent but they differed in their choice of activities older men and women tended to follow the traditional division of labor women cared for family members and helped with housework whereas men tended to retain their breadwinner role by maintaining paid work even after retirement age gender differences did not emerge in terms of volunteering activities we found that the labor force participation rate of both men and women in china was lower than adults aged 65 and older in the united states this is mainly due to the wide implementation of mandatory retirement in china nonetheless younger participants with better health education and financial status were more likely to be employed beyond retirement age congruent with the literature we found that age education health and wealth played important roles in predicting participation in productive activities our results showed generally positive correlations between paid work and physical and mental health however the positive relationship between paid work and depression differed by gender mens psychological wellbeing was positively associated with paid work an association not found among women a similar gender difference has been reported among older korean adults we suspect that older men may benefit from paid work through role identificationthey are able to continue their role of breadwinner and thus feel valued as a contributing member of the family and society men may also benefit from paid employment through the social network they gain in the workplace which may buffer against mental distress our study demonstrated that assisting family members was associated with lower levels of depression and better functionality and selfrated health after controlling for other demographic and health variables such effects were evident among both men and women we suspect several mechanisms may explain how providing assistance to family could result in physical and psychological benefits for older adults first being active and able to help family members could boost the selfesteem of older adults simply by making them feel useful second providing assistance to family implies more frequent interaction with family members which can decrease social isolation and contribute to better subjective wellbeing third assisting the family in various ways fits the traditional concept of mutual support among family members older adults may feel psychologically satisfied by following tradition finally helping the family in one way or another can help older adults stay physically active thus improving their health outcomes however these findings should be interpreted with caution because our measure of providing assistance to family involved only three activities we recognize that older adults involved in highintensity caregiving to family members with serious diseases may experience negative health outcomes in addition inverse causality may exist those who are physically healthy are more capable and more likely to offer help to their families a previous study demonstrated that caring for grandchildren had negative effects on selfrated health among those who were widowed longer possibly due to the physically and mentally demanding nature of caring for grandchildren in our study volunteering was associated with less depression and improved functionality and selfrated health among both older men and women this finding adds to the current literature on the topic and indicates that volunteering is positively associated with mental and physical health among older chinese adults this consistent finding suggests that regardless of cultural variations in volunteer sectors across nations engagement in volunteering itself has positive health benefits for older adults future research should gather more specific information about the intensity length frequency and types of volunteering activities and their produced effects and more importantly examine the mechanisms by which the effects are produced when the effects of three productive activities on health outcomes were compared we found that volunteering had a consistently greater effect that the other two activities for women whereas it had a similar effect on depression and functional health for men we suspect this positive effect on women might be because volunteering provides them with an opportunity to take a break from their traditional role they can network and socialize with others outside of their family and workplace and engage in new roles that are psychologically rewarding this experience may have a powerful effect on women compared with other roles that they have assumed in their life this study is not without limitations first the crosssectional nature of the data only allowed testing of associations rather than causal relationships among productive activities and health outcomes therefore the direction of the relationships we identified could be reversed the associations identified in this study should be vigorously studied using longitudinal data in the future for example how the focal associations varied between different age cohorts and historical time could be further explored however given the paucity of research testing the effects of productive activities on health among older chinese adults this study was an important step second this study was limited by the variables available in the secondary data many of the variables were measured dichotomously leaving us few options to better quantify specific activities for example we could not determine how long and how often older adults volunteered in future research better quantification of type form intensity and duration of productive activities could further refine our understanding of these activities and their effects on health outcomes it is also important to develop more indigenous measures of productive activities specific to older chinese adults such as more specific measures of providing assistance to families in various ways given the high rate of participation in this activity finally this study only examined urban samples because of the availability of data which limited the generalizability of our findings and restricted our understanding of how productive activities may affect rural older adults conceptually productive aging is an emerging concept and practice in china social discourse regarding older adults productive role in society occurs mostly in the urban context in china and much less so in rural areas this is mostly because there is no clear cutoff time for rural older adults to enter their third age however with the process of urbanization and increasingly blurred distinction between rural and urban lifestyles future research would benefit from developing valid definitions and measures of productive activities to document the development of such an emerging concept and practice among rural older adults despite these limitations our findings demonstrated positive relationships between productive activities and health for both men and women in general in addition to suggesting some gender differences in the relationships between particular activities and health these findings have implications for policies and programs that seek to promote productive aging in china national programs such as silver aging action could benefit from expanding the definition of productive activities beyond formal volunteer opportunities by incorporating family assistance and paid employment after retirement structural barriers that prevent older chinese adults from participating in productive activities should be further explored in the future in the meantime given the social and cultural differences in volunteering behaviors in china there is a need to identify indigenous forms of volunteering that older chinese adults are more likely to accept and practice for instance volunteering activities that emphasize peer support family enhancement intergenerational solidarity or health maintenance could be welcomed by older chinese adults as research increasingly demonstrates the potential of productive activities in maintaining the health of older adults this evidence can be used by health care practitioners community advocates and policy makers who promote productive aging to select or develop their strategies accordingly

this study examined whether participating in productive activities was associated with better health outcomes among older adults in urban china including analysis of potential gender differences design and methods using a sample of 10016 urban chinese adults aged 60 years or older from the 2006 sample survey of the aged population in urbanrural china we regressed measures of selfrated health functional health and depression on productive activities paid employment helping with family and volunteering controlling for sociodemographic variables results those who provided assistance to family members or volunteered had significantly lower levels of depression and better functional and selfrated health than their counterparts older adults with paid job providing family assistance or volunteering reported significantly lower levels of depression and better functional and selfrated health than those without those activities however only older men with paid employment reported significantly less depression and the effect of family assistance on functional health also differed by gender implications as research increasingly demonstrates the role of productive activities in maintaining health among older adults our findings can help practitioners or policy makers strategically select or develop health programs to promote productive activities among older adults in urban china

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introduction existing knowledge on the prevalence risk factors and consequences of living with prolapse in lowincome settings is scanty the fertility rate is higher and the access to obstetric care is far more restricted than in more affluent settings factors that may have implications for the risk of pelvic floor disorders 1 it has been argued that prolapse may be more common in resourceconstrained settings owing to risks related to these established factors and to heavy physical burdens and that the condition may affect daily life more severely than in highincome settings 2 the few available publications on prolapse in lowincome settings illustrate how the suffering related to conditions of prolapse severely affects the womens emotional wellbeing and the relationship with their husbands not the least because of the inability to perform chores expected of them 3 4 5 6 depressive symptoms among women with prolapse have also been reported from northwest ethiopia 7 the current study was conducted in the amhara region of northwest ethiopia where the median female age at first marriage is 151 years 8 the major ethnic group in the area is the amhara who practice ethiopian orthodox christianity and speak amharic as their first language 9 skilled personnel attend only 10 of all births in rural areas the fertility rate is 41 children per woman 10 and the maternal mortality ratio is 497 deaths per 100000 live births in ethiopia 11 health facilities in the rural areas are poorly equipped with inadequate emergency obstetric services 12 additionally only 40 of the women in the region are literate 10 with these indicators ethiopia is a lowincome setting that may be well suited to the study of womens experiences and the management of prolapse the present study aimed to explore how women living with prolapse in northwest ethiopia explain experience and handle the potential practical and social implications of prolapse materials and methods the first part of the study carried out in 2011 included 8 women with prolapse 6 of whom were recruited from the sample of women identified with prolapse through the dabat incontinence and prolapse pilot study 1314 the second part of recruitment took place in 2015 at gondar university hospital where all 16 informants were admitted and underwent surgical treatment for their condition the informants were invited to participate in the study based on their home district age and length of time suffering from the prolapse aiming to obtain a wide variety of experiences and the possibility of following them up at a later stage both sessions of fieldwork were carried out by the first author the design during both study periods employed a qualitative explorative approach with indepth interview as the main data collection approach semistructured interview guides with openended questions mainly concerning experiences of the potential practical or social consequences of living with prolapse were employed during the data collection both research assistants were from the area and were familiar with language culture and respectful conduct in the area all the interviews were conducted in amharic with continuous translation to english the interviews lasted 12 h and were aimed at letting the informant speak freely and without interruptions the six interviews carried out in the community took place in the informants homes and outside the health centre or health post located in their village the remaining informants were all interviewed in a private room at the hospital ward where they were admitted a digital recorder was used to record the interviews and all interviews were transcribed verbatim with continuous checks by the research assistants to ensure that the content was correctly captured and culturally specific expressions retained the interviews were transcribed in amharic followed by translation into english the analysis process was based on the principles of systematic text condensation 15 the analysis took place throughout the data collection phase and during a rigorous analysis phase after completion of the fieldwork the data material from 2011 was organized and coded manually whereas the data material from 2015 was organized and coded by the use of nvivo a qualitative data analysis computer software package ethical approval for both study periods was obtained from the regional ethics review board in western norway and from the institutional ethical review board at the university of gondar ethiopia the aim and purpose of the study and the contents of the consent form were read aloud to all informants before the interview written or oral consent to participate was obtained depending on literacy status three women who were asked to participate declined shortly after being approached none of the participants withdrew their consent results a total of 24 women with symptomatic prolapse ranging from stage ii to iv were included in the study all of the informants were from the amhara region and nearly all were orthodox christians the median age of the informants was 4025 years 18 informants were married whereas the remaining 6 included two widows and four divorcées the mean age at first marriage and first delivery was 13 years and 192 years respectively the majority of the informants were multiparous with the mean number of deliveries being 44 furthermore 20 of the informants had delivered all of their children at home twenty of the 24 informants had never gone to school and were illiterate and 21 were unemployed and mainly carrying out housework and helping out with farming activities the 24 women with prolapse had stage ii iii or iv according to the simplified pelvic organ prolapse quantification staging system 1416 approximately half of the women had had prolapse for the last 10 years or more including 7 who had lived with the condition for more than 20 years eleven of the women reported difficulties urinating because of the prolapse whereas five suffered from urinary incontinence ranging from mild to severe leakage conceptualizing the condition most of the informants argued that physical strain on their body such as childbirth labor or food scarcity had caused the prolapse one informant stated bmost of the time it happens due to delivery because most of us didnt go to a health facility for delivery we deliver at home where we go through labor for two to three days when we finally give birth its so hard that the uterus will go out also early age and multiple pregnancies were mentioned as causes others related the prolapse to their heavy workloads bi am busy working and carrying heavy goods due to this my uterus comes out bour area is mountainous and i used to help him husband dig while he was holding the ox ploughing i realize that i have been exposed to this heavy workload and i keep thinking that if i had refrained from working that much i could have been fine some moreover mentioned the lack of appropriate nutrition as putting the body under continuous strain causing the prolapse bit is because of scarcity of food like many other mothers i dont get proper food a few informants blamed their condition on gods will or linked it to the agency of the spirits one informant said bi considered it as gods anger what else shall i think another explained her experiences of bbad eyes bpeoples eyes can make you disabled or can make you die my sisterin lawher eyes are badit is because of her that im sick challenges of daily life in particular the married women in the study were responsible for all household chores including childcare and cooking and the fetching of water and firewood fetching water often involves walking several hours a day holding 2030 l of water on ones back this is considered womens work and is an integral part of everyday life for women and girls in this area married women typically also help their husband in farming activities until the children are old enough to help out almost all of the informants emphasized the constant burden of work and the challenges this caused owing to their condition bi do weeding grinding harvesting the fetching of water and collection of firewood a woman doesnt get rest another woman explained bmy uterus comes out while i am working or when i am walking we dont even get rest during pregnancy or right after delivery while working the prolapse was often experienced as very uncomfortable and sometimes painful as expressed by a large number of informants bit is especially severe when i walk for long i do manage to control the problem although with pain bwhen i walk it the prolapse rubs against my thighs and the skin peels off for a few of the women the challenge was experienced as worst in relation to urination bwhenever the uterus comes out and i go to urinate it the urination is blocked this year was terrible it the prolapse blocked me pressed me from inside it was like giving birth some of the women talked about how they no longer were able to fulfill the social role expected of a wife bi used to invite people to come to our home on st marys day but then i stopped because i was unable to grind to serve food and to host guests sexual implications many of the married informants continued being sexually active as long as they managed although commonly with pain bi used to push my uterus inside and do the intercourse even though i feel sick what can i do it is marriage at times however the prolapse prevented women from having sexual intercourse bwhen my uterus is out i usually sleep alone when im in that situation i tell him that im on period or that im sick other women had not been able to have sex for years bwhen it the prolapse started to become sore i refused him it has been five or six years since i started to forbid him to have sex with me he didnt say anything he started looking for another woman another informant got support from her husband bwhen i told him i have been suffering a lot because of it the prolapse he didnt push me to have sex with him anymore he understood the problem and we stayed one year without intercourse all four divorcées explained that they got divorced due to their prolapsed condition one of them explained bsometimes when we were about to have sex he saw that my uterus was out and we had to stop when that happened repeatedly he started to feel discomfort he then gathered my family and relatives and gave me money we got separated without having any conflict or discussion managing the condition despite the challenges all the women interviewed strove to continue with their lives and not the least with their daily chores bsince i have a husband and children i have to work so i grind and i prepare the meals even if i feel the pain beven though i dont work as i used to i still work as much as i can several practical strategies for managing their condition were employed one woman explained bwhen i walk i feel like something is pushing me down and i get a cramp at my waist when that happens i sit down and take a rest until the prolapse goes back inside then i can continue walking this is how i live another woman explained bwhenever i can i try to work while sitting down however this was not the best solution for all bit is difficult to sit so i usually sit on folded clothes yet another woman explained how she handled difficulties urinating bsince it the prolapse blocks my urine i push it in with my hand in order to urinate for some however pushing the prolapse back didnt help for long and at times not at all a woman with the most severe stage of prolapse explained bi moisten it with oil when i use the oil it becomes soft and i can sit and it will draw back a little after that i can walk again but it is still difficult to make long walks other practical strategies included delegating workrelated chores to children or at times finding excuses for not doing particular chores difficulties of disclosure disclosing the condition was experienced as challenging for nearly all of the women suffering from prolapse was regarded as extremely shameful and disclosing the condition was believed to potentially have severe implications one informant at the hospital after having discussed the issue among other women with prolapse explained bin my home town everyone is equal and healthy talking about our problems will make people ignore us so we are scared to be open about our health problems most had kept it to themselves for years before deciding to disclose bi used to think that it was disgusting to talk about and that no one else in my hometown had a similar problem a few informants had in fact never disclosed their condition to anyone close to them bi asked myself what the use was of telling other people if there is no solution i was scared and wondered what was happening to me since i didnt know what it was i just kept quiet most feared the social consequences bif they hear about it they would discriminate me and talk about me behind my back despite this fear of discrimination or rejection from people close to them more than half had chosen to disclose to trusted family members such as sisters mothers or a child bi have told only my mother and sister they sympathized with me when i told them bmy daughter insisted that i tell her about my problem i told her that it was no use telling her because there is nothing we can do anyway she told me that at least she could share my worry and pain some informants had told a friend or a neighbor bmy neighbor told me a year ago that she has prolapse so then i decided to tell her that i have the same condition both of us were thinking that we were the only ones having this problem then we openly talked about our secret which we had kept for so long we felt so sorry for one another of the 18 married women more than half had disclosed to their husbands most of those chose to do so at a point when the condition had become serious and very difficult to hide bi told him recently when it got worse i told him that i was caught by a disease that people dont know about he got angry and asked me why i had hidden it for such a long time and didnt tell him before however there were women who regarded it as unthinkable to disclose to their husbands one explained bmy husband is not concerned about my health i know of many women who were victims of gossip and i know some who were chased away from their home due to this kind of problem i am very concerned that one day he might know or suspect that i have this problem one of the divorcées explained her previous husbands reaction when disclosing to him bhe insulted me he said i was less than a person discussion most of the women explained that their prolapse was linked to delivery additionally the informants indicated that demanding chores were carried out during pregnancy and shortly after delivery causing undue strain on their bodies in a study from rural nepal women similarly reported that they believed that childbirth lack of rest during the postnatal period and heavy lifting when carrying out daily house chores were the main reasons for their prolapse 4 findings from research in india similarly revealed that hard work soon after delivery was common and was an important factor associated with uterine prolapse among the informants 5 while childbirth is a wellknown risk factor for prolapse 1718 little is documented regarding hard physical labor as a risk factor from studies in highincome settings most likely because physically demanding labor simply is less common in these settings in the dabincop pilot study carried out in the current research area it was found that carrying heavy objects for 5 h or more daily was associated with anatomical prolapse 14 the highly demanding physical labor that women perform in many resourceconstrained settings suggests work load as a factor of particular relevance to be explored in populationbased studies in similar contexts despite the severe difficulties and pain experienced when carrying out expected chores the women in the study strove to manage the tasks while simultaneously working hard to hide their condition although all the study participants feared the consequences of a general disclosure of their condition and some had very negative experiences following disclosure most of the women who had disclosed encountered great support commonly from a mother or sister but at times also from the husband study findings from research in uganda report that half of the women with prolapse did not receive any support from their husbands and several got divorced as a result of the disclosure 3 similarly in a study from nepal some women with prolapse experienced humiliation and harassment both from their husbands and from other family members 4 in rural ethiopia womens power to make decisions is known to be hampered by illiteracy and early marriage 8 the immense shame and perceived stigma connected with prolapse and with other pelvic floor disorders in this area 71314 is likely to be at least partly related to the lack of health education available to women in rural and suburban areas this makes the symptoms of prolapse unfamiliar and in turn nourishes the dynamics of secrecy the dabincop pilot study suspected underreporting by the informants owing to substantial discrepancy between the reported and the clinically observed prolapse 14 this is likely to be at least partly related to the perceived shame and stigma leading to secrecy among women with prolapse kleinman 19 reveals how pain and suffering are rarely limited to individual sufferers and commonly extend to ones family and to the broader social network in the case of prolapse the present study suggests that the entire family might be affected if a woman is unable to provide the household with water firewood or food children may miss school if they have to take on their mothers work and it would affect the children severely if their mothers were expelled from the household this scenario indicates that a potential health information program for prolapse may need to involve not only the women themselves husbands as the prime decisionmakers commonly have substantial influence over how women in practice can handle the condition such concerns however need to be carefully balanced against the potential implications of disclosure for the particular woman living in a setting with high illiteracy rateswhere women have little knowledge about common maternal morbidities and have limited decisionmaking power where household chores include heavy manual labor and where health system resources to meet even minor health challenge are severely limitedliving with a prolapse has very severe implications in addition to the need for further research on the prevalence and risk factors of prolapse in resourceconstrained settings there is also need for increased knowledge on what would enable women to reach the public health care system for treatment of the prolapse such knowledge may importantly inform the development of effective future interventions for this prevalent and readily treatable maternal health challenge in ethiopia and in other severely resourceconstrained settings an important limitation of the present study is the extreme taboo this topic represents in this study setting owing to the shyness of many of the informants we may have lost some of the depth of the illness narration despite several longer researchbased stays in ethiopia the first author has limitations in terms of sociocultural and language competence as commonly pointed out there is however also a possibility that the informants may have been more open about their condition than they would have been in encounters with local researchers as a stranger is presumably not familiar with the culturally embedded taboos and stigma surrounding such conditions conflicts of interest none open access this article is distributed under the terms of the creative commons attribution 40 international license which permits unrestricted use distribution and reproduction in any medium provided you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made

introduction the objective of the study was to explore how women with symptomatic pelvic organ prolapse in a lowincome setting explain experience and handle the potential practical and social consequences of the condition methods an explorative qualitative design was employed using indepth interviews in the data collection a total of 24 women with different degrees of symptomatic pelvic organ prolapse were included 18 were recruited at the hospital and 6 from the community fieldwork was carried out in the amhara region of northwest ethiopia in 2011 and 2015the informants held that the pelvic organ prolapse was caused by physical strain on their body such as childbirth food scarcity or hard physical work particularly during pregnancy and shortly after delivery severe difficulties and pain while carrying out daily chores were common among the women the informants used a variety of strategies to manage their work while striving to avoid disclosure of their condition disclosure was related to embarrassment and fear of discrimination from people living close to them including the fear of being expelled from the household most of the informants however experienced substantial support from relatives friends and at times also from their husband after disclosing their condition conclusions the study highlights how symptomatic pelvic organ prolapse may severely affect womens lives in a lowincome setting the condition is perceived to be both caused by and aggravated by the heavy physical burdens of daily work

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social networks building resources for diverse aging families chair kristine ajrouch discussant toni antonucci social networks provide tangible resources for older adults and their families yet their formation and characteristics may vary across diverse aging contexts friedman and colleagues examine multiple dimensions of caregivers networks using a nationally representative sample latent profile analysis identified three classes of caregiving networks large sparse networks with relatively few kin and only some people who assist with caregiving tasks for care recipients moderatelysized somewhat dense kinbased networks small very dense family networks where caregiving is shared across network members all of which uniquely influence caregiver wellbeing hu and colleagues evaluate measurement invariance of objective and subjective social isolation between usborn and foreignborn older adults using a regionally representative sample findings show indicators of social network structure and perceived relationship quality may be useful for examining social isolation among older immigrants ajrouch and colleagues show distinct dimensions of networks differentially influence older adults cognitive function larger networks and higher proportion of family are positively related while higher contact frequency is negatively related to cognitive function using data from the detroitbased social relations study webster and chin show the extent of similarity in healthrelated behaviors between older adults and their closest social network members analysis of 247 dyads illustrate associations between multiple social network factors and similarity in these behaviors together these papers advance theoretical and methodological approaches to the ways in which social networks serve as a resource across diverse aging contexts social networks provide tangible resources for older adults and their families yet their formation and characteristics may vary across diverse aging contexts friedman and colleagues examine multiple dimensions of caregivers networks using a nationally representative sample latent profile analysis identified three classes of caregiving networks large sparse networks with relatively few kin and only some people who assist with caregiving tasks for care recipients moderatelysized somewhat dense kinbased networks small very dense family networks where caregiving is shared across network members all of which uniquely influence caregiver wellbeing hu and colleagues evaluate measurement invariance of objective and subjective social isolation between usborn and foreignborn older adults using a regionally representative sample findings show indicators of social network structure and perceived relationship quality may be useful for examining social isolation among older immigrants ajrouch and colleagues show distinct dimensions of networks differentially influence older adults cognitive function larger networks and higher proportion of family are positively related while higher contact frequency is negatively related to cognitive function using data from the detroitbased social relations study webster and chin show the extent of similarity in healthrelated behaviors between older adults and their closest social network members analysis of 247 dyads illustrate associations between multiple social network factors and similarity in these behaviors together these papers advance theoretical and methodological approaches to the ways in which social networks serve as a resource across diverse aging contexts personal networks provide social support to both older adults and the family members who care for them yet we know very little about the different structures of caregiver networks and which are most protective of caregiver wellbeing using a new nationally representative survey of 2176 individuals who report providing care to a family member or friend age 50 or older with a health condition during the height of the covid19 pandemic and give detailed information on their personal networks we examine caregivers networks in terms of size density proportion kin and how care is allocated among network members we also examine the implications of network structure for caregiver wellbeing including anxiety depression and hopefulness we use latent profile analysis to identify three classes of caregiving networks large sparse networks with relatively few kin and only some people assisting with caregiving tasks for care recipients moderatelysized somewhat dense kinbased networks small very dense kin networks where caregiving is shared across network members caregivers who are male highlyeducated and providing care for someone with dementia are disproportionately in class 1 being in class 3 is significantly associated with lower caregiver anxiety compared to being in the other two groups even after controlling for sociodemographic factors but not with depression and hopefulness this work has implications for the optimal network structure for facilitating the wellbeing of family caregivers and provides a baseline for examining network change and the implications thereof as the impact of the pandemic wanes abstract citation id igad1040495 similarity in healthrelated behaviors within older adults close social relationships noah webster and kristi chin university of michigan ann arbor michigan united states healthrelated behaviors are socially contagious spreading through social networks via multiple mechanisms it remains unclear though which mechanisms are most salient among older adults guided by social contagion theory and the convoy model of social relations we examine similarity in healthrelated behaviors between older adults and their closest social network members and investigate associations with multiple social factors data are from wave 3 of the detroitbased social relations study collected in 2015 panel respondents nominated people who were close and important in their lives and up to the first three nominated were interviewed analyses were conducted at the dyadlevel and we selected dyads in which at least one member was age 60 or older generalized estimating equations were used due to some panel respondents being in multiple dyads greater homophily was found to be associated with similarity in both exercise frequency and number of alcoholic drinks consumed per week specifically pairs of close social network members who were more similar in selfrated health were significantly more similar in exercise frequency and those of the same gender and more similar in age were significantly more similar in alcohol consumption network structure specifically greater contact frequency was associated with significantly more similarity in alcohol consumption but less similarity in exercise frequency findings suggest the salience of multiple aspects of older adults close social relationships that can be incorporated into behavior change interventions and leveraged to encourage healthy lifestyles in later life while older immigrants are at increased risk of social isolation little research has examined if established measures are equivalent across nativity groups this study evaluates the measurement invariance of objective and subjective social isolation between usborn and foreignborn older adults data are from the detroit area wellness network study and were collected via a telephone survey from three groups prominent in metrodetroit african americans middle easternarab americans and nonhispanic white americans the sample was comprised of 29 immigrants objective social isolation was measured by network size household size and contact frequency with network members subjective social isolation was measured by feeling lonely relationship quality frequency of arguing and frequency of conflict confirmatory factor analysis was used to evaluate the dimensional structure and multiplegroup cfa was used to test for measurement variance by immigrant status the measurement invariance models of objective social isolation showed a good fit after allowing the intercepts of both network and household size to vary in the scalar model the measurement invariance models of subjective social isolation showed a good fit after allowing the estimate and intercept of loneliness and the intercept of argument to vary in the scalar model establishing measurement invariance in both objective and subjective social isolation is essential for valid interpretation of group differences among usand foreignborn adults in aspects of social isolation findings show indicators of social network structure and perceived relationship quality may be useful to examine social isolation among older immigrants

and career opportunities both traditional eg nursing homes senior centers and nontraditional internship settings eg research teaching are examined in regard to providing students with experiences that will enhance their knowledge career development andor future academic goals as both an undergraduate minor and a masters level gerontology student the presenter discusses their own nontraditional internship experiences that helped them to reach their goal of pursuing a doctoral degree in aging studies feedback gathered from other students in a variety of internship types is also presented finally lessons learned finding the right fit and the overall value of internships and similar experiences is discussed from a student perspective

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background globally 12 million individuals aged between 15 and 39 which includes adolescents and young adults are diagnosed with cancer annually 1 diseasefree 5year survival in ayas is 8389 across all types of cancers 2 as survival rates increase survivors are at risk of longterm health problems up to 70 report at least one chronic health problem and up to 40 have severe problems and need ongoing medical intervention or surveillance 34 the period of adolescence and young adulthood is a crucial time for developmental changes socially physiologically and psychologically and the cancer experience in aya could affect the patients longterm life 5 the current aya guidelines for survivorship were developed based on studies from the us and european aya populations 67 but previous studies identified that healthrelated quality of life in cancer survivors varied according to race 8 in fact asian aya survivors who live in asia countries have more unmet needs in communication and information 9 while western aya survivors who live in western countries have more unmet needs regarding support for physical symptoms management 1011 social physical health and psychological health in aya survivors are associated with multiple genetic behavioral environmental and socioeconomic risk factors which may vary substantially across racial groups however differences in longterm health by raceethnicity in aya survivors have not been fully elucidated 1213 thus we aimed to compare psychosocial and physical health among aya survivors by raceethnicity and their matched general population using nationally representative surveys from the usa and south korea methods data source and study participants we conducted a crosssectional study using the us national health and nutrition examination survey and the korea nhanes from 2007 to 2018 both surveys provide nationally representative crosssectional study of the noninstitutionalized population using a multistage cluster sampling design 1415 in both nhanes and knhanes each participant completed the questionnaire only once indicating that each patient received one questionnaire both nhanes and knhanes surveys were conducted in a crosssectional study every year each involving a different sample population the study population included aya cancer survivors 1617 participants who were diagnosed with any type of cancer aged between 15 and 39 years and who were adults over 18 years old at survey year were defined as aya cancer survivors the nhanes data only categorized race as nonhispanic white african american and hispanic and information on the racial group for participants in the other category was not available as a result data from other racial categories could not be included hence we excluded participants who were multiracial had unknown or other races had no cancer type or unknown cancer and had missing data in outcome variables data on participants finally categorized as nonhispanic white african american or hispanic were obtained from the us nhanes dataset spanning 2007 to 2018 to supplement the us nhanes data we obtained data on asians from the knhanes dataset which included a representation sample of koreans although the knhanes dataset only included koreans korean aya survivors shared similar overall characteristics with other asian aya survivors from countries such as taiwan japan or china 18 this made it possible to compare the outcomes of asian aya survivors with those of other racial groups included in the study we also selected 5 times age at survey year sex race and survey yearmatched general population among participants who had never been diagnosed with cancer measurement cancer type and age at diagnosis cancer cases were identified through selfreporting of physiciandiagnosed cancer using standardized selfadministered questionnaires age at diagnosis and cancer type were also obtained from the selfreported questionnaire some types of cancer were written by text thus we categorized them the types of cancer were classified as breast thyroid hematologic gynecologic or genitourinary skinmelanoma liver colorectal gastric lung and others time since cancer diagnosis was obtained based on the time interval from age at cancer diagnosis to attained age at survey year general health general health was assessed using a selfreported question on current general health with a 5point likert scale participants who reported poor or fair general health were considered to have poorfair general health social health the social health data included marital status education level employment status average working hours yearly household income household type and smoking and alcohol status from selfreported questionnaire marital status was grouped as noncoupled with single divorced widowed and separated and coupled with married and living with partner low education level was defined as participants who reported less than high school graduate employment status was classified as unemployed employed and selfemployed low yearly household income was defined as less than 20000 per year which was used in previous studies with nhanes data 19 smoking and alcohol status was classified as never former and current smoker or drinker physical health for female participants reproductive health was measured based on pregnancy and birth experience using a selfreported questionnaire hypertension was defined as systolic blood pressure ≥ 140 mmhg diastolic blood pressure ≥ 90 mmhg selfreported history of hypertension or current use of antihypertensive medications dyslipidemia was defined as lowdensity lipoprotein cholesterol level ≥ 130 mgdl highdensity lipoprotein cholesterol level ≤ 40 mgdl selfreported history of dyslipidemia or current use of lipidlowering medications 20 diabetes mellitus was defined as a fasting serum glucose level ≥ 126 mgdl a selfreported history of dm or current use of glucoselowering medications body mass index and waist circumference were obtained through physical examination we categorized obesity as bmi ≥ 300 kgm 2 for nhw aa and hispanic and bmi ≥ 250 kgm 2 for asians according to the world health organization guidelines 21 other comorbidities including stroke anginaangina pectoris myocardial infarction arthritis thyroid disease and asthma were defined as selfreported physician diagnoses comorbidities were classified as cardiovascular or noncardiovascular diseases psychological health psychological health includes daily activity limitations due to emotional problems depression and suicide ideation with selfreported questionnaire participants who responded yes to daily activity limitations due to emotional problems were defined as poor psychosocial health depression was defined as ≥ 10 total scores in phq9 which is a validated measurement 22 in knhanes phq9 was added after 2014 and was assessed once every 2 years hence we only included phq9 data from 2014 to 2018 in knhanes this approach was also used in the previous article 23 suicide ideation was defined as an affirmative answer to the question i have thought that i wanted to die at some point in the last year or responses to question 9 in the phq9 24 detailed information regarding each study has been published 25 statistical analysis since the nhanes and knhanes data were obtained through multistageclustered sampling we analyzed the survey weights for the complex sampling design weighted values for each merged dataset were calculated when merging the yearly data we performed several tests to evaluate differences between ayas of different ethnicities first we compared different ethnicities among aya survivors for the aya survivor group comparison we compared the overall difference among the groups continuous and categorical variables were compared among the four groups using weighted analysis of variance and χ 2 tests respectively in addition for all health we used logistic regression to estimate adjusted odds ratios and 95 confidence intervals in regression analysis we compared race with references nhw by adjusting for age sex diagnosed age survey year and cancer types we also compared different ethnicities within the general population using the same methods employed for the aya group to address association differences between aya and general we compared the differences between the general population and aya individuals within each ethnicity we compared aya and matched general population within races in continuous and categorical variables using anova and χ 2 tests respectively because the general population were selected using a matching process we did not perform a weighted analysis we also used logistic regression to estimate aors and 95 cis comparing each race and ethnicity group to the matched general population adjusting for age and sex additionally we examined whether the magnitude of the differences between the general population and aya varied across ethnicities using interaction analysis we calculated the pvalue for the interaction to test the significance of the interaction terms between cancer and multiple race groups significance in the interaction pvalues would indicate that different ethnicities could influence the disparities in outcomes between aya and the general population p values 005 were considered significant and twosided tests were used for all calculations however since we had multiple outcomes we also calculated the benjaminihochbergs adjustment we start with the largest pvalue pk and identify the first i such that pi α once this was found then tests 1 i are considered to be significant and the other tests are not significant 26 the adjusted significant level was 0042307692 statistical analyses were performed using r 412 results study participants the average age at diagnosis was oldest among asian survivors and youngest among hispanic survivors the number of men was highest among nhw survivors and lowest among aa survivors the most common type of cancer in all races was gynecologicgenitourinary cancer nhw survivors had higher proportion of skinmelanoma cancer while asian survivors had higher proportion of thyroid and stomach cancer the average time since diagnosis was 1956 1851 1276 and 1057 in nhw aa hispanic and asian respectively the weighted proportions and means with standard errors are presented in table 1 additional supplementary table s1 and figure s1 general and social health and healthy behavior in aya survivors by raceethnicity compared to nhw hispanics had poor or fair general health in the social health domain hispanics had lower education lower household income and less unemployed than nhw survivors aa survivors were more likely to be noncoupled than these in nhw survivors moreover asian survivors more often had lower education than nhw survivors compared to the nhw hispanic and asian survivors were less likely to be formercurrent smokers hispanic were less likely to be formercurrent drinkers while asian survivors were more likely to be formercurrent drinkers in terms of the general population we observed a similar trend to that of aya cancer survivors comorbidities reproductive and psychological health in aya survivors by raceethnicity aa and hispanic survivors were more likely to have comorbidities related to cardiovascular disease with aa survivors having a higher likelihood of hypertension and hispanic survivors having a higher likelihood of diabetes mellitus than nhw survivors hispanic survivors however were less likely to have dyslipidemia and arthritis than nhw survivors conversely asian survivors were less likely to have both cvd and noncvd comorbidities with a lower likelihood of hypertension stroke myocardial infarction dyslipidemia arthritis thyroid disease and asthma compared to nhw aya survivors reproductive health was similar among the aya groups in terms of psychological health asian were more likely to experience suicide ideation than nhw in terms of the general population we observed a similar trend to that of aya cancer survivors 4 nhw survivors had more experiences with depression and both nhw and asian survivors had more suicide ideation compared to their matched general the weighted proportions and means with standard errors among matched general are also presented in fig 2 and additional supplementary table s2 discussion in this multinational study we found differences in type of cancer and social physical and psychological health among race and ethnicity groups in aya survivors compared to nhw survivors hispanic survivors were more likely to report poor general health and lowest levels of education and household income aa survivors were more likely to be noncoupled nhw and asian survivors were most likely to have poor psychological health among the races compared to their matched general nhw and asian survivors had poor general health and psychological health in previous studies the most common cancers in aya survivors were thyroid cancer followed by leukemia and nonhodgkin lymphoma skinmelanoma breast cancer and cervical cancer 227 however we found that the frequency of cancer type differed by race among the aya cancer survivors more than half of the hispanic and aa patients have experienced gynecologicgenitourinary cancer in our study gynecologicgenitourinary cancer especially cervical cancer is the second leading cause of cancerrelated death among aya women in the usa however the mortality rate has markedly decreased over the past few decades 28 due to the availability of human papillomavirus vaccination and the adoption of cervical screening thus gynecologicgenitourinary cancers may have the largest proportion among survivors the asian aya had the highest prevalence of stomach cancer compared to the other raceethnic groups the prevalence of helicobacter pylori infection is higher in asia and south america than that in the usa a study assessing racialethnic differences found that 314 of gastric cancers in asian americans occurred in the pyloric antrum compared with 196 for all races 29 consistent with the possibility that endemic infection and cultural factors contribute to risk several studies have shown that migration from highto lowincidence regions such as from asia to the usa is associated with a decreased risk of developing stomach cancer 29 in social health hispanic survivors had the lowest education level and lowest income in this study according to previous studies hispanic survivors were more likely to be diagnosed with cancer at younger ages than other races 30 and it is strongly related to the interruption of education 31 which led to lower income levels aa survivors were more noncoupled in our study previous studies had consistent result that cancer survivors were more likely to be divorced and separated due to the burden from cancer treatment emotional distress economic hardship and infertility 32 further studies are required to identify longterm marriage and relationship effects from cancer and treatment whether someone marries or ends their marriage in aya survivors in this study it was found that aa and hispanic survivors had a higher likelihood of comorbidities related to cvd but a lower likelihood of noncvdrelated comorbidities compared to nhw in general aas and hispanics in the usa have higher bmi and prevalence of obesity than nhw and asian populations 33 among cancer survivors aa and hispanics also had more than two times higher prevalence of obesity and obesityrelated disease notably hispanic aya survivors were more likely to have dm compared with the other races in our study the prevalence of both diagnosed and undiagnosed type 2 dm is nearly twice as high among mexicanorigin hispaniclatino adults compared to nhws in the fig 2 prevalence of social physical and psychological health characteristics in aya survivors and matched general by raceethnicity aa african american nhw nonhispanic white general age sex and survey year matched general population by raceethnicity group descriptive analysis with proportion and the greatest value was highlighted with red circle cardiovascular comorbidities hypertension stroke anginaangina pectoris myocardial infarction obesity diabetes mellitus dyslipidemia noncardiovascular comorbidities arthritis thyroid disease asthma daily limitation daily activity limitation due to emotional problem usa 34 furthermore aa survivors were more likely to have hypertension than nhw survivors which is similar to previous studies 35 hypertension was also associated with bmi 35 on the other hand asians had the lowest comorbidity it was a similar pattern with a lower prevalence of comorbidities which has been observed in other asian countries 18 the prevalence of cvdrelated comorbidities among asian cancer survivors was 3516 18 in particular the low prevalence of myocardial infarction in asians may reflect lower background rates of the disease owing to environmental or genetic factors 25 the prevalence of comorbidities varies by race and ethnicity hence future studies and guidelines need to consider race and ethnicity in physical health in terms of psychological health we found that nhw and asian survivors had the worst psychological health with experiences of depression and suicide ideation psychological burden is a common lateand longterm effect in patients with cancer 36 selfinflicted injury is the second most common cause of death among individuals aged 15 and 39 years 37 however a limited number of previous studies have examined racial disparities in the psychological burden of aya cancer in longterm survivors 36 hence additional research on racial disparities in the psychological burden is required compared to matched general by raceethnicity aya survivors were least likely to receive education and unemployed compared with the general population aya includes physical cognitive emotional and social transitions to achieve developmental milestones like finding a job becoming financially independent forming relationships and starting a family 38 however a cancer diagnosis and treatment interruption and delay impede the achievement of these personal goals both in the short and long terms 39 additionally nhw survivors had a higher rate of formercurrent smokers than other races and matched general according to the tobacco use supplements to the current population surveys smoking prevalence and cigarette consumption levels have been historically higher in general among nhw than among aa and hispanics 40 although the prevalence of tobacco use has continued to decline in highly educated nhw over the past three decades less educated nhw have remained at risk 40 these findings are in line with the minorities diminished returns theory 41 which postulates that nhw may experience a huge decreasing protective effect with decreasing educational attainment than racialethnic minorities the limitation in returning to a normal life could affect depression and suicide ideation as well as poor general health in aya cancer survivors more than in their matched general population especially asian aya survivors had much higher prevalence of suicide ideation than matched general in this study according to a national survey in korea more than half of the public had negative attitudes stereotypes and discrimination toward cancer patients in spite of medical advancements and improved survival rate 42 such an unfavorable environment would make it difficult for korean cancer aya survivors to return to work after cancer treatment resulting in poor quality of life 4344 several limitations should be considered when interpreting our findings first we used a crosssectional study and did not have information on the timing of the development of each variable however our objective was to compare the current patterns of social physical and psychological health across raceethnic groups and not to identify causal pathways second we used selfreported questionnaire data which might have led to recall bias according to a previous study when compared with confirmed cancer in the national cancer registry data the sensitivity and specificity for selfreporting of physiciandiagnosed breast cancer were 971 and 991 respectively 23 moreover to reduce the recall bias a shorter recall period is effective 45 our study compared the current status of health hence we mostly used questions about the current status third our study included only aya survivors without treatment types however this study aimed to analyze the current health status of survivors fourth the different patterns in health may be due to different cultural and environmental exposures between usa and korea however raceethnicity is also a risk factor for health status and disparities of cultural and environmental background in different raceethnicity might be also contributed to different cultural and environmental exposures which could be affected from racial differences in health 46 furthermore despite korean aya survivors exhibiting overall similar characteristics to aya survivors from other asian countries such as taiwan japan or china there are still variations attributed to differences in healthcare systems therefore future research should focus on broader samples of asian aya survivors to enhance the generalizability of the results lastly while it was not our intention to exclude aya survivors with more severe longterm health issues there is a possibility that their inclusion was limited in our study aya cancer survivors who are still undergoing active treatment and experiencing severe illness may face unique challenges and considerations that fall outside the scope of our research therefore further studies specifically targeting this population are necessary to gain a better understanding of their experiences outcomes and support needs conclusions we identified multidimensional relationships between physical psychological and social health statuses by race and ethnicity racial differences in socioeconomic status are important contributors to racial health disparities 46 individuals from racialethnic minorities may be exposed to socioenvironmental conditions and stressors that affect health throughout life 46 in addition we identified relationships between health and longterm survival of more than 10 years this study provides evidence for future studies concerning longterm health that may vary according to race and ethnicity therefore we believe that race and ethnicity should be considered to improve the overall health status of aya cancer survivors abbreviations additional file 1 supplement competing interests the authors declare that they have no competing interests publisher s note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background the current guidelines for survivorship in adolescents and young adults aya cancer are based on studies conducted in the united states and european aya survivors however previous studies have shown that the healthrelated quality of life in cancer survivors can vary depending on race yet the longterm health differences among aya survivors by raceethnicity have not been fully explored therefore our aim is to compare the psychosocial and physical health of aya survivors and their matched controls across different racial and ethnic groups methods we conducted a crosssectional study using us national health and nutrition examination survey nhanes and the korea nhanes from 2007 to 2018 we included aya cancer survivors who were diagnosed with any type of cancer aged between 15 and 39 years and who were adult with aged over 18 years old at survey year we then stratified the study population by raceethnicity with nonhispanic white nhw n 310 african american aa n 42 hispanic n 81 from nhanes and asian n 389 from the korea nhanes we also selected 5 times age sex race and survey yearmatched general population among participants who had never been diagnosed with cancer n 4110 variables were defined using questionnaire data physical exams and laboratory testscompared to nhw hispanics aor 115 95 ci 100132 had poor or fair general health lower education aor 123 95 ci 107140 and lower household income aor 116 95 ci 101133 aa survivors were more likely to be noncoupled aor 135 and have hypertension aor 118 95 ci 103136 asians were more formercurrent drinkers aor 121 95 ci 105140 nhw are more likely to experience psychological limitation compared to matched general nhw and asian survivors had poor general health and psychological healththis study provides evidence for future studies concerning longterm health after aya cancer survivorship that may vary according to race

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with the política nacional de saúde do trabalhador e da trabalhadora there was a change in strategy establishing the crosscutting insertion of occupational health actions at all points of the ras network aiming for greater reach in addition to this the organization of the health network is still characterized by taylorist precepts especially in the hierarchical separation and distribution of planning and execution tasks among different points of the network as well as valuing and encouraging professional specialization despite more recent contributions from the health management field amidst this context the high prevalence of mental disorders among the working population is not sufficient to draw attention to work as a possible cause of illness with many cases of wrmh going unnoticed to improve wrmh care in the sus implementing of training policies for health professionals is essential considering the responsibility of municipalities in executing public health policies the developing of competencies to deal with wrmh among professionals in primary healthcare is or should be an important issue for municipal health managers however given the perception that the field of occupational health faces difficulties in programmatic insertion it becomes necessary to understand the processes that either enable or hinder such development and how health managers apprehend and mobilize these issues this involves understanding the limitations for developing workers fomative processes concerning this issue particularly regarding the managerial processes involved it is premised that managerial practices are related not only to historical contextual andor programmatic factors but also to shared social representations concerning specific objects understood as knowledge produced and shared by this social group considering that these representations are related to the practices undertaken by the group therefore depending on the representations about the addressed objects the actions of these managers can either contribute to or hinder the process of developing competencies among professionals in wrmh based on this the objective of the research was to analyze the social representations of workers in management positions regarding the competencies to address wrmh and how these representations can interfere with the development of these professional competences among primary healthcare workers in this area although formative processes cannot be limited to the managerial sphere the strategic role of management in the development of competencies and the implementation of permanent health education policies is undeniable which justifies its investigation the concern for the development of health professionals competences has been gaining prominence in recent years including with the institutionalization of the política nacional de educação permanente em saúde it advocates for the transformation of health professionals practices through critical reflection on the work process privileging methodologies that recognize the importance of the work context the knowledge derived from experience and the sharing of knowledge within interdisciplinary teams social representations and competences psicologia teoria e prática 26 eptpsp15745 são paulo sp 2024 issn 19806906 6 these ideas are supported by different authors who discuss the development of professional competences in organizations notably those aligned with the socalled french school of thought sharing the understanding that competence goes beyond the prescriptions of a position or job and is not limited to a set of knowledge skills and attitudes of a specific individual this differentiates them for example from the american and british schools of thought additionally the issue of competence involves a complex combination of ingredients in a dynamic between knowledge and action mediated by values in this perspective the development of competences is directly linked to the work context the situations that workers face in their daily work the ongoing debates on norms and the values that permeate the work environment schwartz argues that every professional activity can be partly anticipated through a protocol however it is also always an experience and an encounter that requires a form of competence suitable for infusing the historical aspect into the protocol as what is done is never solely what is prescribed this reinforces the contingency of the situation as this aspect can never be standardized according to le boterf it is important for professionals to be able to apply what they have learned in each situation to mobilize it in other situations of greater or lesser complexity as this contributes to the development of their own competences and those of the collective of workers aligned with schwartzs proposal durrive argues that understanding competence as the mastery of knowledge when acting in a situation allows for the elaboration of reference systems and their social recognition however this mastery of knowledge is accompanied by a strong point of view that allows for the management of each situation in a singular way mobilizing knowledge from a historical and collective perspective that involves the values of each professional the contributions of these authors align with the proposal of phe since health education and health work cannot be separated because they are mutually constructed contributing simultaneously to the development of professional competences and the construction of the ethicalpolitical subject and care provider identity it is from this theoretical perspective that the development of competences among professionals in wrmh will be analyzed in this article this conception differs from traditional health competency practices which are related to the accumulation of specialized technical knowledge and linked to an approach that defines competence as a set of knowledge skills and attitudes in the adopted perspective work is recognized as a human activity that cannot be dissociated from the historical and necessarily collective process in which it is embedded to aid in the understanding of the investigated problem the contributions of the theory of social representations were also used this theory seeks to understand social representations which are knowledge produced and shared by social groups in everyday life the purpose of sr is to make something unfamiliar familiar overcoming the feeling of unfamiliarity through sr the represented object is integrated into the mental and physical world making abstract concepts more concrete sr are created by individuals as a resource to stay informed interpret events and adapt to identified needs they guide individuals in naming defining and interpreting aspects of everyday reality enabling decisionmaking and defining positions in constructing sr individuals symbolize and interpret the object being part of the construction and expression of the subject sr should not be understood solely as a representational activity as they are immersed in reality the social aspect plays an important role in forming representations as they are related to communication and social practices such as dialogues rituals discourses work processes modes of production and culture in general sr are social phenomena and not just an aggregation of individual representations the formation of sr occurs through the processes of anchoring and objectification anchoring involves classifying the represented object based on the subjects network of meanings seeking a fit for the unfamiliar it refers to the process of integrating new knowledge into the existing network of meanings within the subjects frame of reference in a way that fixes the object and representation in a network of significations the anchoring process can be understood as linking something strange and disturbing to a paradigm that the subject already possesses in this process the object is readjusted to fit properly into a specific preexisting category acquiring characteristics of other objects in that category therefore anchoring is not a neutral process and can reveal the theories that the subject holds about society or human nature the classification in the anchoring process can occur in two ways through generalization when subjects observe a characteristic of the represented object that is compatible with an object within the groups domain and consequently attribute all the characteristics of that domains object to it on the other hand particularization consists of identifying particular characteristics of that represented object in relation to the objects within the groups domain keeping it under analysis as something specific the anchoring process also involves the naming of represented objects including them in a complex of words in culture and allowing their communication and connection to other images objectification consists of identifying the iconic quality of an idea in an imprecise form it is to reproduce a certain concept in an image format for example a comparison can be understood as a way of representing something comparing the concept of god with the figure of a father allows for visualizing god a represented object as a person with whom we can interact the father the processes of objectification and anchoring occur concomitantly and interrelatedly giving meaning to sr these processes can be understood as a way of dealing with memory the anchoring process is continually placing and removing classified and labeled objects people and social representations are produced in various places such as bars streets offices among others where people analyze events and spontaneously develop ways of thinking that guide their behaviors through communication therefore the work environment is a place that provides the necessary interaction for the construction of representations it is worth noting that individuals and social groups are not passive in the process of forming sr which has the everyday shared knowledge as its main element this knowledge merges with scientific and technological knowledge transforming them through their own rationality which cannot be devalued in relation to scientific rationality in the scope of this article the identification of sr about competences and the development of wrmh competences shared by the interviewees helps to understand the knowledge opinions and values that guide practices directed at the process of developing competences in the wrmh domain this is a qualitative analyticaldescriptive research the empirical locus was the municipal health department of a large municipality located in the metropolitan region of vitória espírito santo brazil instruments and materials the data were collected through individual indepth semistructured interviews qualitative interviews serve as a key tool for researchers to explore the subjects experiences and understand their world through the description of their activities experiences and opinions in their own words procedures the interviews were audiorecorded transcribed and analyzed using thematic content analysis this approach was chosen due to its emphasis on the meanings and senses conveyed in the messages the transcripts were subjected to an exploratory reading and a coding matrix was developed codes were organized into themes categories and topics using the software atlas ti all participants signed an informed consent form and were told about the researchs objectives and potential risks the research received approval from the ethics committee of the universidade federal do espírito santo under protocol no 3378498 results and discussion the analyzed discursive contents encompass the general theme of competence and its specificities related to wrmh as explicitly mentioned in the text the contents were organized in the category of attributes of competence the managers identified factors that contribute to a professional being considered competent in the work context being selftaught proactive seeking knowledge and working in a team these attributes align with the phe guidelines emphasizing that the practice of learning and teaching should be incorporated into the work and daily life of health organizations they also corroborate the need for initiative and responsibility on the part of the worker however the attributes listed are strongly related to the personal characteristics of the workers and to some extent moralistic as a worker who does not possess these attributes may be seen as a burden to the team as suggested by luanas statement for me the health professional must be selftaught one of their main competences they dont need to wait for me to arrive with a directive saying they have to study no they must seek knowledge by themselves i cant just sit here waiting to be told what to do i have to be proactive this leads to the individualization and accountability of these workers for their own development even teamwork is seen as an individual attribute that the professional needs to have as mentioned by iracema i think these are competences and skills that the professional needs to have knowing how to work in a team is one of them in accordance with a conception of competency linked to individual characteristics still prevalent in public health systems the context of developing these attributes at work and the responsibilities of managers in the process are not explicitly addressed and consequently downplayed to enable workers to take responsibility for situations it is necessary to provide them with the means including training and support to exercise these responsibilities durrive synergies of competences relying on a support network to deal with specific situations regarding the knowledge required to operationalize the causal link between mental health and work the managers mentioned the need to have a broader view of health for me the main is to have a broader view of what health is what the determinants of this healthdisease process are this broader view of health can be understood as recognizing the effects of social dimensions including the labor market modes of production and working conditions on health processes going beyond strictly biological aspects the scarcity of statements and the mention of a single theme demonstrate that the interviewees have difficulty identifying what knowledge is required to operationalize the causal link in wrmh the process of anchoring sr helps understand the mention of the broad view of health in an effort to think about the knowledge needed to handle wrmh issues about which they do not have much expertise the interviewees seek references in already established knowledge among them such as the expanded concept of health however it is worth mentioning again that the model of care based on the expanded concept of health has not fully consolidated yet being in dispute with the biomedical model which remains an important anchor for representations and practices in health this dispute poses difficulties for the development of competences in wrmh which necessarily depend on a model that considers the social determinants of health this result corroborates the difficulty in establishing the link between mental health and work perceived by professionals in the state of espírito santo the clinical guidelines in mental health provide albeit in a superficial manner guidance for the identification and management of cases of smrt in the investigated municipality documents of this nature were not identified however the existence and mastery of such protocols by professionals do not guarantee competent action considering the importance of values in the dynamics of competence it is necessary to discuss in training processes the impacts of work on mental health from a broad perspective such a conception will help expand the range of values around health production processes on the other hand the belief that merely developing a broad view of health and all the values it entails is sufficient for the realization of the link between mental health and work can be relativized this is because even considering the high incidence of mental illness among the working population it may not be enough to raise awareness of work as a possible cause of mental illness having a broad view of health may also not be sufficient as professionals lack investigation tools case management tools and specific knowledge the absence of these factors hinders the mobilization of competences in wrmh as this mobilization depends on means that allow workers to take initiative and assume responsibility moscovici proposes that the emergence of social representations is influenced by three factors in the communication process 1 the dispersion and distortion of information about the object with uneven access to information between groups and fields of interest 2 the focus with greater attention to certain aspects of the environment by the group to the detriment of others leading to inevitable variation in the relationship with the object from one group to another and 3 pressure for inference referring to the need for readiness to act and position oneself in everyday situations considering the responses given by the managers regarding the knowledge required in wrmh it is necessary to reflect on how policies and productions on the subject reach the various management sectors and materialize in guidelines and work prescriptions in other words to what extent this topic is present and which aspects are focused on in training meetings and management instruments based on the responses given by the managers it is reasonable to assume that the identified social representations are based on a communication process in which the dispersion of information about competences in wrmh and pressure for inference are uneven among the sectors concentrating in the specialized area occupational health surveillance for this reason when asked to take a position on the subject the managers focus their response in a very generic way on that notion that would be closer to an attempt to analyze an element that includes the work element which is the notion of expanded health in the category of social representations of competences the prevailing representations understand competences as a set of responsibilities and attributions what the professional has in terms of assignments in the exercise of their work activities as specific activities of the professional category i think competency for diagnosing mental health issues i dont know whether its occupational medicine or occupational nursing i dont know if really i dont know if i a nurse can make a diagnosis related to the workers health i dont know i believe not and as skills and tools that the worker possesses in general i think it is the role of to develop some skills of professionals so that they feel increasingly capable more competent to deal with health demands these representations are more frequent among managers in the hs field and are aligned with the american and english currents on competences this is due to the wide dissemination of this theoretical current in the field of management including health management in brazil as pointed out by moscovici influenced by theoretical models that are closer to everyday experience thus closer contact of these managers with this perspective contributes to the formation of these representations the mentioned representations contribute to the operationalization of the concept by the interviewed managers however there is a limitation in considering the notion of competency as a characteristic that is entirely predictable from some requirements of the work activity that can be anticipated this can lead managers to overlook the contextual aspects of work and the importance of support networks for competent action making it difficult to mobilize competences in daily life training processes based on these representations may contradict the logic of phe which emphasizes the importance of the work context for the development of competences regarding wrmh linking the notion of competences to the specific activity of the professional category a rationality linked to the long trajectory of professional training and corporate disputes seeking to segment health practice and assign specialties and powers to specific areas of work hinders the implementation of comprehensive health care for sus users contrary to the guidelines of public policies that highlight the need for all ras professionals to be able to establish relationships between living conditions healthdisease and current or past work of users on the other hand in smaller numbers and specifically in the area of health education there is recognition of competence related to the possibilities of the context and how the ability to deal with situations sometimes the public servant comes takes the course but when they get there they cant sometimes they cant do it even on their own because it doesnt depend only on them it depends on the director it depends on colleagues to help organize that action they learned here sometimes they cant implement it this demonstrates openness to a contextual notion of competence in the field of health education provided by the influence of the logic of pneps it is thus evident that there are internal debates between forces that seek an expanded view of health which is in fact the anchoring object for wrmh and those related to the usual practices of segmenting knowledge and practices of professionals in the face of existing demands this specificity of representations in the he field demonstrates how social insertion and belonging as well as lived experiences are important conditions for the production of representations as this is an area specifically dedicated to training processes it can be assumed that they have more regular contact with experiences and information about more plural approaches to the process of developing health competences in the category of competence development five themes were identified strategies evaluation of learning conditions for competence development upward planning and guiding documents for competence development the higher occurrence of this category in health education reflects the sectors specific characteristics which deal directly with the subject these documents are important for competence development because it is from the prescriptions that the worker places themselves in the situation interpreting the singular through the prism of values pneps plano de desenvolvimento institucional and cabstt recognize the importance of context for mobilizing competences in line with the french current however in the mhp it is possible to observe representations of the notion of competence more linked to the anglosaxon currents these documents present generic guidelines that recognize the social determinants of health and the need for continuous development of professional competences to meet the demands of services the more direct guidelines for primary healthcare professionals on wrmh are found in the cabstt guideline in the absence of locally developed protocols to deal with wrmh the documents that guide professional action have a more general and nonprotocol content however when combined with other contextual elements they act as work prescriptions thus the reproduction of more consolidated professional practices is expected in this case the segmentation of knowledge biologistic care and fragmentation of assistance as previously indicated upward planning is highlighted as the way in which the mhd schedules activities that contribute to the development of professional competences based on the needs of the work context we do the upward planning visit the units try to identify what demand is being pointed out there talk to the management try to organize it with material with indicators with data from the previous year to think however in some statements it is possible to observe that the responsibility for pointing out the necessary actions is concentrated in sectors and management so what they even call upward planning for educational actions each sector each management points out what is necessary what they understand as necessary for some actions processes to occur the exclusion of the professionals who actually perform the activities in the daily process of defining the trainings to be carried out can lead to the inadequacy of the training for the specific work context this information indicates that in the management of policies in this municipality and possibly in a significant part of brazilian municipalities there is still the need to overcome this taylorist bias that is still prominent in the public sector of the country there are those who execute and there are those who plan even recognizing the efforts of disruptive policies regarding more traditional practices such as phe the discourse of centralization in decisionmaking about training and execution at central levels is still relevant sr and practices are inseparable and mutually engender in a dialectical process where representations guide practices which in turn act in the creation and transformation of representations the latter are rooted in a collective history in which practices and experience in relation to social interactions play an essential role thus the concrete practice of centralization in management regarding decisions on planning formations ultimately reinforces representations of competence that are more traditional and less aligned with the more recent discourses of policies the conditions for competence development are seen positively especially regarding the openness and participation of different professionals in the discussion spaces yes i understand that i see this moment more as a very powerful tool for work management case handling and there is indeed no degree no hierarchical character in knowledge its really an exchange this active participation in discussion spaces is essential for sharing knowledge and reflecting on work processes allowing for their transformation on the other hand the need for professionals to be absent from work to participate in training courses or events and the underutilization of team meetings are identified as challenges for competence development we have a problem when you involve these workers in the discussion i would need to release the workers for a certain process sometimes the health units process does not allow everyone to have access to all the opportunities that the department offers in practice team meetings still happen but they are not utilized enough for this purpose even though it could be the space for it since it is guaranteed these factors demonstrate the difficulties in ensuring the necessary means for professionals to take initiative and assume responsibility for certain work situations since the update promoted by training processes is essential for professionals to adequately meet the demands of sus users and team meetings need to be conducted to promote the constant reorientation of work processes at this point it is important to once again point out that social practices in a particular context are also determining factors for social representations specifically considering professional practices it must be considered that work organizations impose constraints and force the adoption of certain behaviors when representations and practices are divergent in a context of strong constraints the tendency is for representations to transform according to practice when workers do not have much autonomy in this sense the social representations present among managers regarding the notion of competence as a set of personal attributes and workers health as an assignment of specific professional categories do not contribute to identifying wrmh as an issue of interest among processes is seen as an important advancement for phe in the municipality according to the interviewees all training processes use this type of methodology which requires openness to discussing issues specific to the work context all our courses here are based on active methodologies as i use active methodologies i necessarily need to give some room the displacement of professionals from management to the territory for example is mentioned as one of the ways to apply active methodologies which is essential for addressing wrmh planned by the department this movement we are making with the occupational health team raising awareness in these professionals who are in our service with these visits to their service raising awareness for them to recognize these patients conditions so this has really been planned being part of our planning matrixing understood as a phe strategy that aims to expand the offer of health actions through articulation and shared responsibilities among different actors involved in health care is pointed out as a more direct possibility of addressing wrmh based on the demands of the territory per se through this strategy according to the interviewees there could be a sharing of knowledge and operational strategies among others with the pedagogical team that would assist primary healthcare teams in identifying the causal link between mental illness and work this debate was initiated among managers for subsequent implementation in the units as suggested by luana we often do what is called matrixing in the pedagogical support of our team with the health unit when a professional comes there with this demand so it is up to us to work on the link here together with those who are on the frontline this strategy is seen as a possible and necessary path for the inclusion of wrmh policies in primary healthcare holding zarifian 2012 in this aspect the approach to work allows for the identification and sharing of knowledge specific to that reality incorporating elements of competence that cannot be identified without this approach however this approach to professionals reality also did not prioritize the need for competence development in wrmh ie it was not sufficient to break the vicious cycle resulting from the lack of connection between work and mental health the adopted strategies seem to directly contribute to the development of professionals knowledge regarding topics relevant to wrmh however they do not necessarily lead to prescriptions for returning to work after the discussions therefore the potential impact of these strategies on transforming work and work organization to incorporate wrmh into primary healthcare as indicated by the interviewees is not achieved among the possible reasons for this limitation it can be mentioned the lack of priority and visibility of wrmh the absence of protocols and care guidelines that pragmatically guide practice the lack of data indicators and specific training on the subject as well as the managers social representations regarding competences and workers health phe assumes a dialectical relationship between professionals training and health care practices that enable the transformation of work processes therefore the transformation of prescribed work from training processes is an important step for phe to what extent the real constraints imposed by precarious working conditions in health are limiting factors contributing to this difficulty in revising prescriptions requires further research nonetheless it is evident that the traditional taylorist separation between planning and execution contributes to hinder the return of discussions held in collective contexts to prescriptions regarding the evaluation of learning different views were observed among the interviewees some point out the evaluation of students satisfaction with the courses offered by the health education area and the evaluation of the faculty as the main evaluation forms our evaluation process is listening to the workers who went through the training process evaluating the instructor who provided the training evaluating the infrastructure evaluating the contents other interviewees mention the improvement of services and health indicators as a result of training actions when i carry out these actions and see that these indicators improve i think that it is not a fundamental part but it is a part that contributed to the improvement of this indicator along with other issues however it is also possible to observe the lack of systematic monitoring of the impact of training actions on services we have been doing this frequently but i cant see today a way to verify its impact a way that i say systematically as an instrument to verify the impact of these activities on work anyway i dont know of anything that has been done like that the absence of a systematic evaluation process as mentioned by one of the interviewees in addition to complicating the identification of the impacts of competence development actions on health services may discourage the implementation of phe policies and participation of the professionals in the actions offered in this perspective training management is disconnected between prescribed work and real work this transformation is possible when competence is recognized as a complex mix of ingredients with different degrees of adherence to specific work activities and when the subject that engages in the situation is recognized through mobilized values however as discussed this transformation of representations is closely related to social practices from this perspective the implementation of evaluation practices that incorporate collective reflection on the outcomes of training in daily service actions can gradually transform representations of competence development although the actions described by the interviewees may contribute to the development of necessary competences to deal with wrmh by these professionals the strategies used and the evaluation methods described are not sufficient on their own to improve services since they do not promote the necessary transformations in prescriptions professionals who participate in roundtable discussions matrixing or other competence development strategies based on a situation involving wrmh may broaden their repertoire of knowledge to deal with this issue however they still have to start from the same prescriptions about work that are disconnected from reality thus without transforming work processes and given the absence of specific guidelines on the subject as well as the representation of wrmh as an assignment of specific professional categories wrmh remains neglected final considerations the based on these findings it is understood that the processes of developing professional competences in the analyzed context can be enhanced by disseminating a notion of competence that is not linked to job assignments as adopted by the pneps among healthcare professionals the articulation between phe principles and the french approach as well as the recent dynamic approach to competence based in ergology represents theoretical contributions of this work the main theoretical contribution is the relationship between managers social representations and the competence development process as the representation of competence as personal attributes and wrmh as the responsibility of specific professional categories tends to limit the actions taken by managers in contributing to the development of frontline professionals competences to address this issue from a practical standpoint this study provides municipal health departments with an analysis of the development of competences among primary healthcare professionals based on sr shared by health managers in the municipality it also suggests pathways to effectively achieve the desired changes editorial board editorinchief

this research aims to analyze the social representations of workers in management positions regarding the competencies to address workrelated mental health wrmh and how these representations can contribute to or hinder the development of these professional competencies among primary healthcare workers in this field this is a qualitative analyticdescriptive research nine semistructured interviews were carried out with occupants of management coordination or technical responsibility positions the interviews were analyzed using thematic content analysis the results show to different representations about competencies and smrt among the interviewees the use of active methodologies for the development of competencies and limitations to the development and mobilization of competencies in wrmh due to the representations of the managers and the absence of work process transformations the absence of the wrmh theme in the ongoing devices and work processes potentiates the difficulties in this area these results indicate the need for actions that favor the understanding of health processes broadly the perception of wrmh as a collective responsibility the delinking of the notion of competencies exclusively to individual attributes and the development of protocols and instruments for investigating the causal link between mental health and work

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introduction consumer behavior has undergone significant changes in recent years technological influences increased access to information the rise of social classes and the need to consolidate the image projected by the individual based on what is consumed made the awareness of the symbolic value of consumption even more evident during decisionmaking process this value has been studied by several researchers leibenstein in their classification of motivation for the demands for goods and services which highlights consumption as a factor of social distinction either by its stimulus or even by its disincentive any of these attitudes fits the consumer in different social niches reaffirming identity and distinguishing oneself from the mass leads to the search for more specific products and services the choice of what to consume or not is closely associated with the individuals selfperception and his or her socioeconomic status from the moment that elements which are symbolically inherent to an economically higher class are consumed by members of a distinct class the representation of status is questioned for this reason the symbolism of consumption has more influence on the choices of those who consume than the merely functional perceptions of the products offered in the tourism industry factors such as the economic prosperity of the emerging classes and social media have also altered the consumption behavior of tourists the search for more authentic experiences and the possibility of sharing these moments as a factor of differentiation from others have contributed to the improvement of individuals social identity to the directing of choices towards a certain destination and even to influence the travelers conduct deciding on the next vacation trip became more complex and aspects related to the representativeness of the destination and its relation with the image of the people with whom one wishes to equate were included in the process individuals desire to differentiate themselves from others or to be in line with their peers through their travels has already been discussed by correia et al who observed how much the social context interferes with how tourists perceive and experience conspicuous travel the term conspicuous relates to socially advertised consumption that makes it possible to sustain or increase the social position of a certain individual‖ veblen conceptualizes it as a consumption intentionally used to guarantee status when applying the concept to the context of tourism destinations the conspicuous destination can be defined as a place capable of guaranteeing its visitors prestige and social visibility by simply sharing the experiences lived in that environment but it is not enough to differentiate themselves from others they also need to be in agreement with those to whom they aim to associate their image with thus the electronic word of mouth understood as a communication process developed between consumers has a fundamental role when choosing the destination ewom represents an important tool for consumers in search for information kim and lee emphasize that before making their consumption decisions individuals usually consider the opinion of other consumers in the tourism sector as an intangible product the opinion of those who have already tried a particular service gains even more relevance and the use of social media as a mechanism to encounter content generated by their peers in order to strengthen social relations is also enhanced in order for these relationships to become closer their peers must provide the expected positive reinforcement it is in this context that social return takes place that is the feedback tourists expect to receive with the sharing of their trip on social media considering that conspicuous consumption represents the purchase or use of a certain service aiming to receive prestige from other individuals social return would be a way of confirming and identifying whether the destination in question meets the requirements demanded by the group moran boley woosnam jordan kline identified that this construct constitutes one of the greatest predictors when choosing the trips destination another factor that may contribute to the intention to visit a conspicuous destination is the symbolic image of the place for correia et al the conspicuity of destinations derives from their image in the tourism field each touristic region must be seen as a brand and be associated with a certain social image the greater the congruence between the identity of a particular group and the image projected by a destination the greater the likelihood that the members of said group will choose to travel to that location the content generated by individuals helps not only in the obtainment of information about the place but also in identifying the public that frequents it thus it is possible to measure the symbolic image of the destination and the possibility of social return from the visit an increasingly common concern in a connected society where a persons image is partially derived and acquired from digital platforms just as people influence they are this research brings an important contribution to the tourism literature more specifically in the area of tourist consumption behavior for conspicuous destinations the conspicuity approach in this sector and more precisely applied to the destination is still very recent despite the work developed by phillips and back and correia et al there is a need for a greater number of studies since society has undergone significant transformations and social media have dictated not only the way people relate but also the way they behave reaffirm their identity and project their image therefore the objective of this article is to understand how factors such as ewom social return and the symbolic image of the place influence the consumer in the intention of visiting a conspicuous destination literature review conspicuous tourism destination the discussion of consumption as a factor of differentiating and signaling wealth and status has been going on since the 19th century more specifically when veblen released the classic the theory of the leisure class in this piece originally published in 1899 the author presents how american society used consumption to distinguish social classes individuals used to purchase goods and services to display their income and to obtain social prestige which defines conspicuous consumption leibenstein points out that the relationship between status and consumption has been linked since the middle of the 19th century and in an unprecedented way he applies the concept of conspicuity in the formation of demand the author seeks to understand how conspicuous consumption can interfere in the search for a certain good he also states that the status can be improved according to the consumption and nonconsumption of mans desire to equate himself with individuals of the same class or even incite the envy of others has aroused the interest of academics the number of studies that have been carried out addressing this comparative behavior has grown significantly the sharing of values and the desire to fit into a certain social group contributes to the development of equivalent behaviors which leibeinstein identified as the bandwagon effect consumption based on the desire to be part of particular group although it is widely studied in the context of marketing conspicuous consumption has been relatively seldom explored in tourism research researchers seem to neglect that travel is one of the main ways to show status and that when leaving their daily context travelers seek to give their experiences visibility josiassen and assaf identified that consumers classify their travel experiences as public or private according to the social image that the destination could project to understand the degree of social visibility that a tourist destination can have one must take into account the level of symbolism and status that the destination attributes to the individual and its ability to affect the perception of others about the image projected by the visitor it is important to note that the conspicuous destination is not related to the price of the trip but to the symbolic value of its image thus taking into account the academic literature in the field the present study adopts the following definition of conspicuous destination the location where the tourist activity is developed and which has the ability to raise or maintain the status and social prestige of individuals regardless of price ewom the way consumers are interrelated and can influence the purchase decision of others has already been widely discussed by the marketing area word of mouth is one of the most traditional examples of said influence and can be understood as the informal communication process based on the evaluation of goods and services without the interference of companies with technological advances and the advent of social media wom has spread into the electronic environment which has been known as electronic word of mouth this means that the evaluations have become virtual and have acquired much greater proportions for zhang craciun and shin the internet has intensified the dissemination of information related to products consumers became more attentive and increased their influence over potential customers in the most diverse segments in this context erkan and evans affirm that social media enabled a new aspect to ewom the discussion about goods and services with their contact network when consumers share information on virtual platforms regarding their experiences the influence power over others is stronger as people tend to put more trust in a message generated by a common consumer the level of comprehensiveness of comments and information provided by users in addition to enabling a communication process often honest among consumers also interfere in their behavior before choosing to consume certain services customers acquired the habit of checking the assessments provided by other individuals and tend to pay attention to the consensus of the information regarding intangible activities these evaluations gain even more meaning since the identification of the attributes of services can be limited as is the case of tourism marketing tourism review • belo horizonte mg brasil • v 6 n 2 2021 neecim tur • núcleo de estudos e estratégias em comunicação integrada de marketing e turismo • ufmg harrigan et al identified that peoples engagement with social media during their travels has been an increasingly growing trend in the latest years and has contributed significantly to user content generation ewom among consumers has the peculiarity of providing information free from commercial interest which consequently entails greater credibility to the generated content litvin goldsmith and pan claim that stimulating ewom can result in greater commercial activity given the constructs influence power on consumer behavior the influence power of this tool has already been widely studied in other sectors in tourism research aimed at measuring ewoms degree of influence on the destination choice is still recent and restricted to a specific group of researchers user generated content through ewom might indicate a strengthening of social ties taking into account the equivalence of similar values and consumption patterns therefore it can be assumed that ewom not only provides a range of information to other consumers but can also influence the visit of a given destination based on what has been discussed the first hypothesis was formulated h1 ewom positively influences travelers intention to visit a conspicuous destination social return the influence of a group on the consumption behavior of its members has been measured in previous studies ajzen states that the social pressures imposed by the approval or disapproval of certain actions significantly interfere in the attitude of individuals in society the opinion of people who are close to the individual or the community that he or she wants to join affects this consumers decision making and the perception and positive reinforcement provided by peers intensifies the relationship of proximity the feeling of being in compliance with reference groups and the recognition received by its members serve as a stimulus for the purchase it is important that the individual as a member of a certain group meets the expectations created in this social environment marketing tourism review • belo horizonte mg brasil • v 6 observing the persons normative behavior allows the predictability of his or her attitudes regarding the acquisition of goods and services leibenstein when developing the concept of the bandwagon effect identified the variation in the utilitarian perception of a product based on its demand and the influence that consumers suffer from and exert over their social circle as an individual in society the human being is commonly influenced by the environment and tends to acquire a collective identity as a way of combating exclusion and purchasing behavior not only indicates similarities between individuals but also serves to differentiate groups the internet has contributed to these interpersonal relationships to be intensified and even to alter the buying attitude of consumers the use of social media to display possession and behavior serves as a consumption showroom and the visibility of user generated content may even impact their selfperception in the tourism sector travel experiences have different social values depending on their symbolic load destinations can be classified as public in which case there is a real interest in sharing them with their peers or private the ones that do not motivate social media posting from this perspective a second hypothesis was formulated marketing tourism review • belo horizonte mg brasil • v 6 n 2 symbolic image consumption as a tool for social distinction or reaffirmation of identity has been commonly researched since the 1980s the symbolism involved in a particular purchase and the need for buyers to impress other people are often associated with the relationship between consumption and emotion in tourism specifically this association influences the intention to visit certain destinations since as customers identify that a given experience reinforces their identity they usually choose to experience it in the work of ekinci et al it was found that consumer loyalty to a given destination is not only related to its functional aspects but is also associated with the places capacity to reinforce the individuals social identity and symbolic lifestyle the way tourists see themselves or would like to be seen besides contributing to reinforce their symbolic identity also legitimizes their participation in certain groups for such reasons a places image becomes one of the central aspects to be analyzed when defining the trip when dealing with the symbolic aspects of a destinations image the relationship of this image with the individuals selfcongruence must be observed and it can be analyzed under two distinct dimensions these are real selfcongruence related to the way individuals see themselves and the ideal selfcongruence which concerns how individuals would like to be seen by society although ekinci et al found aspects related to selfcongruence as influencing tourists loyalty to a given destination ahn et al did not find the same in their study these authors came to the conclusion that the functional aspects were significantly influential when choosing the trip and that this is due to the possibility of tangibility taking into account the methodology this study has the interest of testing previously formulated hypotheses based on the existing theory for which a quantitative approach was designated the research is characterized as descriptive and explanatory as it was intended to describe and subsequently explain the relationships between the variables studied given the studys crosssectional design data were collected during a single period of time the population represents the group from which it is desired to obtain significant conclusions for the research therefore it was considered that any and all brazilians who have the habit of sharing their travels on social media could provide relevant data for the construction of this work given the unascertained totality of members in referred universe together with the time constraints that limit every research a nonprobabilistic sampling was adopted using convenience sampling as a technique and snowball as a strategy online survey was the elected procedure for data collection the destination of porto de galinhas beach located in ipojuca a city in the northeast region of brazil was used in the formulation of the questions as a substitute for the term conspicuous tourist destination‖ so that there was a greater understanding of the respondents about the attributes that constitute this type of destinationit is believed that porto de galinhas beach materialized the term as it is one of the main tourist locations in northeastern brazil with consolidation on the international stage arousing the desire for visitationin addition porto de galinhas beach based on the findings of silva and durão is perceived by adjectives as beautiful stimulating attractive and sensational both by national and international tourists silva and durão still analyze the ebranding developed by the destination management organization and realize through their promotional material that the place is designed as a unique destinationthese factors contribute to characterize porto de galinhas beach as a conspicuous destination since taking into account the aspects reported by correia and kozak it would allow the visitor when sharing his moments in the locality visibility and social prestige to be visiting a single destination the questionnaire consisted of 16 items that aimed to measure the constructs presented in this study in addition to questions related to the populations sociodemographic profile the variables were presented in a 7point likert scale in which 1 is the lowest agreement level and 7 the highest agreement level after its elaboration it was submitted to a content validation process through the thorough analysis of 10 researchers in the tourism area after the recommendations of these evaluators some items were changed and the instrument went through a pretest with 20 respondents with characteristics similar to the population studied and which were not counted in the final sample of this research social media posts of travel to porto de galinhas beach make the traveler look cool social media posts of travel to porto de galinhas beach make the traveler look more popular social media posts of travel to porto de galinhas beach make the traveler stand out social media posts of travel to porto de galinhas beach make the traveler look unique social media posts of travel to porto de galinhas beach make the traveler look savvy social media posts of travel to porto de galinhas beach make me envious of the traveler data collection was carried out between december2018 and february2019 by sharing the questionnaire which had been applied in portuguese on social media with the request that the respondents after recording their answers should share it with their friends and family in total data were collected from 160 respondents bearing in mind that the survey was conducted through the google forms platform with all questions flagged as mandatory there was no need to validate the nonresponse error after the end of data collection the database was extracted to microsoft excel at which time the database was refined coded and the nominal data were transformed into numeric data then the spreadsheet was imported into the statistical package for the social sciences software used for statistical analysis after data collection the analysis procedures occurred as follows initially a description of the samples sociodemographic profile was made using basic descriptive statistics distributed between percentage mean and standard deviation the next stage was devoted to inferences of the resultsbefore however tests of reliability and dimensionality of the data were carried out in order to guarantee the validation of the collection instrumentto examine the reliability of the items in each construct cronbachs alpha was used with acceptable levels from 06 the dimensionality of the items was assessed by an exploratory factor analysis using tests such as kaisermeyerolkin and bartletts test of sphericity finally to confirm or refute the hypotheses proposed by the theoretical model multiple linear regression analysis was carried out results and discussion marketing tourism review once the data were collected the next step was directed to their treatment and investigation as described in the previous section thus the next topics present the elementary findings of this investigation discussing them according to the theoretical basis sociodemographic profile of the sample the first results refer to the outlining of the respondents sociodemographic profile taking into account the variables of the instrument that were intended for that purpose initially this profile was determined based on frequency statistics as presented in table 2 the findings reveal that the studys sample is predominantly characterized by the female gender in addition the education of these individuals is for the most part divided between the levels of higher education and postgraduation demonstrating the respondents overall high level of education furthermore individuals annual travel frequency was also measured through this variable it was observed that this frequency is mostly 2 times a year although the percentages are showing variation between the other options finally the predominant geographic region of residence was the northeastern of brazil a situation that may have been caused by the studys place of origin then the mean and standard deviation of the remaining sociodemographic variables were measured based on the results it was found that the respondents average age is around 31 years the average family monthly income is brl 530617 considering that the average number of individuals living in the same household is 291 people the average income per person that is the per capita income resulted in brl 182342 all of these data are displayed in table 3 presented below once the sociodemographic profile of the sample that composed this study had been traced the next step was directed at analyzing the reliability of the variables that composed the collection instrument in addition to the dimensionality of the data collected these statistical procedures carried out through spss are important to ensure methodological rigor in quantitative research and must precede the performance of multiple linear regression analysis the next section therefore will describe these protocols reliability and dimensionality of data initially the reliability analysis procedure was performed in each of the constructs in order to verify the effectiveness of the scales in measuring the proposed constructs therefore cronbachs alpha statistics were used considering acceptable indexes of at based on the results of factor analysis it was necessary to remove item srts06 from the social return construct given its low factor load the other constructs showed adequate values and all the items were maintained on the scales of each construct theoretical model analysis once the previous procedures were carried out the regression was tested at first the descriptive statistics of the constructs were verified using the other variables however did not achieve high scores social return for instance achieved an intermediate result the descriptive findings also revealed that the studys sample does not seem to relate with ewom and the symbolic image since both behavioral attributes received scores below the average of agreement table 6 presented as follows details the multiple regression enter method from this test it was found that all elements theoretically assumed as predictor variables indeed exert a statistically significant influence on the intention to visit conspicuous tourist destinations in sequence table 7 summarizes the theoretical model statistically accepted once the three independent variables were inserted in model 1 the value of r indicates the correlation degree between the predictors and visit intention this coefficient explains the variation proportion finally the values of the coefficients were verified in order to certify whether the proposed hypotheses would be confirmed or refuted at first the values of sig were observed with reference standard as 005 to ascertain if the predictors actually influence the dependent variable the results showed that only social return influences the intention to visit conspicuous tourist destinations given that the other components had higher rates than the established parameter thus h1 and h3 were immediately rejected the beta value of the social return in turn shows that this behavioral attribute positively influences the dependent variable with an index of 0277 therefore h2 couldbeconfirmed indicates that sharing information about experiences tends to influence consumer behavior and strengthen social ties according to the equivalence of similar values and consumption patterns proved to be inversely proportional to the intention to visit a conspicuous destination the rejection of h1 meets the results obtained by abubakar et al however it can be better explained based on the findings of boo and kim in a study developed in the context of gastronomy boo and kim identified that a previous negative ewom experience has a strong impact on individuals intentions although there is evidence regarding the influence of ewom as a source of confirming information provided by online advertising of destinations aspects related to the intangibility of the activity and subjectivity of the individuals experience must be taken into account by nature conspicuous consumption represented here through the intention of visiting tourist destinations with such a characteristic is induced by the desire to express social status in these cases once destinations become objects of discussion in ewom it is possible that instead of producing greater credibility for decision making the lack of exclusivity of the destination becomes apparent the need to make others desire consuming the same experience is only possible when the destination is still scarcely explored thus the evaluations of other visitors may not have an effect on demand as observed by the results of the present study order to signal ownership and obtain the social return that results from it in an increasingly connected society social media represents an opportunity to reaffirm identity reinforce the similarity of behavior and thus increase the sense of belonging in a peer group oliveira araujo tam reinforce this argument by identifying that sharing the trip is closely related to achieving personal goals such as identification therefore the positive feedback that can come from sharing a trip mainly from peers influences the intention to visit a specific destination unlike what happens with the ewom effect social return has shown to have a positive impact on the visit intention it is possible to infer that while the evaluations of others about destinations measured through ewom discourages interest in destinations the desire to share locations on social media expressed by social return predicts demand hence it appears that the desire for conspicuity in the case of destinations is aroused by the need to share experiences and reaffirm identity on social networks however evaluations carried out by others do not positively succeed in a consumer attitude furthermore symbolic image similarly to ewom does not predict the intention of visiting conspicuous tourist destinations since this type of consumption is composed of individuals who wish to express social value it was expected that the way an individual would like to be seen by society would reverberate in the interest of visitation however in this case the utilitarian aspects seem more pertinent to the constitution of the demand ahn et al for instance pointed out that the analysis of the destinations functional attributes attenuates the intangibility of tourism and allows consumers to adopt a more conscious choice process thus reducing the possibility of frustration another factor to be highlighted is related to the validity of the symbolthe findings of witt demonstrate that the validation of the and 1999 would be more relevant in practical and previous aspects in conspicuous consumption there is a very conscious and defined desire to show purchase power and obtain social prestige given such longing the desire for products being no different for tourism destinations may not be a process based on subjective issues but on rational decision making based on utilitarian attributes as explored by ahn et al social return for example the only construct to have explained the intention to visit is useful since it has a welldefined function conclusion in order to assess whether factors such as ewom social return and the symbolic image of the place influence consumers intention to visit a conspicuous destination this study has reached some conclusions first it is important to note that although the use of social media represents a great source of information about destinations and is a widely used tool in travel planning the experiences posted in these channels by the individuals networks showed to have no influence on their intention to visit the shared places the positive influence of social return on the intention to visit a destination indicates that individuals expect positive reinforcement from their peers when sharing their travel experiences in this case the desire to belong and demonstrate behavioral agreement with the members of their social circle the main contribution of this research was to discuss the concept of conspicuous tourism destination and to contribute for the clarification of attributes necessary for touristic regions to fit into this concept in addition we sought to identify through constructs related to consumer behavior and never before studied under this conjuncture their level of influence on the intention of tourists to visit a destination the study also contributes to the current discussion about the use of social media to obtain status and visibility regarding its academic implications the study provides evidence which contributes to the debate of existing divergences as to the role of ideal selfcongruence and the symbolic image of a destination and predictors that theoretically influence consumer behavior during the planning of their trips the research also helps to identify criteria that allow a destination to be classified in the category of conspicuous destination based on the literature developed in the scope of tourism future research that aims to reach consensus regarding the ideal selfcongruence and the symbolic image of a destination as well as new studies that increase the debate over factors that classify destinations according to their conspicuity degree and which criteria present greater influence on consumers may bring important evidence and enrich the discussion on such topics declaration of interest statement the authors declare no conflict of interest

the aim of this study was to measure the influence of electronic word of mouth ewom social return sr and symbolic image si on the intention to visit a conspicuous tourist destination the research had a quantitative approach thus data were collected through an online survey and the analysis realized by multiple linear regression the results revealed that ewom and si have no influence on the intention to visit a destination these findings are not in line with most academic researches but may be associated with the degree of intangibility of tourism activity and the subjectivity of the individual consumer experience sr demonstrated a positive influence on the intention to visit a conspicuous destination such result is congruent with and reinforces the findings obtained by previous researches on consumer behavior the main contribution of this study consists in confirming the influence of social media on the intention to visit a tourism destination in search of visibility distinction and social prestige travel has become a tool for displaying status

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background china is undergoing a rapid population aging process by the end of 2021 the number of chinese elderly people over 60 had reached 267 million accounting for 189 of the total population 1 in addition compared with the number of elderly people in 2000 when china became an aging society the net increase of elderly population is approximately 138 million it is estimated that by 2050 the number of elderly people over the age of 60 in china will rise to a peak of 488 million representing 356 of the total population 2 however china is an unhealthy aging society more than 30 of elderly people suffer from at least one kind of chronic disease and more than 15 of elderly people need care services provided by others 34 at the same time china established a primary pension insurance system to cover elderly people but the pension is low and is growing slowly as many as 150 million chinese elderly people receive a monthly pension from 100 to 200 cny 5 which means that if there is no financial support from adult children the income of most elderly people will not exceed the poverty line of 2300 cny set by the state in 2016 a study showed that the poverty rate among elderly people in china reached 30 6 which highlights the importance of adult childrens financial support in reducing the risk of poverty among elderly people in the transformation from a traditional society to a modern one china is experiencing a decline in fertility rate a shrinking in family size a separation in intergenerational residence arrangement and the reversal of intergenerational family status according to statistics the fertility rate in china dropped from 581 in the 1970s to approximately 115 in 2021 7 the average family size is only 262 and the proportion of oneperson household and twoperson households exceed 50 8 empty nesters accounted for more than 50 of elderly peoples households and 131 of elderly people lived alone in 2015 3 during this period the way in which elderly people receive care services has gradually changed from single informal care provided by family members such as adult children and spouses to a mixed pattern that includes informal care provision and a small amount of formal care provision but informal care is still the mainstay of elderly care services 910 in china the type of formal care mainly includes paid care services provided by nursing homes hospitals and home care staffs these formal care provisions are open to all elderly people since 2015 after the government provided subsidies of longterm care the general price structure of formal care was revised to 170 cny to 200 cny per day for care in hospitals 65 cny per day for nursing homes 50 cny per day for home care staffs 11 elderly people with better economic conditions especially those in urban areas could purchase marketbased care services to meet their needs for personalized care services 12 china has launched a series of policy initiatives to develop a system of services for elderly people which consists of three tiers of social services homebased care as the basis communitybased services as backing and institutional care as support 13 in particular formal care has developed dramatically over the years on the one hand the chinese government has begun to strengthen the construction of facilities for communitybased care services since 2000 14 by the end of 2021 the facilities of communitybased care services reached 318000 and communitybased care services are usually funded by local government and free to community residents 15 on the other hand chinas marketbased elderly care services are also gradually developing by 2016 the gdp of the marketbased elderly care and nursing services reached 57 billion cny 16 there has been approximately 70 growth in the number of care home beds reaching the target of 30 beds per 1000 elderly people 17 studies in some developed countries have demonstrated that there are substitutions between informal and formal care in germany longterm care policies provide cash benefits which made family caregivers reduce the time of home care increase labor supply and pay more formal care for older people 18 longterm healthcare services have reduced informal care from family members in the nordic countries such as norway and sweden but population ageing and strained public resources will likely challenge the future provision of formal oldage care 19 in contrast other studies estimate a complementary effect which found that formal care increases the provision of informal care 20 a similar complementary effect of community and informal care is also observed in japan 21 in china there seems to be a substitution between formal and informal care and the use of formal care services for elderly people is regarded as a sign of the decline of the traditional filial piety culture and the informal care model by some studies 2223 however more studies have shown that first adult children are still the main providers of care services for their parents and that more than 80 of care services come from elderly peoples adult children especially in rural areas where formal care services are underdeveloped 24 second adult childrens financial support constitutes the most important source of income for the majority of their parents and has become an important way to compensate for low pensions income 25 in addition although there is a trend of separation of intergenerational coresidence arrangement most of elderly people and their adult children still live closely to each other in same communities or villages 2627 therefore financial support and informal care provision of adult children to their parents will not disappear but instead they will remain as a strong connection which is compatible with modernization financial support and informal care provision are two core contents of adult childrens support to their parents and they are also indispensable resources to ensure the happiness of elderly individuals in the decision making within the family the association between financial support and informal care provision is changing and its ultimate goal is to maximize the benefits of the family 28 however there are some obvious differences between financial support and informal care provision taking care of parents especially who come with poor physical conditions requires more time energies and patience from their adult children which made negative influence on the physical condition income and leisure of adult children 2930 compared with informal care provision financial support is easier to perform under the background of the shrink in family size frequent population mobility increasingly fierce labor market competition and improved accessibility of formal care services 3132 some scholars pointed out that intergenerational relationships have shifted from reflecting filial piety in terms of both financial support and caregiving from younger generations to increasing financial transfers accompanied by a decreasing responsibility of informal care provision 3334 and recent research found that financial support from the younger generation was negatively associated with the informal care provision 35 based on that we propose the following questions what is the association between financial support and informal care provision of adult children to their parents in china what is the trend of this association what are the group differences in this association although previous studies found that there is a negative association between financial support and informal care provision they are mostly based on crosssectional data or data in some regions and some studies mainly focus on a particular group such as elderly people with a disability or dementia or living in cities 3536 it is necessary to investigate the relationship between financial support and informal care provision from a dynamic perspective using multiperiod data which will make the research conclusions more reliable in addition there is strong heterogeneity within chinese elderly people such as groups of different household registration residence arrangement and the availability of communitybased care services household registration in china determines eligibility for various welfare benefits such as education health insurance pension insurance housing and employment which has led to a huge difference in social welfare and economic status between urban and rural residents 37 coresidence represents an important source of informal care and elderly people living alone are much more likely to rely on formal care while those who live with adult children receive more informal care 19 currently china has vigorously developed communitybased care services such as housekeeping services rehabilitation care and spiritual comfort services in order to make up for the lack of informal care however the services provided at community centers varied greatly in quality and quantity some communities even do not provide services for elderly people 38 there were group differences in the association between financial support and informal care provision of adult children to their parents which has not been considered in previous studies and deserve further study the marginal contributions of this study are as followed first we described the trends of financial support and informal care provision of adult children to their parents from 2008 to 2018 second the dynamic association between financial support and informal care provision of adult children to their parents was explored by using longitudinal data from 2008 to 2018 which overcomes the limitations of research based on crosssectional data third we analyzed the difference of household registration residence arrangement and the availability of communitybased care services in the association between financial support and informal care provision form adult children to their parents methods data sources the data was derived from the chinese longitudinal healthy longevity survey which was a nationally representative survey performed jointly by the center for healthy aging and development studies at peking university and duke university a baseline survey was conducted in 1998 and was followed by seven waves of surveys in 200020022005200820112014 and 2018 which was from 22 sample areas in 31 provincial administrative units the population of the surveyed region accounts for 853 of the total population in china which could be regarded as a nationally representative sample 39 all respondents were tracked in the later waves unless death or loss to followup occurred and the response rates are 88 to 90 in the waves of clhls 40 the ethics committee of peking university approved the clhls study additional details such as the sampling design sampling weight and assessment of data quality can be found in previous studies 4142 this study employed the longitudinal sample from 2008 to 2018 which contained rich information on financial support informal care provision health status and lifestyle family resources adult childrens information communitybased care services as well as characteristics of the respondents after excluding cases with missing information on key variables and considering that there is insufficient information to confirm the age reported by extremely elderly people we also excluded elderly people aged 120 and over the final sample consisted of 2996 elderly people aged 60 and over in the 2008 wave 3287 in the 2011 wave 2054 in the 2014 wave and 4344 in the 2018 wave and there were 9402 respondents who participated in one wave accounting for 7414 2665 respondents who participated in two waves accounting for 2102 597 respondents who participated in three waves accounting for 471 and 17 respondents who participated in four waves accounting for 013 the study sample selection process is shown in fig 1 measures dependent variable informal care provision the dependent variable is informal care provision in the clhls the respondents were asked how many hours did your children and their spouses spend in providing care to you last week in total that reflects the received time of informal care of the elderly the informal care provision variable ranged from 05 to 168 h we subsequently categorized informal care provision into three groups high medium and low intensities high intensity of informal care provision is defined as receiving more than 50 h of informal care per week medium intensity is defined as receiving between 21 and 50 h of informal care per week while low intensity is defined as receiving 20 h or less of informal care per week the classification method of informal care intensity is based on a number of previous studies 4344 independent variable financial support the independent variable is financial support financial support is measured by the amount of cash and value of materials received from adult children in the clhls participants were asked the following questions how much money did you get from your children and their spouses no matter living with you or not last year after eliminating the extreme values we subjected logarithmic processing of financial support we had adjusted financial support for inflation during processing the data covariates all analyses included a series of covariates associated with the care recipient according to the previous studies 1925364546 the sociodemographic characteristics included gender age marital status education level household registration health status and lifestyle included chronic disease activities of daily living smoking alcohol consumption and exercise adl included the six items of eating bathing dressing bathroom use getting in and out of bed and moving around fig 1 flowchart describing the sample selection indoors for each item the respondents were provided with three choices the total adl scores ranged from 6 to 18 and the higher scores indicate more limited function of the respondent family resources included the number of adult children and family income bargaining power included whether the respondents owned real estate in their own name whether the income is sufficient for paying daily expenses and the frequency of performing housework intergenerational relationships included residence arrangement and frequency of communication with adult children residence arrangement were assessed by whether elderly people coresided with adult children social services included medical insurance pension insurance and the types of communitybased care services there are eight types of communitybased care services included personal daily care services home visits psychological consulting daily shopping social and recreation activities legal aid health education and neighboring relations these communitybased care services are funded by local government and provided free for community residents statistical analysis we first used descriptive analysis to describe the general characteristics of the participants and examined the trends in financial support and informal care provision of adult children to their parents from 2008 to 2018 then we assessed the association between financial support and informal care provision of adult children to their parents by random effects models finally considering that there are differences in household registration residence arrangement and the availability of communitybased care services among elderly people we explored the association between financial support and informal care provision in different groups all analysis was conducted using the statistical software stata15 results sample characteristics table 1 shows the characteristics of the participants from 2008 to 2018 the average financial support of adult children to their parents was 607 the average informal care provision of adult children to their parents was 4639 the low intensity of informal care provision accounted for 484 the medium intensity of informal care provision accounted for 2233 and the high intensity of informal provision accounted for 2927 women accounted for 6247 in the participants the average age of the participants was 9110 the average education years of the participants was 199 the participants who are singledivorcedwidowed accounted for 7556 in the participants and individuals from rural areas accounted for 4779 in the participants most of the participants come with the following features which had chronic diseases no adl limitations no alcohol consumption two or more adult children low family income no real estate in own name sufficient income for paying daily expenses medical insurance and had no pension insurance and most of the participants didnt smoke exercised performed housework rarely or never coresided with adult children often communicated with adult children and had fewer types of communitybased care services the trends of financial support and informal care provision from 2008 to 2018 there are differences in the family economic status of chinese elderly people we divided the family income of elderly people into ten equal parts and considered the top 10 percent as the highincome group and the bottom 10 percent as the lowincome group 4748 then we investigated the trends of financial support and informal care provision of adult children to their parents among the two groups from 2008 to 2018 figure 2a shows the trends in financial support and informal care provision from 2008 to 2018 among lowincome group of elderly people although the financial support of adult children to their parents reduced slightly from 2014 to 2018 it showed an upward trend from 2008 to 2014 generally and the average of financial support in 2018 increased by 111972 cny compared with that in 2008 informal care provision of adult children to their parents showed a downward trend from 2008 to 2018 and the average of informal care provision in 2008 decreased by 582 h compared with that in 2018 figure 2b shows the trends in financial support and informal care provision from 2008 to 2018 among highincome group of elderly people on the whole financial support of adult children to their parents showed a rising trend from 2008 to 2018 and the average of financial support in 2018 increased by 44015 cny compared with that in 2008 informal care provision of adult children to their parents showed a downward trend from 2008 to 2018 and the average of informal care provision in 2008 decreased by 236 h compared with that in 2018 it could be found that adult children provided less informal care provision and more financial support to their parents among lowincome and highincome group of elderly people the association between financial support and informal care provision table 2 shows the results of the random effects models which indicated that there was a significant and negative correlation between financial support and informal care provision of adult children to their parents 0761 to 0239 after adjusting for the covariates we also found that some covariates were significantly related to informal care provision respondents who were female were older had chronic diseases had worse adl had real estate in own name had sufficient income for paying daily expenses coresided with children and had pension insurance were more likely to receive more informal care provision from their adult children compared with elderly people in rural areas those in urban areas were more likely to get less informal care provision from their adult children elderly people who performed housework frequently and had medical insurance were more likely to get less informal care provision from their adult children time variable was significantly and positively with informal care provision the association between financial support and informal care provision among different groups table 3 shows the results of the difference in the association between financial support and informal care provision based on the household registration residence arrangement and communitybased care services first the association between financial support and informal care provision of adult children to their parents was significant in urban areas but this association was not significant in rural areas second the association between financial support and informal care provision of adult children to their parents was significant among elderly people who coresided with adult children but this association was not significant among those who lived alone third the association between financial support and informal care provision of adult children to their parents was significant among elderly people who had communitybased care services but the association was not significant among those who had no communitybased care services discussion based on the national representative sample with longitudinal data this study attempted to focus on all chinese elderly people exploring the association between financial support and informal care provision of adult children to their parents and analyzing this association based on the differences in household registration residence arrangement and communitybased care services the results indicated that financial support showed an upward trend while informal care provision showed a download trend on the whole it was found that financial support was negatively and significantly associated with informal care provision of adult children to their parents and the association was significant among elderly people who were from urban areas coresided with adult children and had communitybased care services it was found that financial support was negatively associated with informal care provision of adult children to their parents and financial support is increasing with the downward trend of informal care provision for lowincome and highincome groups of elderly people the results were consistent with previous studies 35 which indicated there is negative association between financial support and informal care provision economic reforms and laborrelated migration have both improved the economic status of adult children enhancing their capacity of offering more financial support to their parents as the childrens disposable resources have increased 49 the informal care provision in practice could be eroded due to the mobility and lack of availability of adult children 50 the corporate group model has suggested that constrained by the decision to maximize family utility there may be an alternative association between financial support and informal care provision of adult children to their parents 3551 that is adult children reduce the informal care provision by providing more financial support to their parents on the one hand the financial support fig 2 the trends of financial support and informal care provision for lowincome and highincome groups from 2008 to 2018 note the left side of the figure shows units of financial support and the rightside shows units of informal care provision it was found that there was difference of household registration in the association between financial support and informal care provision of adult children to their parents for elderly people in urban areas financial support was negatively and significantly associated with informal care provision of their adult children while the association is not significant for those in rural areas that could be explained by the differences in concepts of filial piety pensions and the availability of formal care services caused by the dual structure of urban and rural areas in china in rural areas filial piety emphasizes the importance of informal care provision of adult children to their parents while filial piety is gradually declining in cities with a higher level of modernization 10 in urban areas the formal care service system is gradually being established and improved particularly elderly people in urban areas usually enjoy a relatively a high level of monthly pension which enable them to purchase more formal services 5253 in contrast in rural areas due to the lowerlevel pensions and the lack of formal care service the elderly people can only rely on the support from adult children to meet their own economic and care needs 2425 the results showed that there was difference of residence arrangement in the association between financial support and informal care provision of adult children to their parents the association of financial support and informal care provision was significantly negative among elderly people coresided with adult children but the association was not significant among those who lived alone this suggests that adult children are more likely to replace informal care provision with financial support even if they coreside with their parents which could be explained in two ways on the one hand elderly people who coreside with adult children have more intergenerational communication and get more filial piety from adult children 26 it is obvious that financial support is an easier way to express filial piety which could meet elderly peoples daily economic needs 12 on the other hand in china many elderly people who coreside with adult children tend to provide intergenerational care to their grandchildren which makes adult children return the favor in the form of financial support there was difference of communitybased care services in the association between financial support and informal care provision of adult children to their parents for elderly people who had communitybased care services financial support was negatively and significantly associated with informal care provision while the association was not significant for those who had no communitybased care services the welfare triangle theory showed that the public care services provided by the government will have a crowding out effect on informal care provision 5455 the provision of basic public care services in china is developing rapidly and the supply of communitybased care services brought chinese family more alternative ways of elderly care services 48 many adult children could provide financial support rather than informal care provision to their parents when community provided some elderly care services 56 as a result communitybased care services make crowding out effect of informal care provision of adult children to their parents and the association between financial support and informal care provision of adult children to their parents was significantly negative among elderly people who had communitybased care services evaluating the association between financial support and informal care provision of adult children to their parents is beneficial for constructing a perfect care system aimed at providing and improving elderly care services outside the family numerous elderly people in china especially in rural areas are confronting the dilemma of being left at home with nobody to take care of them in consideration of the association between financial support and informal care provision varies in terms of the household registration residence arrangement and communitybased care services the chinese government should pay more attention to the planning of the elderly care service system expand the coverage of communitybased care services and establish a support system for family caregivers first chinese government needs to mobilize social resources to establish longterm care programs policymakers should leverage available policy instruments such as tax exemptions and subsidies to explicitly encourage the construction of longterm care facilities especially those in rural areas 57 second supervise and manage the supply of communitybased care services to promote the development of community stations that provide daycare and temporary nursing services third it is suggested that provide financial emotional and physical health support for home caregivers in particular financial and care assistance should be provided for disabled elderly and lowerincome households nevertheless the research findings from this article should be interpreted cautiously due to some limitations first the indicator of informal care provision was selfreported by the elderly people the elderly people who coresided with adult children may overstate the length of time about informal care provision which would cause measurement inaccuracy of informal care provision second some characteristics of adult children such as occupation and working status are important factors affecting the association between financial support and informal care provision unfortunately these factors are not included in the clhls and we cannot select these variables in analysis last due to the lack of detailed data on the financial support and informal care provision provided by each adult child the distribution of financial support and informal care among each adult child was not fully considered in this study despite these limitations this study discovered that the association between financial support and informal care provision of adult children to their parents was negative and significant which provide evidence from chinese families conclusion this study demonstrated that financial support was negatively and significantly associated with informal care provision from the dynamic perspective which fills the gap in literature on the association between financial support and informal care of adult children to their parents in china it was found that the association of financial support of adult children to their parents and informal care provision was significant among elderly people who are from urban areas coresided with adult children and had communitybased care services but the association was not significant among elderly people who are from rural areas lived alone and had no communitybased care services considering the trends of decreasing informal care provision with increasing financial support of adult children to their parents the social policies and social services should be initiated to support families policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system from adult children promotes parents ability to purchase formal care services in the market and meet their care needs on the other hand adult children also have sufficient time to meet their career income and leisure needs to maximize their own utility as family structures change and formal care develops more adult children will choose to provide financial support to their parents and reduce informal care provision 35 competing interests the authors declare no competing interests

background the changes in demographic and family structures have weakened the traditional norms of filial piety and intergenerational relationships dramatically this study aims to examine the dynamic association between financial support of adult children to their parents and informal care provision in china and its differences in household registration residence arrangement and communitybased care services methods data was derived from the 20082018 chinese longitudinal healthy longevity survey clhls which is a longitudinal survey of a nationally representative sample of individuals aged 60 and over random effects model was used to assess the association between financial support and informal care provision of adult children to their parentsit was found that financial support showed an upward trend while informal care provision showed a download trend from 2008 to 2018 the result indicated a significant and negative association between financial support and informal care provision of adult children to their parents b 0500 95 confidence interval ci 0761 to 0239 and the association was significant among elderly people who were from urban areas b 0628 95 ci 0970 to 0287 coresided with adult children b 0596 95 ci 0939 to 0253 and had communitybased services b 0659 95 ci 1004 to 0315 financial support was negatively associated with informal care provision of adult children to their parents in china and the association has differences in household registration residence arrangement and communitybased care services it is suggested that policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system

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introduction the losses caused by worldwide extreme events have escalated in recent decades application of the resilience concept to a socialecological context emerged as the means to bring about a shift in the disaster risk reduction approaches designed to improve the safety of humans and their wellbeing in this paper floods are the natural hazard included in a social resilience assessment the concept of resilience in disaster risk management and socialecological fields has been evolving progressively some authors have pointed out that its origin is the latin word resilire or resilire which means bounce which in this context means to bounce or to spring back hollings work has given a major spur to the inclusion of the resilience concept in the socialecological field for several years thereafter this inclusion of the resilience concept was based on the comparison between resilience and vulnerability and between resilience and adaptation adaptive capacity the evolution of this inclusion process has progressed through the referred phases up to the most recent evolutionary classification of the concept of socialecological resilienceevolutionary resilience a special focus is given in our approach to the evolutionary resilience concept as it embeds the challenge of including two dimensions in the social resilience assessment which are not trivial to measure the individuals and communities 1 evolving capacity with a nonstable time view and 2 learning ability the aptitude to respond to changes hence the idea of equilibriumstability is put aside by the inclusion of the systems natural tendency to change currently politicians and international organizations are pushing for the application and inclusion of resiliencebased approaches and assessments in disaster risk reduction actions and planning especially since the launch of the sendai framework in 2015 however sr still lacks clarity in its conceptual frame as well as accurate methods of assessment and procedure quantitative methods are essential whenever observing or analysing any kind of system this lack of accuracy in the assessment methods is more evident when comparing the methods to assess social resilience with for instance the methods to assess social vulnerability the latter has far more applications in many countries around the world namely in portugal where this research is being conducted this paper addresses a scientific gap identified through bibliography reviews ie the need for a clear conceptual framework that can provide quantitative assessments of social resilience at a given time rather than only in postdisaster situations the aforementioned gap is due to the fact that the resilience concepts and approaches in risk governance developed so far are too broad since they apply to many different fields and therefore are not focused on a specific scientific area or type of disaster this paper presents the results of social resilience in floodaffected communities these results consist of a stable set of keywords key dimensions and the means to measure themindicators framed within a type of disaster such as floods to reach such results the proposed methodology included scientific peerreviewed papers experts opinions and text mining this work is a contribution to the stabilization of social resilience assessment in the risk governance field as it presents a scientific basis to outline an indicators database a conceptual overview regarding the state of the art and this work view regarding this concept is found in section 2 the state of the art concerning indicatorbased studies on social resilience is presented in section 3 the description of the proposed methodological approach can be seen in section 4 the results and their consequent discussion are explained in section 5 the main assumptions and next steps are in the conclusion section social resilience overview and main scientific gaps addressed despite the widespread discussion amidst the scientific community regarding the concept of sr applied to disaster risk management several scientific gaps remain that prevent its wider application some of these gaps are identified in scientific publications the theoretical and methodological proposal of this paper being a contribution to the muchneeded enhancement and advancement of sr assessment sr just like any social science field finds its topmost difficulty in the nonstatic and noneasily quantifiable nature of the studyobject communities and individuals the nature of the studyobject the wide conceptual discussion combined with its lack of conceptual clarity and its few robust practical applications turn sr into a scientific area with large methodological gaps sr applies to communities that are groups of individuals with interconnected practices in which social and natural processes take place time dependence must somehow be contemplated but the dependence might not be linear given the intrinsic learning capability of communities and individuals another question arises about the independence of sr from disasters although this is a social and therefore a nonspatial phenomenon resilience promotion has a somewhat preparedness facet which tends to frame sr studies according to some disasterhazard or threat to the individuals and communities the purpose of its study is to contribute to resilience promotion within a certain location where individuals are exposed to floods the third question under consideration concerns the main components that can determine the indicators of sr assessment despite the still inaccurate conceptualization resilience has become part of the political agenda worldwide and this might result in a twosided problem first the lack of dialogue between academia and politicians and secondly the excessive interdependence between research and political needs given the importance of using sr it is necessary to identify the determinants and dimensions to be included in its assessment for example an index suitable to respond to the different phases of disaster governance or an index just to monitor resilience since it is necessary to find indicators and assessment methods that go beyond the postrisk stage overview framing decades of discussion into tendencies the definition and dimensions of sr may change according to the perspective or field in which sr is used figure 1 shows a summary of some interpretations of the resilience concept within the socialecologic context over time several works have described the evolution of the concept of resilience and its inclusion under the disaster risk reduction field the main scientific tendencies are presented in figure 1 using some of the mentioned reviews as references to compare and identify the main differences and similarities amongst them 2002holling 1973 figure 1 shows quotations from different works at different periods that facilitate the comparative analysis of distinct views of the concept of resilience and its integration into the socialecological field those quotations show that as a cycle the recently named evolutionary resilience as proposed by davoudi is very similar to the ecology systems theory proposed by holling in 1973 in fact both refer to the ability to change or to absorb change and to the relationships between organizations inside the systems that were also referred to by folke et al davoudi et al 2012afolke carl since latin root of the term to 19th century • engeneering view of the concept of resilience in the first half of the nineteenth century resilience was still used in the sense of rebounding 2nd half of 20th century to 1st decade of the 21st century • systems theory viewapplication of resilience to ecology it is useful to distinguish two kinds of behaviour one can be termed stability which represents the ability of a system to return to an equilibrium state after a temporary disturbance the more rapidly it returns and the less it fluctuates the more stable it would be but there is another property termed resilience that is a measure of the persistence of systems and of their ability to absorb change and disturbance and still maintain the same relationships between populations or stable variables • socioecology view resilience for socialecological systems is related to the magnitude of shock that the system can absorb and remain within a given state the degree to which the system is capable of selforganization and the degree to which the system can build a capacity for learning and adaptation building socialecological resilience requires understanding of ecosystems that incorporates the knowledge of local users 21st century • community view centred on societycommunity aspects of resilience the purpose of disaster resilience research is to enhance the ability of a community to prepare and plan for absorb recover from and adapt to adverse events in a timely and efficient manner including the recovery and improvement of basic functions and structures of social systems that is a resilient community depends on sustainable livelihoods and the loss of resilience is associated with negative impacts on livelihoods • evolutionary view of the systems theory for socialecological systems i concur with the latter view and call it evolutionary resilience in this perspective resilience is not conceived of as a return to normality but rather as the ability of complex socioecological systems to change adapt and crucially transform in response to stresses and strains systems are conceived as complex nonlinear and selforganising permeated by uncertainty and discontinuities it suggests that faced with adversities we hardly ever return to where we were this in itself is not such a ground breaking idea what is new is the acknowledgment that such regime shifts are not necessarily the outcome of an external disturbance and its linear and proportional cause and effects carpenter steve elmqvist thomas gunderson lance holling cswalker 2002holling 1973 however there are several works such as the ones by alexander in 2013 that compared or overlapped resilience with adaptation or vulnerability it might be an attempt to integrate this new and not yet quantifiable concept into existing established concepts according to holling the main ideas behind the evolutionary view are that time is nonlinear that society has a selforganizing capacity derived from its relationships that can be described as learning capability and it must be taken into consideration and that resilience is intrinsic and does not emerge only in the face of danger the recent conceptual approach of evolutionary resilience is after all not so different from the one presented by holling as both recognize the socialecological systems as being unstable and everchanging therefore we agree to call it evolutionary resilience though acknowledging it as being based on the systems theory as proposed in 1973 by holling chuang et al presented a comparison between ecological resilience and community resilience and found that the main difference concerns the approach to scales the authors also concluded that the application of ecological resilience to community quantitative assessment may be a good way to manage change in systems that include human and natural dimensions and interactions therefore it can be assumed that as in any territorial phenomena concerning socialecological relations the problem of scales is also a challenge in social resilience to floods adopted conceptual frame having presented a short review of literature highlighting some of the ideas on social resilience as referred by alexander it becomes clear that it is so extensive as to make a full review an almost impossible task therefore a conceptual framework is presented herein this research theoretical framework of social resilienceconsiders sr as a relevant dimension of risk governance whose central concern are the individuals and their sustainability and security sr is an inherent characteristic of individuals and therefore of communities and society sr is part of a socialecological context where risk and territory governance are put into practice via public policy actions and agents in this context individuals communities and society present social resiliencepositive characteristics or enhancement of inherent capacities that promote wellbeing and recovery as well as the ability to learn and social vulnerabilitydebilities that intensify the possibility of damage or the susceptibility to harm and a lack of sustainability for the individuals and communities especially when facing a disastrous event figure 2 conceptual framework source authors elaboration social resilience assessment a review of indicatorbased studies the measurement of resilience has been pointed out as one of the scientific gaps in this field as well as the major difficulty for the implementation of the sendai framework measurementquantification methods need to be developed to i evaluate beyond the postevent in the normal state ii reveal the multidimensional reality of individuals and communities which are composed of multiple systems and iii capture the reality at different scales the approaches developed so far to assess resilience are indicatorbased as previously mentioned the political contexts and policy requirements now call for the implementation of resilience assessments the development of such approaches is of great importance not only to the scientific advancement in the field but also because it may help people and institutions to deal with uncertainties these approaches are now starting to use composite indicators and be compared concerning the dimensions they include a summary of the main results and conclusions of the ongoing challenge of measuring resilience is presented in this section by showing different indicatormeasurementbased studies over the last decade and of the resilience assessment in the disaster governance field freemam project developed from may 2009 to september 2011 was one of the first that attempted to apply the resilience concept to the flood risk management field in europe it focuses on three case studies flanders niedersachsen and calabria in which the use of indicators was made for three dimensions the interplay of institutions flood risk communication and flood modelling tools the increase of both stakeholders participation and bottomup investments was considered as a crucial point to be strengthened davoudi et al regarded the studies that assessed resilience solely by means of indicators such as time of emergency response as reductionist approaches the authors presented a conceptual model in which the main componentsvariables to manage a pasture socialecological system were treated in an integrated way these main componentsvariables are external controls socialecological system slowchanging components and socialecological system fastchanging components focussing on the social dimension of disaster resilience khalili and morley restemeyer et al proposed a strategybased framework for assessing the flood resilience of cities using a case studybased approach they concluded that holistic resilience building requires boosting social and political capital and therefore policymakers should consider social justice and equity aspects a framework of eight steps to generate composed indicators was presented by asadzadeh et al their study showed through a comparison of different frameworks that there are mainly two types of methodologies to assess resilience i deductivehierarchical eg usage of expert surveys and ii inductive eg principal components analysis a reference is made in the literature review section to the absence of the environmental dimension in the resilience measurements the work squaring the circle reconciling the need for rigor with the reality on the ground in resilience impact assessment béné et al show the process and the results of a 3year programme in order to enhance resilience they presented a log frame with indicators grouped by nature level of intervention and data collection frequency the data frequency varies with the required inputs of the model and with the impact and stressor in the following order evaluationinitial state evaluationfinal state the level of intervention varies from the input to the impact programme individual household community or this approach included a control group and a treatment group for validation the authors noted that resilience assessments are still in the starting phase in 2017 wickes et al presented indicatorbased research in which the level of stability the collective efficacy and the social capital of a neighbourhood were analysed in two different periods before and after a disaster in order to verify if the analysed community dimensions could persist after a significant shockflood some of the main findings of this research were neighbourhood measurements are very stable across time regardless of whether the neighbourhood is affected by floods or not collective efficacy is a dormant characteristic that appears to be activated only when needed they also suggested that the social processes are relevant at the neighbourhood level and highlighted the need for preparation of nonaffected neighbourhoods against risk chuang et al presented a comparison of different quantitative methods to access community resilience they grouped these methods into placebased resilience metrics coupled socialecological metrics and teleconnection metrics according to the recent history of resilience assessment several studies show the need to clearly define the variables to be measured to better understand resilience and even to improve its definition several works show results about possible dimensions and indicators based on theoretical discussions or specific case studies this works contribution is to set standard dimensions and to present for each dimension a group of different indicators based on scientific literature and experts opinions the methodology developed in this research is explained in the next section methods in order to reach new conclusions different perspectives and methods must be attempted several questions related to resilience measurement and to the current state of the art need answering some of those questions are i which dimensions and which indicators pertaining to each dimension should be chosenselected ii which weight should be assigned to the various dimensions which indicators and dimensions weights are more adequate for each reality and how to include the natural learning and adaptive capacities of individuals and communities text mining the text mining approach was chosen to ensure an objective method that takes into account the keywords and key dimensions selection it was applied to identify the frequency with which terms and expressions occurred in the group of preselected fully or partially extracted texts of scientific articles journal preproof text mining has been used in social sciences and has also been applied for instance in lake basin governance studies extraction of data was achieved by means of tm application on selected texts two software were used knime and r studio tm package having applied knime and r studio for term frequency absolute the number of times a term appears in a set of textsthe results of the two software were compared postprocessing of the results was implemented to remove outlier keywords as well as to remove duplicates for each tf abs results the selection criteria consisted in adopting the 15 most frequent terms since the analysis of the 3 rd quartile showed large differences in the number of words between knime and r this lack of correlation between the results resulting from the application of two different software determined that only one could be used for other indicators knime was chosen to analyze tf abs and other variables this means that the selection of bigrams as well as the term frequency relative were implemented only on knime this research methodology involved selecting keywords and included the comparison of the 15 most frequent terms in knime and rtm out of which only the five most frequent ones were selected the term resilience was maintained as part of the results meaning that many composed keywordsbigramscontain this term amongst the 15 most frequent bigrams the six most frequent ones contained two or at least one of the five selected keywords it is important to refer that this research methodology has some limitations namely it doesnt contemplate all the literature on social resilience it is also conditioned by the keywords and the search engine used to collect the original texts as well as by the authors selected excerpts nevertheless the adopted research methodology is impartial as the authors excerpts used to in the current work were not subjected to personal interpretations experts survey expert opinions were collected via an online survey using esurvey creator the selection of experts was done through literature review and an online search of authors profile in the scientific academia network the authors of the preselected texts were contacted and asked to complete a questionnaire adini et al used a comparable approach by applying an online survey of experts to extract resilience concepts approaches and practices data collected through the online survey gathered the tendencies and keywords on how experts define assess and evaluate social resilience further to the preselected options the experts had the opportunity to express their own ideas using the open and feedback fields survey questions 1 2 and 3 requested experts to convey their level of agreement to a set of predefined sentences questions 13 dealt respectively with resilience concept resilience assessment and methodologies to assess social resilience question 41 required the selection of one or more dimensions of resilience calculation from a predefined list of resilience dimensions and provided the possibility to add other optionsdimensions question 42 was an open question that encouraged experts to give their opinion on whether the dimensions had the same weight eleven experts from seven countries mostly in europe provided complete answers results from the experts survey were used for validation of the selected keywords and bigrams the number of complete answers was expected to be larger nevertheless it was already relevant that some of the answers were from widely cited authors which articles have been in the base of this research theoretical frame other scientific fields as referred in the first three sections of this research social resilience assessment must be multiscale and observe both individual and collectivecommunity indicators most of the scientific works that used tm and the majority of the experts who contributed to the applied survey were from the geography and disaster risk management scientific fields a literature review of other scientific fields revealed that social psychology provides the most useful information regarding the need for an evolutionary resilience approach a social psychology approach to resilience confirms the need for multiple scales of analysis individuals community multiple spheres of the same reality and neighbourhood as well the following dimensions geographical health society environment and evolving time concept this review was very useful in the selection of indicators to evaluate the resilience of individuals and social networks validation through the comparison of tm and es only the five sentences from the experts survey that scored the highest number of totally agree and partially agree choices were selected a comparison of the lists of results of tm and es was made in order to validate the results of tm and this comparison resulted in the acceptance of the tm results with a satisfactory certainty out of the total tm keywords and keyexpressions extracted from the referred lists 95 had correspondence with the es results the comparison of the two approaches tm and experts surveysprovided key information to establish the social resilience to floods dimensions and therefore the type of indicators to be included in an indicators database the results of the text miningbased methodology depend on the papers selected for analysis a systematic mapping of articles related to social resilience assessment allows a broad and comprehensive spectrum of perspectives representative of different approaches and publication dates the results of the experts survey depend on the responses received in this case it was not possible to assure identical representativeness of different approaches since the completion of the survey depends on the availability of the experts who were contacted however there was a significant convergence between the answers given by experts of seven countries which suggests that the results are robust besides there is a significant consistency between the results of the two methodologies used results the main result of this paper is a database of indicators organized by dimensions the indicators were collected from peerreviewed papers and international projects outputs and reports the sourcereference is presented together with each indicator the resulting sr to floods dimensions is an output of the comparison of tm with es as previously explained these dimensions are independent of the type of risk to which the communityindividual are exposed as it generally includes the disastershockstressor dimensionindicator it further includes the propensity of the communityindividual to be affected the results show through the application of tm and es that four of the six dimensions refer to the social aspect of the risks and that two relate to the environment and to disaster 3 that were extracted from published scientific articles and grouped by dimension according to the results presented in figure 5 the transition from figure 5 to table 3 was done keeping the identified dimensions and using the type of indicators as categories to group indicators extracted from the literature in order to shorten the table some indicators were rewritten or simply grouped in one line as they were considered equivalent and might be chosen or dismissed according to the reality of the case study where it should be applied it might also be the case that the indicators are applied with a focus on resilience management in which instance scaling should be seen from this perspective not only regarding each indicator but also in a regional rather than a local context conclusions for several decades the wide debate surrounding the resilience concept and its applicability to socialecological systems have drawn attention to the need to find tangible ways to assess social resilience and include it in risk governance strategies and plans the current state of the art in this field points to journal preproof j o u r n a l p r e p r o o f an evolutionary resilience concept based on the systems theory the socialecological systems are multiple coupled systems according to this view time is not linear as the systems evolve and learn across time consequently challenges arise to assess multiple dimensions of these multisystems and to find the key dimensions and indicators that will reshape the concept of social resilience this paper therefore presents a methodology to compile and summarize the dimensions that should be included in risk governance of social resilience combining literature review text mining and experts opinions the obtained results show that text mining can be an appropriate tool to support decision making and research in social fields and theoretical research as its results converge with the opinions of experts the combination of the two methods has lent robustness and certainty to the results and confidence to organize a database of indicators based on scientific literature review the information provided by the experts survey was used to compare and validate the text miningbased methodology the 5 most mentioned words in the answers to each of the questions and the categories totally agree and partially agree the selected words were synthesized in key expressions the later plus the sum of the categories totally agree and partially agree correspond to more than 90 of the answers given by the experts in order to validate the results of text mining a comparison was made with the results of the experts survey out of the total of keywords and key expressions extracted through the text miningbased methodology 95 corresponded to the results of the experts survey comparing evolutionary resilience with social and community resilience highlights the changing and learning capacity of individuals and communities through time the challenge is to find the dynamic indicators that adequately reflect this capacity of individuals and communities the solution might be the inclusion of psychological indicators through social media collecting psychological data requires intensive fieldwork social media is accessible worldwide and it is massively used by individuals on a daily basis to share their life and emotions this research findings point out the next steps the need for real world cases as any indicatorbased approach requires its application to specific case studies while the generalization and standardization of such approaches require the application to as many diverse realworld cases as possible acknowledgements this research was funded by the fct fundação para a ciência e tecnologia know where to turn for help know how to plan and prioritize have historical knowledge level of education béné et al 2017bobby rahman et al 2016davydov et al 2010 al 2014 capacity to deal with changes and stress selfcontrol and regulation security and feeling of control over ones own life positiveness individual health motivation knowledge sense of belonging 12 healthdisability health care 13 age and demography demography household household resources 14 migration native language proficiency place attachment population diversity 2 society 21 associativism volunteerism 22 social networking sense of community collective efficacy community building informal safety net 23 institutions governance interaction involving formal and informal actors 24 livelihood conditions household characteristics 25 insurance insurance capacity 3 governance 31 planning and governance strategies policygovernance approach community involvement research risk governance prevention 4 built environment 41 infrastructures technologies transportation services 42 buildings resistance types and conservation of buildings 5 natural environment 51 hazard susceptibility and exposition analysis hazard assessment and proxy indicators 52 natural environment 6 disaster 61 learning from the past resilience and drr evaluation 62 disasters and recovery assistance to citizens recovery action during crisis risk communication source authors elaboration discussion the question resilience for whom arises from the conclusions of asadzadeh et al when setting the conceptual foundation of a framework to assess resilience it is important to know whose resilience will be boosted in this papers conceptual frame individuals and community are the central elements this can be seen as a twosided argument to deal with when choosing the indicators and components weight if they are to be used in one indexcomposed indicator or any quantitative method indeed the characteristics of individuals and community might be given more weight since it is important to boost their resilience conversely if we want to boost the resilience of individuals and institutions we need to put in place adequate policies and infrastructures to protect the community and individuals pizzo considered that most resilience studies focussed on the hazard whereas few studies addressed the multidimensional reality of resilience that includes different dimensions this research results showed that multiple dimensions met this requirement the scientific gaps identified so far show the need to apply the results of this paper to different case studies with different weights to try to find a standard way of applying such indicators to a given context appendix 1 figure promoting integrated approaches to livelihoods disasters and climate change protection of citizens as an obligation of governments number of households attending workshops and activities research evaluate readiness to cope with crisis application of longterm perspective for disaster risk reduction understanding the trends and their local impact on the community to promote adaptive capacity research on flood risk risk governanceprevention early warning adini et al 2017béné et al 2017 declaration of competing interest the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper highlights this paper aims at presenting an innovative methodology to compile and summarize the analytical dimensions able to evaluate social resilience in flood affected communities the methodology combines literature review text mining and experts opinions the main result is a database of indicators organized by analytical dimensions based on lr through the application of tm and eo to that database we found that four of the six dimensions refer to social aspects of risks and that the remaining ones refer to the natural environment and to disaster

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introduction one way of community welfare can be seen from the socioeconomic situation or condition of the family the socioeconomic condition of the family is the condition of each family in society as seen from the level of education income employment and number of family members which are considered to have an impact on the welfare of society and the welfare of families in the smallest scope of society socioeconomic conditions as seen from income have an impact on welfare the income received by each individual or family generally comes from the work they do an income that is greater than the consumption level means that the family has a level of prosperity whereas those with a small income will have an impact on the familys lack of prosperity apart from income the socioeconomic condition of the family can be determined from the number of family members the number of members in a family also has an impact on family welfare the greater the number of members in a family the greater the level of needs and if income does not support it it will have an impact on the familys prosperity because it will not meet the needs of the family then if the number of dependent family members is small and the income is large it will have an impact on family welfare a prosperous family is a family that can meet all its needs and is called a quality family with needs met in the aspects of education health economics socioculture family independence and spiritual mental and religious values in a family meeting needs is closely related to the amount of income generated from work and spent as a form of consumption to achieve prosperity it can be interpreted that income and consumption are simple variables that determine welfare because both individually and householdly they can be used to achieve human welfare family consumption is one of the familys economic activities to meet various needs for goods and services from the commodities consumed the family will have its own satisfaction therefore consumption can be used as an indicator of family welfare according to law of the republic of indonesia number 52 of 2009 a prosperous family is a family that is formed on the basis of a valid marriage is able to fulfill material and spiritual needs lives with dignity is devout devoted to god almighty has harmonious harmonious relationships and balance between family members society and the environment a family is a group consisting of two or more that is formed due to a marriage bond with or withoutno children which has its own function and role among its members in the family there are various functions including religious socialization economic affection and so on which aim to achieve family prosperity this is supported by puspitawatis opinion that family functions are activities related to the division of roles within the family in order to achieve a common goal namely realizing family prosperity one of the family functions related to the role of women in improving the family economy is the economic function the economic function aims to ensure that the family can improve the quality of life which is reflected in the fulfillment of lifes needs such as food drink health education and so on which are basic things in meeting the familys life needs the phenomenon that occurs can be seen from the human resources of saolat village a persons ability to work depends on the educational level of saolat village farmers some have graduated from elementary school middle school high school and so on even without educational qualifications most members of the farming community in saolat village do not have special skills so they only focus on agricultural activities many people have other skills such as trading and driving because income from agriculture is not enough to meet their daily needs judging from the education level of the husband or father it is still very low and lacks the skills to work as a driver and other types of work in the mining sector to meet the familys needs because that is how the husband or father as the head of the family should play a large role in the familys economic needs the family only needs to work on coconut plantations and going to sea of course not enough so there are women who want to help meet the familys needs while working women who develop many roles in the family must be able to balance the family economy such as being a housewife and housewife housewives in saolat village work as market gardeners anchovy workers and there are also teachers and workers in mining areas so it cannot be denied that the role of women in saolat village has a quite important role in improving food and the economy families in the saolat village consisting of married and unmarried women certainly face their own challenges in having to divide their time between taking care of their husbands and taking care of the needs of their children in the family family this allows women in saolat village to balance their time between working inside and outside the home women are able to adapt to various contexts of vulnerability family economic theory this theory emphasizes the importance of womens economic participation in increasing family income and economic welfare this theory focuses on the concept of division of labor between family members and how women can make a real contribution to increasing family wealth family economic theory of division of labor skills and education contribution to household maintenance and entrepreneurship women with all limitations try to help their husbands work to earn a living so that their living needs can be met there are factors that enable women to finally decide to work as anchovy employees and as mining employees for married women and unmarried women in methods the research carried out includes field research namely that this research goes directly to the field to conduct direct observations about the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province thus the research was carried out in descriptive form the research focus in this paper focuses on married mothers and unmarried women who are already working to improve the family economy and discusses the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province data was collected through interviews observation and review of secondary data documents the data analysis technique used in this research is qualitative data analysis according to bogdan and biklen the stages consist of data reduction data presentation and drawing conclusions and verifying them results and discussion in the past saolat village was a community unit area which started with the name parapara which was led by a traditional elder who was usually called a deputy saolat village is an old village located in the eastern southern region of east halmahera regency based on data in 2023 the village population will be 549 people and there will be 145 heads of families with a population of 549 people consisting of 295 men and 299 women most families in saolat village have their livelihoods in agriculture basically the role of women in gaining the freedom to work helps their husbands in improving the family economy women do everything from gardening farming trading to factory workers to be able to meet their familys needs for this reason in order to improve the economy families must be able to carry out their duties well by learning a lot from information or experience while carrying out their responsibilities towards authority and carrying out every activity related to work dewantara says a mother or unmarried woman is the queen of a family the position and obligations of women as housewives are very important because women are guardians household caregivers as well as educators for children unmarried women can also try to meet the needs of the family and involve themselves in social activities in the community so that the family can prosper so it can be said that women in the family have an important role in improving the economic prosperity of the family both married and unmarried women the general characteristics of east halmahera society in a social and cultural perspective on the social structure and function of women through the role of women and the position of women in improving the family economy of married and unmarried women in saolat village south wasile district east halmahera regency culturally the term for halmahera women recognizes two categories based on marital status and position in the household or those who are not yet married namely mohole and moyoka mohole means an unmarried girl while moyoka is a term for a sons daughterinlaw or wife in the hibualamo tradition the moyoka is protected by customary law in the context of the cultural understanding of east halmahera society the position of mohole as a woman as an unmarried woman has a very important role regarding responsibility in meeting the needs of womens families in saolat village south wasile district east halamhera regency when they have graduated from high school at the age of 18 24 years old they immediately look for work in the mining industry work for figures and some after completing high school they immediately continue their studies at universities in the area or outside the area after completing their studies they choose to work in their field some work as teachers honorarium and working in the mining industry is seen from the fathers income is not sufficient for the familys needs because it is influenced by the age of 52 years which is no longer easy to work at that age so women have to replace the father to find work to meet the familys needs in the saolat village community south wasile district east halmahera regency moyoka as a halmahera woman is related to social structures and functions which are universally integrated with hibualamo cultural values moyoka as a woman has an important role in four social spaces with different functions namely the household space large household space based on clan socialcommunity space and virtual space moyoka in the household carries out functions related to raising children cooking food in the kitchen planting shortterm productive crops in the yard for household consumption or cultivating coconut corn rice and banana plantations furthermore the role of married women in large households is bound by tradition to help each other and assist each other in various activities or what in local terms is called hirono or makiriwo the role of women in the social sphere in general can be seen from their awareness of participating in sorrow and joy apart from that the development of information technology through social media has also increased the social space of married women in the virtual space to support micro small and medium enterprises entertainment and maintain social relations among netizens as users of social media accounts this shows the integration of cultural values in social structure and function thus placing the role of halmahera women or the position of moyoka as an essential part of the social livelihood of society the resilience of household livelihoods in saolat village is influenced by the context of vulnerability namely shocks and trends in the context of east halmahera the livelihoods of households that depend on the coconut plantation sector experience obstacles that threaten the sustainability of the lives of village communities because the purchasing price of copra is susceptible to decline due to price fluctuations based on primary data the buying price for copra set by collectors in good market conditions can reach a price range of idr 900000 to idr 1100000 per kilogram so that it benefits coconut plantation farmers however if market conditions are unstable the buying price for copra set by collectors is in the range of idr 400000 to idr 600000 per kilogram at that time coconut plantation farmers experienced losses because the purchasing price of copra was not balanced with the energy and time spent on copra production and transportation costs in the context of saolat village womens involvement in copra and anchovy production is part of mutual cooperation activities in the social space within the household as well as the social space within the extended household the involvement of halmahera women in agricultural and fishing activities is also a strategy to deal with changing trends in this case in the form of fluctuations in copra purchasing prices apart from that the ongoing obstacles to the livelihood of the community in saolat village are also influenced by the decline in the price of coconut in this research the author directly carried out research on the role of women in improving the family economy in saolat village south wasile district east halmahera regency therefore the role of women in improving the family economy can be seen as indicators in this research which were directly put forward by abraham maslow namely physical needs factors economic factors educational factors factors social and cultural physical needs factors gender there are differences in physical needs between men and women high levels of physical activity result in greater energy needs certain medical health conditions and environmental extremes of temperature and humidity affect a persons physical needs for example in a hot environment social and economic factors such as income level access to food and culture can also influence a persons physical condition social and economic conditions factors such as income level access to food and culture can also influence a persons physical condition the physical influence also exists when they are sick so they dont work judging from the location of the garden it can also affect the physical quite a lot and judging from education it is also very minimal and knowledge is also limited because there are few obstacles in sharing work time with children so that work is also limited based on the results of research conducted with the title the role of women in improving the family economy research in saolat village regarding the role of women in improving the family economy participation in the form of selling cakes apart from gardening from the garden in the form of banana chips eggplant tomatoes chilies and coconut oil she sells through small kiosks and via social media from the results of the income being sufficient and very helpful in increasing the husbands income for the physical influence there is also when he is sick then he does not work seen from the location of the garden it can also affect the physical quite a lot and seen from the education it is also very minimal and knowledge is also limited as an obstacle to sharing work time with there are fewer children so work is also limited judging from the cultural factor laziness also exists such as watching soap operas from morning until evening this factor can influence economic activity judging from education it can also influence education and technology so that more people learn how to use fertilizer so that human resources are very lacking and reduce the culture of laziness so that they can focus more on working to help their husbands income there is also a physical influence when you are sick so you dont work seen from the location of the garden it can also significantly influence physicalweather conditions as seen from the prolonged hot month of october so that many plants also experience water shortages so that income also decreases due to these physicalweather factors which can influence economic activities for the age factor there are no obstacles seen from the need for greater energy the health of the environment where you live or work for example in a hot environment the socioeconomic conditions family income in working in the mining industry one way to meet the familys needs in my opinion is by working as an employee for physical factors there are obstacles due to the lack of being able to speak but this does not limit working as an anchovy employee because working as an anchovy employee has a large enough income to meet the familys needs economic factors including access to material resources and financial adequacy it can affect a persons ability to meet physiological needs such as food shelter and clothing economic factors mean that a person has a greater opportunity to meet needs at higher levels in the hierarchy material resources and financial adequacy can influence a persons ability to fulfill physiological needs such as food the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province they must be able and able to take responsibility for helping their husbands income so that the familys economy becomes stable the resulting results can be seen as to the role of women in improving the family economy in saolat village east halmaher regency research regarding the title the role of women in improving family economic welfare in maneron village sepulu district the results of this research show that the role of housewives in families in maneron village is not only based on the concept that women only work in the kitchen and take care of the family but also plays a role in helping and improving the familys economy participation in the form of selling cakes apart from gardening from garden products in the form of banana chips eggplant tomatoes chilies and coconut oil i sell through small kiosks and via social media from sufficient income and is very helpful in increasing the husbands income these economic factors can influence economic activities saolat village south wasile district east halmahera regency that the role of women in improving the family economy can be seen from economic factors with increasingly rapid technology we can take advantage of it by selling the harvest garden by selling on social media and being able to interact with more than 2 buyers at the same time economic factors can make someone have greater opportunities to meet financial needs to increase their husbands income economics namely how the role of women in improving the family economy in saolat village is by utilizing social media by the increasingly rapid development of technological knowledge to meet physiological needs such as food shelter and clothing from economic factors has a greater opportunity for a person to meet family needs educational factors plays an important role in individual development and can influence a persons ability to achieve higher level needs a good education can provide the knowledge and skills needed to achieve levels of social needs esteem and even selfactualization individual development and can influence a persons ability to achieve higher levels of needs good education can provide the knowledge and skills needed to reach the level of social needs one of the educational factors in saolat village is that most of them only graduated from high school including me because of my parents income i couldnt go to college and finally i was determined to work in a mine as a i feel that education is really needed in it can be concluded that the educational factor is very influential in the world of work opening up opportunities for job applicants education also provides the skills needed to reach the level of social needs regarding the role of women in improving the family economy in saolat village south wasile district east halmahera regency one of the educational factors one of the educational factors in saolat village there is still minimal and knowledge is also limited so that most people only work as gardeners so many job opportunities are also limited because in terms of skills they are still very lacking one of which is that my husband in terms of educational background only graduated from junior high school and only focuses on working with coconuts from that income it was not enough to meet my needs so i also helped work as an anchovy employee from the income i could help my familys economic needs in the form of childrens education and daily meals one of the people in saolat village didnt know how to use fertilizer so there wasnt even any garden produce using fertilizer but planting it naturally it can be concluded that there is a lack of education in saolat village so that there is an obstacle that human resources are still very lacking and the educational factor is also very influential in improving the family economy social and cultural factors also plays a role in fulfilling human needs social relationships interactions with the community family support and cultural norms can influence the satisfaction of social and esteem needs fulfillment of human needs social relationships interaction with the community family support and cultural norms can influence the satisfaction of social needs in saolat village south wasile district east halmahera regency north maluku province research with the title the dual role of housewives in improving family welfare in allude village kolongan subdistrict talaud district this research determines the research focus namely the dual role of housewives in improving welfare the family is in fulfilling basic household needs informants are sources of research information the informants in this research were 8 housewives selling cakes and making processed coconut oil the research method used in this research is a qualitative method based on the results of the research and discussion regarding the dual role of housewives in improving family welfare in allude village kalongan subdistrict talaud islands district namely in meeting basic household needs the researchers reached the following conclusions socioeconomic conditions of the families of cake sellers and processed coconut oil makers increased after they sold cakes and made processed coconut oil meaning they could meet their daily needs namely food clothing decent housing and childrens education by selling cakes and making processed coconut oil they can increase their family income save money and renovate their houses from bamboo houses to semipermanent houses or even permanent houses the obstacles faced by women who sell cakes and producers of processed coconut oil in improving their familys welfare are when their merchandise is not sold out and they fall ill and are unable to carry out their activities the role of women in saolat village is less active in terms of a community and interaction is also rare they only watch a lot of soap operas from morning to evening there is also a culture of laziness i think in meeting the needs of the family only some of them work as anchovy employees and so on working as mining employees to add more motivation for women to be more active in empowering women so that the village develops more and more proudly that the way to improve the family economy is by working more diligently and further developing the empowerment of women in the prayer village this can be influenced by one of the factors of the lazy prayer culture unmarried women also participate in family income and also work as teachers honorarium and opening an online shop to increase the familys economy it is concluded that the role of women in saolat village is very popular in terms of working to help with family needs and smooth social relations with the community and supported by the family and there is also a culture of laziness that can influence social needs conclusion based on the research results and discussions that have been described in detail in the previous chapters the researcher can provide conclusions based on research indicators that the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province is that the physical needs factor is the role of women in improving the familys economy can be said to result in sufficient income and is very helpful in increasing the husbands income there is also a physical influence when he is sick and does not work judging from the location of the garden it can also significantly affect his physical age economic factors in the role of women in improving the family economy must be able and able to take responsibility for helping their husbands income so that the family economy becomes stable well resulting from economic factors namely how the role of women in improving the family economy in saolat village by utilizing social media with developments in technological knowledge increasingly rapidly to meet needs we can see the role of women in improving the family economy in saolat village east halmaher regency the education factor is very influential in the world of work opening opportunities for job applicants education also provides the skills needed to reach the level of income social needs education the lack of education in saolat village so there are obstacles human resources are still very lacking and the education factor is also very influential in improving the family economy social and cultural factors show that the role of women in saolat village is very much in demand in terms of working to help with family needs and smooth social relations with the community and supported by the family and there is also a culture of laziness which can influence the social needs of unmarried women who also participate family income and also work to open an online shop to supplement the family economy based on the research that has been carried out it is hoped that elderly women will no longer work because the location of work is quite far away and unmarried women really need more work to help with family needs it is hoped that womens awareness will work more actively in order to improve the family economy and there is a need for cooperation between womens empowerment in saolat villages in improving the family economy it is hoped that there is a need for awareness of cooperation between husband and wife in dividing work time and taking care of children in childrens education in terms of learning for unmarried women so that they can work more actively to

every family is faced with various needs therefore to be able to achieve needs the role of all family members is needed this research was conducted to determine the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province the research was conducted using a qualitative design data was collected through interviews observation and review of secondary data documents the data analysis technique is carried out in the stages of data reduction data presentation and drawing conclusions and verifying them the research findings show that the role of women in improving the family economy in saolat village south wasile district east halmahera regency north maluku province results from sufficient income and is very helpful in increasing the husbands income the family economy becomes stable education has a big influence on the world of work social interactions become better

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background stroke is the leading cause of disability in the us and the third leading cause of death ischemic stroke accounts for 85 of all strokes the only fdaapproved treatment for acute ischemic stroke rtpa must be given within three hours of stroke onset stroke patients who receive rtpa have been shown to have at least a 30 relative chance of having minimal to no disability compared with those who receive placebo this translates into higher rates of patients being discharged to home or rehabilitation rather than to a nursing home and has been shown to be a costsaving treatment for stroke yet only a small percentage of the ischemic stroke population receives rtpa the major barrier to receiving therapy is arriving to the hospital within the threehour window this is due at least in part to a lack of recognition of stroke signs and symptoms which are variable and include weakness numbness clumsiness and visual loss usually restricted to one side as well as language disturbances and confusion the method of arrival to the hospital is also important as patients who arrive via emergency medical services significantly shorten their arrival time and time to head ct a critical step prior to receiving rtpa however stroke patients usually do not activate emergency medical services themselves due to impairment of language motor function and cognition thus in order to improve acute stroke therapy it is imperative that close family and friends be able to recognize stroke symptoms and understand the urgency in seeking prompt medical care by activating emergency medical services education cannot focus solely on stroke symptoms but must also motivate behavioral action by explaining the efficacy of early acute stroke therapy in one study 29 of patients presenting after three hours recognized their stroke symptoms but chose not to seek medical attention quickly hispanics americans are the largest minority in the us today with those of mexican origin being the largest subset the incidence of both ischemic and hemorrhagic stroke is approximately 15 2 times higher in mas than nonhispanic whites with higher rates seen at younger ages conversely stroke symptom recognition while poor across all ethnic groups is lowest among has with spanishonly speaking has having the worst symptom recognition given these facts as well as the large public health impact expected from the ha stroke burden educational outreach programs must target this community with culturally specific interventions while several communitybased media campaigns have been reported in the literature to improve stroke knowledge a review of the literature did not identify any controlled trials of schoolbased interventions that target improvements in the emergency treatment of stroke through increased stroke knowledge and behavioral intention to call 911 additionally few programs have targeted improved stroke knowledge among mexican americans or among children this article describes the design implementation and interim results of the theorybased multiethnic kids program designed to increase middle school students and their parents or other adult partners knowledge of stroke symptoms and intention to call 911 immediately when witnessing a stroke methods procedures the kids program was designed as a threeyear prospective randomized controlled schoolbased trial six of the twelve corpus christi texas middle schools were randomly selected and then randomized 11 to the intervention or control groups within each of the three intervention schools one sixthgrade science or health teacher was randomly chosen students assigned to that teacher received the kids stroke education program taught by kids program staff while the students in the control schools were given the standard health or science curriculum in subsequent years the students who received the intervention in the sixth grade were taken out of a regular classroom to attend the kids project lessons the stroke education program was divided into four onehour classes each year during the 6 th 7 th and 8 th grades each class session also included a homework assignment that involved the students adult partners a pretest was administered to student participants 3 months before the 6 th grade lessons began the day of the pretest students were asked to identify two adults in their community with whom they were closest to participate in the kids followup tests and homework assignments while most students chose their parents as adult partners other common adult partners included grandparents aunts and uncles and adult siblings pretests for adult partners were sent home with the students the same day if they were not returned a second copy of the test was mailed to the students home two months later to provide guidance in developing the final year of the project an interim test was given to students and adult partners following the 7 th grade kids intervention additionally a posttest was scheduled to be given to students and their adult partners 3 months following the 8 th grade kids intervention followed by a persistence test 1 year after the intervention the interim test posttest and persistence test are identical to the pretest the kids program scope and sequence the kids curriculum was written one year at a time with each successive year building on the previous years experiences social cognitive theory was used to guide curriculum development throughout the threeyear project the kids planning committee met weekly to discuss the lessons as they were designed and implemented additionally each years curriculum was pilot tested with middle school students and refined prior to implementation in the intervention schools the 6 th grade lessons provided a general introduction to the symptoms of stroke availability of rtpa and the need to call 911 right away the 7 th grade lessons were designed to provide more indepth information on stroke symptoms and their relationship to the portion of the brain that is damaged students and their adult partners also began to explore common bystander reactions to witnessing a stroke and internal and external influences on behavior that would influence them to call 911 right away the 8 th grade lessons included a more specific and indepth look at influences on seeking immediate emergency care for stroke table 1 presents an overview of the kids curriculum development of the kids program the kids program was systematically developed using several specific types of information community surveys in east texas and in corpus christi provided insights into stroke related knowledge attitudes and behavioral intentions of both mas and nhws schoolbased focus groups added information essential to planning a culturally relevant intervention social cognitive theory offered a framework for crafting an intervention that would increase stroke knowledge and motivation to contact emergency medical services when witnessing a stroke interimtest results from student participants provided important feedback for finetuning the final year of the kids program community surveys in preparation for the kids project a telephone interview survey was conducted in nueces county texas to determine differences in knowledge of stroke signs risk factors and treatment resources among mas and nhws this survey found that mas were significantly less likely than nhws to 1 recognize that a treatment was available for acute stroke 2 indicate that there was a short time frame for being eligible to receive acute stroke treatment and 3 say they would call 911 if they or a loved one were having a stroke additionally mas were less able to recall stroke symptoms and risk factors although both groups responses indicated a lack of knowledge neither mas nor nhws were able to identify rtpa or clotbusting drug when asked to name an acute stroke treatment needs assessment data collected previously for another project the tll temple foundation stroke project was also helpful in planning the kids project a random digit dialed telephone survey of 691 people in east texas had found that the best predictors of individuals most likely to call 911 for a witnessed acute stroke included 1 being nhw 2 having a perception that peers would call 911 3 selfefficacy 4 expecting that calling 911 would lead to a good outcome and 5 reporting one would promptly go to the doctor when medical problems occur taken together this needs assessment data from two telephone interview studies in eastern texas clearly indicated that selfefficacy outcome expectations perceived norms and knowledge of stroke symptoms and treatment are critical components for a successful acute stroke health education intervention cultural relevance in designing the kids curriculum special care was given to reflect the corpus christi dominant ma culture while also being appropriate for the needs of the nhws and african americans hispanic cultures especially mas place great value on the family it is common for has to have multiple generations living together in a household the kids program incorporated this multigenerational contact by teaching middle schoolaged children about stroke and having them teach the information to adult partners at home through specific homework assignments the kids project staff included ma health professionals from corpus christi who provided guidance in developing lesson activities that incorporated aspects of the local ma culture additionally kids project staff conducted focus groups with volunteer students parents and teachers from corpus christi early in the planning process as another way to ensure cultural sensitivity focus group questions addressed perceptions about preferred teaching methods and parents previous experiences with participation in homework assignments students parents and teachers agreed that active learning strategies were preferred with students noting that using technology is helpful parents and teachers revealed that parents are used to providing assistance on student homework assignments but have little or no experience with students being assigned to teach their parents parents suggested that homework activities such as interviews would be acceptable students believed that giving rewards for returning adult partner homework assignments might encourage participation teachers pointed out that some parents spoke primarily spanish which would have implications for homework assignments all adult partner homework assignments were created in both english and spanish roleplay and webbased scenarios were created to reflect the ma culture using backgrounds such as the celebration of el dia de los muertos and a tejano dance scenarios and roleplays were based in settings familiar to the students such as the corpus christi waterfront interviewing was incorporated by having 7 th grade students interview their adult partners about personal and environmental influences on immediately calling 911 incentives ranging from gel pens to movie passes were provided to students each year based on both their participation in classroom activities and the number of homework assignments returned social cognitive theory social cognitive theory focuses on the dynamic and reciprocal interactions between personal factors environmental influences and behavior as they relate to learning emphasizing that individuals can learn by observing the behaviors of others and the outcomes of those behaviors as well as from personal experiences based on the needs assessment sct was chosen as the theoretical framework for the kids project behavioral capability selfefficacy and outcome expectations received special emphasis behavioral capabilityin sct behavioral capability refers to the knowledge and skills that are necessary to be able to do the recommended behavior the kids project focused on strengthening the behavioral capability of students and their adult partners by increasing their knowledge of symptoms of stroke and acute stroke treatment as well as the need to get to the hospital within 3 hours after symptom onset throughout the project information and training about the correct actions to take when witnessing a stroke were provided including noting the time the symptoms started calling 911 immediately and giving the correct first aid while waiting for the ambulance to help students gain important knowledge about stroke symptoms an interactive web site was developed for the 7 th grade curriculum the kids class met in a school computer lab where students participated in a web activity that illustrated the specific signs and symptoms expected from damage to various parts of the brain when students moved the cursor over the different parts of the brain the stroke damage for that part of the brain was highlighted both on screen and through audio dialog students were given a handout with illustrations from the kids web site to use when teaching their adult partners about the brain and stroke symptoms roleplaying emergency situations of stroke vs nonstroke were used to promote skill mastery students worked together in small groups to analyze each scenario and decide if symptoms of stroke were depicted student groups then acted out the scenarios for the class calling 911 if stroke symptoms were present selfefficacyselfefficacy refers to a persons belief in hisher capabilities and confidence in performing a specific behavior it includes the belief that one can choose to do the specific behavior under difficult circumstances the kids project focused on increasing selfefficacy for recognizing the symptoms of stroke in an emergency when stress levels are high and calling 911 right away even if bystanders make other suggestions for how to handle the emergency individuals interpret several types of information to form their selfefficacy beliefs mastery experiences are a strong influence on selfefficacy selfefficacy can also be influenced through vicarious learning especially when the person modeling the behavior is similar to the individuals observing vicarious learning experiences were integrated throughout the kids curriculum one example involved the kids web site where students observed a scene at a dance with tejano music playing a woman has sudden numbness and weakness in her right arm and leg while dancing as students move the mouse over the various bystanders they hear a number of suggestions regarding what the woman should do the middle school aged boy suggests calling 911 right away modeling a ma youth recommending the correct behavior to adults students used a handout illustrating this scenario to teach their adult partners about how important it is to call 911 when witnessing a stroke even when others suggest different actions outcome expectationsin sct outcome expectations refer to beliefs about the consequences of performing the recommended behavior specifically the kids lessons were designed to teach students and their adult partners that getting to the hospital in time to receive rtpa increases the chances of having a better recovery and decreases the chances of disability from stroke in the tejano dance web activity students were asked to choose which bystander suggestion they thought was correct outcomes for each choice were given including how much time it took to arrive at the hospital whether the woman received rtpa and the level of disability she had when leaving the hospital a worksheet highlighting the tejano dance scenario was created in both english and spanish for students to share with their adult partners interim evaluation to provide feedback on the efficacy of years one and two of the intervention an interim test was administered 4 months after the 7th grade intervention to all students and adult partners the test was identical to the pretest students in each intervention and control school were located and asked to leave their classes to complete the tests in a central location students were then asked to take the test home to their adult partners and return the completed tests to the school fivedollar movie passes were given as incentives to students who returned tests from their adult partners the test consisted of 12 questions divided into three domains of four questions each domain 1 tested knowledge of stroke pathophysiology domain 2 tested stroke signs recognition and domain 3 assessed behavioral intent and treatment knowledge the test was written by a stroke neurology professor and an health education professor who had stroke education experience the kids project stroke educators were blinded to the test questions so they would not teach to the test prior to planning the 8 th grade kids lessons interim results were shared with the kids stroke education staff by domain only thus protecting the blinded test questions interim analysis methods the primary outcome measures were improvement among both students and adult partners in the three domains knowledge of stroke pathophysiology stroke signs recognition and behavioral intent and treatment knowledge the mean number of correct responses for the pretest and interimtest were calculated for each domain for those individuals who completed both preand interimtests a paired ttest was used to compare mean number of correct responses on preand interimtests for the control and intervention schools the relationship between intervention status and improvement in domain scores by at least 1 correct response was assessed with a chisquare test interim results in year one 515 sixth grade students and 454 adults enrolled in the study of the control students 90 selfidentified as hispanic and 42 were male among the intervention students 78 selfidentified as hispanic and 55 were male of the control adult partners 89 selfidentified as hispanic 38 were male and 88 were between the ages of 30 and 49 among the intervention parents 68 selfidentified as hispanic 37 were male and 83 were between the ages of 30 and 49 interim tests were completed by 181 control students and by 149 intervention students school transfers resulted in the loss of 60 intervention and 27 control students who thus did not complete an interim test interim tests were completed by 98 control and 39 intervention adult partners student transfers accounted for lack of interim test completion for 30 intervention and 6 control adult partners the results of the student pretest and interimtest are shown in table 2 students in the intervention group had significant improvement in their interim test scores compared with their pretest score in all domains students in the control group had smaller but significant improvement in domains 2 and 3 and deterioration in domain 1 scores intervention students were more likely to improve their scores by ≥1 correct response too few adult partner interimtests were returned to provide meaningful results discussion interim results indicated that the kids project intervention did have an impact on student knowledge and behavioral intention specifically the first two years of this schoolbased educational intervention were successful in improving student knowledge of stroke pathophysiology recognition of symptoms of stroke stroke treatment and intent to call 91 1 upon witnessing a stroke though even the control students improved their knowledge in the latter two domains their improvement was not as robust as that of the intervention students the minimal improvement of the control students likely reflects the general accumulation of health knowledge as children age the interim results were helpful in guiding the design of the final year of the intervention students in the intervention group scored the highest on behavioral intention to call 911 and understanding that treatment for acute stroke is available while students showed significant improvement in their knowledge of stroke symptoms it was clear that additional instruction was needed the 3 rd year curriculum was designed to reinforce learning about stroke symptoms a corpus christi teacher who had experienced a positive outcome after receiving rtpa for a stroke agreed to share her story with the kids project a short rtpa success story video that highlighted symptoms of stroke calling 911 receiving rtpa and a positive recovery was produced and shown to students a fotonovela based on the video was created to help students share the story with their adult partners through teaching the students and reviewing adult partner homework assignments in the first two years of the intervention we learned of additional barriers to seeking urgent medical care for stroke students and parents were fatalistic regarding efficacy of early stroke treatment and worried about negative consequences of activating emergency medical services if the witnessed symptoms are not due to a stroke these misconceptions were also addressed in planning the 8 th grade lessons specifically a lesson was designed to discuss the results of the students 7 th grade parent interviews on influences that might cause someone to delay calling 911 following the discussion students were asked to demonstrate their understanding of these influences by creating public service announcements designed to influence others to call 911 right away when they witness symptoms of stroke limitations of this study have become apparent student attrition defined as the percent of students who took a pretest but did not take an interim test was high between intervention years one and two a large proportion of those students lost were due to transfers out of the schools no factors have been identified to explain the imbalance in the transfer rates between control and intervention schools a large proportion of students remaining in the schools simply did not return an interim test the distribution and collection of interim tests was difficult and time consuming in both intervention and control schools as each student had to be individually located this is a function of the cohort design of the study with standard middleschool course scheduling issues it was necessary in year 2 to ask students to miss an elective class on the days kids lessons and the interim test were given some teachers were unwilling to allow students to miss class for participation in kids once this problem was identified kids staff members worked with the schools and teachers to educate them on the importance of participation and identify times to deliver the year 3 kids lessons and posttest that would be the least disruptive to student schedules the interim test process thus served as a pilot for the posttest process alerting kids staff members to potential student and parentadult partner attrition issues that could be addressed prior to administering the posttests and persistence tests we do not know if we were successful in transmitting stroke knowledge and behavioral intention to call 911 to the parents and other adult partners as we were unable to collect an adequate number of adult interimtests for analysis incentive prizes were used to increase the return rates of adult partner interim tests but the percent returned was still too low most of the adult partners were between the ages of 30 and 49 it is possible that these adult partners did not participate because they didnt perceive themselves to be at risk for stroke due to their young ages to address this a lesson was added in year 3 to teach the students and their adult partners about stroke risk factors including the increased stroke risk for mas at an earlier age the kids project also stressed that a person having a stroke is often physically not able to call 911 for themselves and must rely on family members or other bystanders to call 911 for them evaluating adult partners is a critical piece of this educational outreach to correct for low response rates prior to completion of the intervention greater efforts were planned for distributing and collecting adult posttests and persistence tests for example a banquet for the students and their adult partners was scheduled for the end of the project at each of the schools with an opportunity to complete and turn in posttests at the banquet since the persistence test occurs during the students first year of high school it is being mailed to students and adult partners preceded by a notification postcard and accompanied by monetary incentives both of these survey strategies have been shown to increase return rates conclusion targeting the younger generation for stroke education is one way to improve community knowledge of stroke symptoms and the need for urgent evaluation particularly in the ma community where rates of stroke are higher and occur at earlier ages and family units are cohesive with frequent contact between multiple generations this is especially important considering that less than 5 of stroke patients call 911 themselves due to an inability to speak or dial the telephone family members are most likely to be in a position to recognize the symptoms of stroke and call 911 immediately increasing the chances that the stroke patient may receive acute stroke therapy a culturally specific stroke education intervention for middle school children so far appears to increase childrens knowledge of stroke pathophysiology stroke symptoms stroke treatment and intent to call 911 upon witnessing a stroke this could be a model for middle schoolbased stroke education in multiethnic communities using homework assignments to transmit this knowledge to parents of middle school students may or may not be effective and requires further study ultimately the determination of the success of projects aimed at reducing delay time to hospital arrival for acute stroke must involve surveillance of stroke cases in a community this community has such a system the brain attack surveillance in corpus christi study we were not able to utilize this system to monitor the effect of kids due to the small proportion of students participating in the study the studys next phase an intervention involving all middle school students may well utilize the basic system

the kids kids identifying and defeating stroke program is a threeyear prospective randomized controlled multiethnic schoolbased intervention study program goals include increasing knowledge of stroke signs and treatment and intention to immediately call 911 among mexican american ma and nonhispanic white nhw middle school students and their parents this article describes the design implementation and interim evaluation of this theorybased intervention intervention students received a culturally appropriate stroke education program divided into four 50minute classes each year during the 6 th 7 th and 8 th grades each class session also included a homework assignment that involved the students parents or other adult partners interimtest results indicate that this educational intervention was successful in improving students stroke symptom and treatment knowledge and intent to call 911 upon witnessing a stroke compared with controls p 0001 we conclude that this schoolbased educational intervention to reduce delay time to hospital arrival for stroke shows early promise

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background globally about 53 million underfive children died in 2018 1 more than half of these deaths were preventable and these children could have survived by simple accessible and affordable interventions including adequate nutrition and appropriate childcare practices such as exclusive breastfeeding recommended complementary feeding child bathing and cleaning proper sanitation and hygiene practice 12 however teenage mothers have been found to deviate from the standards and recommended infants and childcare practices 134 in ghana it has been documented that about 28 of all underfive children are stunted and 40 of these cases involved children aged 18 to 23 months 5 several incidences of child illnesses malnutrition and developmental delays especially among children born to teenage mothers have been reported in the country 6 7 8 the need for improved and sustained effort in halting and reversing the situation is not only critical for ensuring and improving the health of children but also at the core of achieving the sustainable development goals goal 3 which seeks to ensure healthy lives and promote wellbeing for all at all ages target 32 of the goal specifically seeks to end preventable death of newborns and children under 5 years of age 9 also the new global strategy for womens childrens and adolescents health agenda seeks to ensure that women and their babies survive and reach their full health potentials in life 10 appropriate childcare practices such as exclusive breastfeeding complementary feeding child bathing and cleaning umbilical cord care and sleeping pattern or arrangement of children are beneficial and therefore recommended for children 411 in some communities in ghana childcare is influenced by culture and some traditional practices that are transmitted from older mothers to the young ones throughout the generations 10 young mothers required knowledge and assistance to be able to perform their maternal roles and cope with motherhood in light of the challenges they face 12 these complex dynamics continue to shape how mothers especially teenage mothers care for their babies therefore an indepth understanding of teenage mothers childcare practices within the family structures and cultures is thus worthwhile exploring besides policymakers and health professionals must acquire a deeper understanding of the diverse childcare practices to better appreciate and interact with teenage mothers bearing in mind the dynamics our study is situated within the ecological system theory to offer a broader contextual understanding of the childcare practices among teenage mothers theoretical framework the ecological systems theory was adapted as the framework for the study propounded in 1979 by urie bronfenbrenner the theory recognises the ecology of human growth and development and draws heavily on complex interplay of individual relationship sociocultural and environmental factors to understand the role of motherhood 13 according to bronfenbrenner an ecological perspective encourages individuals to consider the holistic environment for themselves these factors must be considered in terms of their existence at each level and their interactions across each system 13 in this study teenage mothers were placed at the centre of their social context and their lived experiences with childcare practices were discussed the est identifies the importance of the immediate environment through to the broader layers exo macro and chrono systems the first ecological system which incorporates the immediate environmental surroundings of the individual and those with whom the individual interact such as the parent neighbourhood peers and babys father focuses on the support and the interactionrelationship that exist among them the second layer is the mesosystem which fundamentally underline and incorporate the relationship that occurs within the microsystem for instance the interaction between the individual and health service or education as a support network this web of relationships is associated with a positive influence on the family or individual and the baby 14 the macrosystem refers to the larger social and cultural environment in which all the other systems exist it consists of the wider environment and draws heavily on attitude ideologies culture and beliefs that have indirect effects on other systems and the individual thus it involves teenage mothers child care practices and motherhood where their closest individuals provide support skills and guidance to sustain them in light of the challenges they face regarding motherhood and their effects over the life course transitions of the teenage mothers at the chronosystem the est has been modified holistically to help in understanding the domain and the impact of the health and social contexts on childcare practices and experiences of teenage mothers here challenges constraints coping strategies support or a combination of both positive and negative experiences exist the experiences of being a teenage mother are shaped at many levels as such the est provides a framework to explore these levels and the interactions between and among them this makes the framework useful as it includes multidimensional social context and provides a multilayered approach for data analysis est has been widely used to study various social phenomena and its power in offering meaningful insight into social problems has been adequately documented 15 16 17 methods setting the study was conducted in the komendaedinaeguafoabrem municipality in the central region of ghana the municipality is bounded on the south by the atlantic ocean the east by the cape coast metropolis the north by the twifo hemang lower denkyira district and the west by the mpohor wassa east district and shama district perched between longitude 1 o 20′ west and 1 o 40′ west and latitude 5 o 05′ north and 5 o north 15′ north the municipality covers an area of 1′37245 km 2 91995 mile 2 18 the keea has four traditional states and further divided into 6 zonal councils with 54 electoral areas 11 subcommunities with elmina being the municipal capital which became independent in 1988 fishing farming and salt winningmaking are the main economic development activities the keea municipality has one of the highest incidences of teenage pregnancy in ghana 19 map of the study area study design this study employed phenomenology as a study design with its attendant qualitative methods as they provided us with the necessary tools to explore the phenomenon from the perspective of teenage mothers drawing on their lived experiences 20 phenomenology is not only concerned with a description of the phenomenon but also an interpretive process in effect we connect the different meanings of the lived experiences and perspectives shared by teenage mothers phenomenology has been widely used across the humanities and social sciences where the design has demonstrated enormous strength in helping to construct meaning into peoples experiences and unique perspectives 2223 with the aid of this design we were able to obtain appropriate data that offered us a deeper understanding of child care practices from the perspective of our study participants population the study targeted teenage mothers aged 13 to 19 years in the keea municipality in the central region with a child less than 2 years at the time of the fieldwork this was done to safeguard against recall biases as it will be difficult for a mother to recall vividly their daily childcare practice after 2 years also teenage mothers with fig 1 adapted ecological systems theory source bronfenbrenner to the best of our knowledge fig 1 in this adapted form has never been published elsewhere therefore no permission is required for its publication as part of this manuscript children more than 2 years might have passed the childcare practices stage for instance breastfeeding and may not be able to contribute in this regard as such we aimed at participants that could provide us with indepth information that covered a wide range of childcare practices sampling and sample size teenage mothers were purposively selected from the five communities in the keea municipality in all thirty teenage mothers were recruited for the study guided by the concept of saturation the sample size was not determined a priori but evolved during the data collection the point of saturation was based on the recommendation by marshall et al 24 who demonstrated that theoretical saturation mostly occurs between 10 and 30 interviews data collection the research instruments used for this study were indepth interview guide and pictorial diary the idi guide and the pictorial diary were specifically developed by the authors for this study the idi guide was broadly categorised into two sections the first section looked at the teenage mothers sociodemographic characteristics teenage mothers age level of education religion marital status and current occupation the second section focused on teenage mothers fig 2 map of the study area source gis lab of the department of geography and regional planning university of cape coast the map of the study area was specifically developed for this study permission has been obtained for it to be published as part of the manuscript childcare practices also pictorialguide interview method which combines photos andor illustrations in support of the indepth interviews was employed we first administered the pictorial diary where we took notice of all perspectives shared by the participants and then explored the issues further in the indepth interviews using both the interview guide and the pictorial diary methods augment data collection and ensured completeness not only did the pictorial guide served the function of supplementing the interviews but also provided us with the opportunity to gain at least some modicum of access to naturally occurring events whose meanings were then explored in the indepth interviews 27 before the commencement of the interview the participants were informed about the purpose of the study in order to encourage the participants to open up the interviewer reiterated that their right to anonymity and confidentiality would be respected as such their names will not be attached to the data or included in the final report of the study the selected participants consented to participate freely the interviewer read and explained the information sheet and the informed consent form to the participant in the language they best understood participants were asked to either sign or thumbprint a consent form indicating they have willingly chosen to participate in the study all interviews were conducted by the first author and supervised by ekmd the facetoface interview method was employed during the data collection in the homes of the participants to ensure that participants feel most comfortable to respond adequately to the questions the interviews were based on oneonone interaction between the interviewer and the participant alone all interviews were taperecorded and field notes were taken during the interviews each interview lasted for about 55 min on the average data analyses the data were analysed using systematic qualitative oriented text analysis 28 with the assistance of qsr nvivo 12 pro software for qualitative data analysis first all audiorecorded interviews were transcribed verbatim and field notes were typed into microsoft word and then imported into the software to help create parent and child nodes the issues were described interpreted summarized and organized to demonstrate the key issues that were identified from the data for analysis 2829 a numeric scheme of coding was employed to mark all parts of the written discourse that contained one category or another 1 for instance was used to code exclusive breastfeeding 2 for complementary feeding 3 for benefits of breastfeeding and so on these categories were then reduced into a much smaller size by grouping similar and related themes to arrive at comprehensive new categories the initial coding was independently done by rft and pja codes were later compared and the few inconsistencies were mutually resolved systematic qualitativeoriented text analysis was used to develop a framework for analysis to gain an intuitive sense of the data and to determine our approach to coding the data rather than have it managed solely by the software therefore we made use of the query function of the software to search for specific words and phrases that were critical to the observed themes see 30 in the process of analysis fortythree quotescodes and nine categoriessubthemes were obtained specific participants quotations were represented by unique identifiers r1 to r30 quotations from participants were used to support the final emergent themes all the conceptual expressions that emerged from participants were categorised in a way that reflected the salient and subtle meaning participants attached to their expressions the consolidated criteria for reporting qualitative research was adopted in reporting our study results 30 results sociodemographic characteristic of participants table 1 represents the sociodemographic characteristics of the teenage mothers ten per cent of the study participants have completed senior high school and were married approximately 64 of them were never married ninety per cent of the participants were christian half of the participants had no occupation while 20 engaged in petty trading with others involved in vocational and mobile banking services a summary of the background characteristics of the study participants is provided in table 1 childcare practices of teenage mothers figure 3 presents the main and subthemes that were obtained from the data analyses the main theme was the childcare practices of teenage mothers the subthemes comprised child positioning and attachment of babies when breastfeeding child bathing and cleaning practices accommodation and sleeping arrangements difficulties and challenges associated with breastfeeding most of the pertinent issues gathered from the participants through the indepth interviews have been described and interpreted babys positioning and attachment practices most of the mothers demonstrated healthy and good child positioning and attachment when breastfeeding their babies irrespective of whether deliveries were at home or hospital a participant for instance had this to say yes i sit down and put my baby on my lap and support the head like the one showing in the pictorial guide picture 2 and i hold the breast in the mouth of my baby this helps the baby to suck or feed well because if i dont do it this way the breast milk can pass through the babys nose ¬r 1 17 years with a male child however we found that this healthy practice required time for some teenage mothers to master a teenage mother with a 3 monthsold male child who during the first few days following delivery struggled to position her baby when breastfeeding had this to say yes exclusive breastfeeding practices teenage mothers shared their views about exclusive breastfeeding and why they think exclusive breastfeeding is beneficial for every mother to know and practice as a requirement for the childs growth and development some of the study participants indicated that they breastfed their babies well because they know the reasons for and benefits of breastfeeding their babies exclusively a participant had this to say yes i breastfeed my baby all the time i know the breast milk has all the nutrients my child needs and it is safe and natural god specifically made it for me to be given to my baby so i have to give the benefits of exclusive breastfeeding teenage mothers believed that the only food for their babies in the first 6 months of the baby is breast milk almost all participants mentioned at least one benefit or importance of exclusive breastfeeding and accentuated the need to breastfeed despite the challenges associated with breastfeeding practices most of the participants shared the view that it should be encouraged the following quotes highlight the perspectives shared by the study participants i know that breast milk is the only food for my baby at this time so i breastfeed her because i know my baby can become strong and healthy when i breastfeed her from now till the time i have to stop breastfeeding ¬r 3 18 years with a female child this was corroborated by a 19yearold mother with a baby aged 4 months old … it helps my baby to grow well and protect my baby against any infections and makes my baby strong and healthy ¬r11 19 years with 4 months child knowledge of exclusive breastfeeding the microlevel influence teenage mothers are faced with the task of learning to breastfeed their babies through guidance discipline nurture and support almost all the teenage mothers mentioned varied means through which they acquired knowledge of breastfeeding participants frequently mentioned community health nurses mothers friends family guidance and observation as sources of knowledge on breastfeeding teenage mothers were asked about what they know about breastfeeding and sources from which knowledge on breastfeeding was acquired one participant had this to say my mother supports me and educates me on the kind of food items which when eaten can increase milk supply breast milk and shows me how to position the baby for optimal and successful feeding ¬r 2 19 years with 3 weeks child another teenage mother who was practising exclusive breastfeeding based on what the nurse told her when she gave birth at the facility had this to say when i gave birth the nurse educated me that i should breastfeed my baby for six months before i can give my baby any food so i am just doing that ¬r 27 18 years with a female child complementary feeding practices teenage mothers mentioned why they resorted to complementary feeding of their babies and how those foods or infant formulas also help their babies participants whose babies were above 6 months mentioned the various kinds of food they give to their babies and what they think complementary feeding does for their babies with the aid of illustration in the pictorial guide teenage mothers mentioned what they feed their babies with as complimentary food and demonstrated how they do it some of the participants had this to say oooh yes sometimes i give my baby cerelac a canned baby food and porridge koko but i prepare the koko at home i dont buy it outside … yes i use the same position as in the book pointing at picture 3 in the pictorial guide when feeding my baby i know when i give other food to my baby it also makes my baby healthy and stronger ¬r 9 19 years with 7months child … i give my baby porridge cowbell mix and water for now because the breast milk is not sufficient for her so i have even decided that when she is oneyearold i will stop breastfeeding and give her other heavy food like mashed kenkey rice yes i put my baby on my lap like it is shown in the pictorial guide number three when i am feeding her ¬r 17 19 years 10 months female child challenges associated with breastfeeding practices generally teenage mothers shared the view that there are enormous benefits associated with breastfeeding and that mothers need to breastfeed their babies well while some reported positive experiences few viewed their experiences to be challenging many recalled difficulties that had to be overcome for them to continue breastfeeding for longer however the situation was unpleasant for them to continue doing so when there were difficulties with latch sore nipples tickling abdomen and breast pain it was not the case that teenage mothers who experienced these problems were unable to breastfeed exclusively however participants reported some difficulties and unpleasant experiences regarding breastfeeding these were some observations made by the participants i felt some pain from my stomachabdomen as my baby suckled and this continued for a while so i went to the hospital and the midwife told me my womb is getting back to its shape and the doctor prescribed medicine for me but it was still unbearable ¬r 22 17 years with a female child this was further corroborated by a teenage mother aged 18 years with a female child i baby care signs of hunger and satisfaction teenage mothers shared their knowledge and experiences on how they usually get to know when their babies are hungry and signals that suggest they are satisfied many of the participants shared similar views some noted the signs their babies made when hungry … my child sometimes cries hard ¬r7 18 years with 3 months old child with regards to the childs satisfaction some participants revealed that they usually pick up signals or sound that their babies usually make when they are satisfied with breast milk the following are some statements made by one of the teenage mothers when my baby is satisfied she would reject the breast when i give it to her when i see that i turn her back against my lap and tap her at the back lightly … this act of tapping the babys back gently is called abatan bo the baby will belch that tells she is full and satisfied she giggled ¬r 5 18 years with 5months female child baby bathing practices nearly all the participants mentioned that they get initial support and guidance from their mothersparent mothersinlaw grandmothers and other relatives when bathing their babies it was evident that the microlevel has much influence on teenage mothers when it comes to bathing and taking care of children especially during the initial stages of birth one participant had this to say for the first three months i had to observe my mother doing it because i did not have the courage to it so she asked me to look carefully anytime she was bathing the baby after sometimes my mother helped me to do it but nowadays i do it by myself i even bath my baby twice in a day one in the morning one in the evening and i do it very well yes i gently place the baby in the rubber bowl like the one in picture 4 in pictorial guide ¬r29 19 years with 15 months child it emerged from the data analysis that bathing children come with challenges for several teenage mothers teenage mothers acknowledged that bathing children especially in the early days of the child require a lot of skills which they lacked participants conveyed feelings of fear lacking in confidence and skills especially when it comes to cleaning some parts of the body one participant had this to say i think the little problem i faced when bathing my baby is when i want to clean her vagina it is very difficult for me because im not too sure whether her vagina is clean or not ¬r 7 18 years with 3 months child concerning child bathing and cleaning practices teenage mothers were asked to provide a narrative of how they clean their babys umbilical cord almost all the participants mentioned that their guardian parents motherinlaw or traditional birth attendants assist them at the initial stage teenage mothers mentioned they have been using substances such as methylated spirit and cotton wool capsules mixed with powder palm kernel oil and shea butter to the cord stump while others put a wet towel on a hot stone to make it warm and then put the warm towel on the umbilical cord one participant had this to say when i returned from the hospital my mother was the one bathing and cleaning my babys umbilical cord for me she sometimes uses palm kernel oil mixed with some medicine like ash and black colour herbs i dont know the name and she rubs it around the chord she said it relieves the pains and help the wound to heal fast ¬r12 18 years with 2 weeks child this was further corroborated by another teenage mother i did not clean it myself the woman tba who helped me to give birth did it for my baby she puts a stone in a fire and after removing it she put a wet clothtowel on the hot stone to make bit warm and apply it on the cordstump ¬r 14 17 years with a female child sleeping practices and arrangements most of the teenage mothers were found to be living in poor households or environment and had poor sleeping arrangements participants were asked to describe where they sleep with their babies they reported different accommodations such as an extended family house wooden and metal container structures some of them together with their mothers live in a rented single room others live in their family apartment while some live with their boyfriendsbabys father most of the participants mentioned that they slept on a mat folded cloth blanket with only few of them sleeping on beds with mattresses very few of the participants indicated that they sleept under mosquito bed nets some of the participants had this to say hmm that wooden structure pointing at it i have a mat pointed at picture 6 in pictorial guide that i and my baby sleep together on … sometimes i feel pains when i wake up but i am used to it besides i dont have any option ¬r 10 19 years with 20 months old child to corroborate this statement another teenage mother mentioned i was living with my friend at esuakyire one of the suburbs of elmina but when i gave birth i decided to come home and stay with my mum we all sleep in a single room i have a mat pointed at picture 6 in pictorial guide that i and my baby sleep together on it i put rubber under the babys cloth to avoid urine penetrating the mat when the baby urinates on it … i will say it is ok for me and my baby but i wish we sleep on a good bed and under an insecticidetreated bed net ¬r 21 19 years with 22 months child another teenage mother aged 18 with a baby aged 5 months who sleeps in an old metal container and wanted to prevent malaria had this to say hmm where i stay there are a lot of mosquitoes because of the big gutter there so i always put my baby under a mosquito net i sleep under it too oh yes like picture 7 in the pictorial guide i know its good to sleep under an insecticidetreated bed net ¬r 6 18 years with 5months child discussion this is a qualitative study which explores childcare practices among teenage mothers in keea ghana the major childcare practices were child positioning and attachment of babies when breastfeeding knowledge and benefits of breastfeeding difficulties and challenges associated with breastfeeding child bathing and cleaning practices housing and sleeping strategiespractices the findings of the study are situated within existing empirical studies and the theoretical framework that guided the study starting breastfeeding early especially within 30 minutes after birth is a good and recommended practice 11 breast milk provides all the food and water that a baby needs in the first 6 months of life and this liquid protects the child from diseases 131 our study revealed that most of the teenage mothers appeared to know proper positioning andor attachment of their babies the teenage mothers have learned to do so from their immediate environment at the microsystem where they live including experience from parents peers relatives and mothersinlaw 13 others who despite being pregnant for the first time noted that they had already cared for their younger siblings and had some experiences in childcare practices this is consistent with existing literature where there is documented evidence of the crucial role of the family especially mothers in providing education on childcare to young mothers 32 the childcare experiences of the teenage mothers were based on the use of common practices that were part of their family and community culture instead of scientificbased practices given by health professionals when caring for their babies 232 moreover we observed that some teenage mothers used methylated spirit and cotton wool while others used traditional means such as herbal medicine mixed with powder palm kernel oil shea butter a hot towel that is heated from hot stone on the cord stump as a common way of cleaning and caring for the childs umbilical cord these findings are in line with existing literature where the application of harmful traditional substances such as cow dung to the cord stump in neonatal care was reported 133 we observed that teenage mothers experienced several challenges when performing some of the childcare practices for instance child bathing and umbilical cord cleaning present enormous challenges to teenage mothers hence most of them usually depended on their parents motherinlaw guardians and tbas for support this support is found in the exosystem of the theoretical framework where through education the community health nurses help teenage mothers to cope better in light of the challenges that they encountered in their maternal roles this finding is consistent with a study conducted by gee and rhodes 34 on the adolescent mothers relationship with their childrens biological fathers where they found that adolescent mothers struggled to cope with their new maternal roles we also found that knowledge skills and experiences of breastfeeding were very important in ensuring good breastfeeding practices especially with regards to exclusive breastfeeding similar results were reported by a previous ghanaian study amidst fewer mothers lacking knowledge of healthy feeding practices 35 the finding of the current study corroborates those found in a study on knowledge of breastfeeding practices in ghana where it was reported that teenage mothers were practising exclusive breastfeeding successfully irrespective of the associated challenges and other unpleasant situations 3 this is because teenage mothers know the benefits of breastfeeding their babies which they learnt through the connection and interaction that exist between them and the various systems in the ecological systems theory here experiences and historical perspectives and ideologies of culture and beliefs relating to the importance of breastfeeding informed teenage mothers childcare practices also knowledge skills and guidance from the health and community workers where older girls observe their mothersrelatives when breastfeeding their younger siblings from their immediate home are linked in a way that offers a holistic childcare experience 13 again this is in line with smith et al 36 who posited that sufficient breastfeeding knowledge is a critical element needed to successfully breastfeed findings of the present study regarding complementary feeding revealed that most teenage mothers generally resort to the use of koko as first complimentary food and other foods which are made from cerealsbased flour such as maize rice and cassava this is part of the cultural values and ideologies of the teenage mothers the family and the community which bronfenbrenner observed in the macro system of the est however these foods may not offer any significant nutritional benefits to the baby this finding corroborates that of nti and larteys study on young child feeding practices and nutrition status in rural ghana which reported a general use of unfortified porridge with low nutrient as a first complementary food 37 a similar observation was made by fjeld et al 38 where the common complementary food that is introduced from 6 months to infants aged 2 years is maize flour porridge often fortified with vitamin a salt and pounded groundnut meanwhile complimentary food or weaning food should under an ideal circumstance be clean contain high energy and protein and easy to digest culturally appropriate and locally available as concurred by arora et al 39 the results of this study also revealed a lot of challenges associated with breastfeeding teen mothers lacked the experience and confidence to control or overcome these challenges in a study conducted by ahmed 40 there was evidence of support for mothers of infants immediately after delivery as a way of overcoming breastfeeding problems and enhancing confidence however as conceptualised in the ecological systems theory teenage mothers will need their mothers or guardians from the microsystem and openminded healthcare providers that are willing to listen to them and help them overcome challenges with breastfeeding 13 this is evident in a study conducted by kridli ilori and verriest 32 that revealed that the family mothers mothersinlaw and sometimes female relatives play a primary role in supporting the teenage mother in taking care of herself and her newborn after birth regarding sleeping practices of teenage mothers in the communities we found evidence of inappropriate sleeping arrangements among teenage mothers these findings corroborate those found in a study by hanna 41 where the author alluded to the fact that the homelessness of teenage mothers is explained by a variety of factors including teenage pregnancy pregnant girls escaping abuse and teenage girls leaving home due to conflict with parents family members or feeling unloved homeless teenage girls or mothers are therefore those who spend the night at lorry parks kiosk or in abandonuncompleted buildings the finding from the current study is in resonance with the conceptual framework where teenage mothers often explore the hopes and dreams of receiving support such as income health and social services and other material resources from both the exo and microsystems the literature further suggests that homelessness or having a poor sleeping condition is common among young mothers especially in resourcelimited settings exposing them and their children to health risks 42 limitations and strengths handling issues of trustworthiness in qualitative research are very crucial and determines the worth of the study in this study the potential threats to trustworthiness were adequately addressed and demonstrated to avoid researcher and participant biases for instance after each interview the content of the interview was summarised to the participants to be sure if their responses have been captured accurately however the decision to exclude teenage mothers with a child above 2 years could be seen as a limitation as it may be argued that an important insight from them might have been lost nonetheless attempting to reduce recall biases the study therefore aimed at getting the pertinent information about teenage mothers childcare practices besides situating the study within a theoretical framework adds to the strength of the study our study contributes to the existing literature by giving credence to the fact that in many resourcelimited settings like ghana traditional childcare practices with potentially negative health consequences still exist especially among vulnerable groups such as teenage mothers also our study highlighted the multifaceted nature of the problem as such interventions that are aimed at addressing the problem of harmful childcare practices in lowand middleincome countries would have to adopt a holistic approach to dealing with the problem conclusion there is a wide range of childcare practices by teenage mothers both positive and negative generally teenage mothers were inexperienced and found it difficult to properly care for their babies especially during the early stages of childcare whereas few teenage mothers received some sort of support and assistance in caring for their children they are only limited to the microsystem we recommend the development of comprehensive approaches that encourage scientific knowledgebased childcare practices needed to improve maternal and child health health professionals should be mindful of culturebased traditional childcare practices when developing health education protocols for teenage mothers and ensure that the needed support skills knowledge and guidance are provided to ensure their wellbeing and that of their babies thus support from the exo and macrosystems need to be given adequate attention additional file 1 abbreviations who world health organisation unicef united nations international childrens fund gss ghana statistical service ghs ghana health service sdgs sustainable development goals un united nations est ecological systems theory keea komendaedinaeguafoabrem idi indepth interview coreq consolidated criteria for reporting qualitative research authors contributions rft and ekmd conceived and designed the study with inputs from pja rft and pja performed data analyses rft drafted the manuscript with inputs from pja ha ekmd and kkk all authors reviewed the manuscript and provided substantial contributions to the interpretation of the data to improve the intellectual content again all authors approved the final draft and gave consents for publication competing interests the authors declare that they have no competing interests

background while appropriate care for children is essential for optimal growth and protection against child morbidity and mortality teenage mothers have been shown to deviate from the recommended childcare practices this study explored the childcare practices among teenage mothers in ghana using ecological systems theory by bronfenbrenner as a theoretical framework methods employing qualitative approach to inquiry evidence was drawn from 30 teenage mothers using indepth interviews the data were analysed and presented following systematic qualitativeoriented text analysis strategy with verbatim quotes from study participants to support the emergent themes results it was evident that teenage mothers have limited skills in childcare practices and often resorted to practices with potentially adverse health outcomes for their children they for instance applied hot towels they had heated with hot stones to the childrens umbilical stump we found that teenage mothers were not in sync with their macroand exosystems thereby depriving themselves and their babies of the muchneeded guidance and support in caring for their babies teenage mothers were often confused and sometimes clueless about best childcare practices at a given point in time conclusions childcare practices by teenage mothers are far from the ideal to improve on child health especially children born to teenage mothers efforts at both the macroand exosystems should be directed at exposing teenage mothers to best child care practices that inure to the benefits of their children anteand postnatal visits should be used to provide specific education for mothers especially firsttime teenage mothers on the care needs of babies and how to provide these needs

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a peoples capacity to tell its own stories for its own purposes and to choose how these stories are presented beyond its own citizenry is an expression of the right to selfdetermination it has methodological and ethical implications for how research is done by whom for whom and for whose purposes the special section addresses each of these questions in specific context while inter alia contributing to the broader scholarship of selfdetermination in the first article of the special section thorpe christen booker and galassi argue that museum library and archival collections have contributed to the colonial narrative through practices that demean indigenous people and cultures in the telling of their stories in the ways that their sacred artefacts are stored and displayed and in the ways that they address the repatriation of these artefacts in many cases questions of repatriation concern human body parts collected in contravention of indigenous cultural norms and as objects of scientific curiosity thorpe et als underlying question is then how do colonial archives repay the colonial debt they argue for the reshaping and rebuilding of archival management systems data governance and preservation so that indigenous priorities are central to their work they show that collection management is not a culturally neutral process and argue that concepts of sovereignty are underdiscussed in the context of library and archive management they make a case for alternative collection management practices the article draws on and develops papers that each of the authors presented to the international conference on archives in 2019 they discuss a collaboration between the waramungu nation in northern australia and the centre for digital scholarship and curation at washington state university as an example of a project that supports the indigenous nations expectations of why items should be collected and how and for which purposes they should be curated while thorpe et als article is the only one of the three to make an explicit connection between their arguments and the united nations declaration on the rights of indigenous peoples their discussion illuminates selfdetermination as a common theme this thematic commonality shows how the articles may be located within a broader indigenous data sovereignty scholarship to show that they have a theoretical and empirical relevance beyond their immediate subjects the declaration provides that indigenous peoples have the right to practice and revitalize their cultural traditions and customs this includes the right to maintain protect and develop the past present and future manifestations of their cultures such as archaeological and historical sites artefacts designs ceremonies technologies and visual and performing arts and literature it also affirms that indigenous peoples have… the right to the use and control of their ceremonial objects and the right to the repatriation of their human remains in the second article of the special section kutay considers the recording and transmission of histories and other stories of significance the cultural aspects of indigenous relationships with technology must therefore be considered she proposes knowledge sharing as a community narrative and that the employment of new technologies should consider target audiences and their worldviews she describes and analyses projects that use digital technologies to record and present culturally significant knowledge these include recording stories of the stolen generations and the development of an information sharing system for the sydney koori interagency network her discussion of a project involving the distribution of broadcast materials for remote radio and television is a further example of information systems research and practice supporting selfdetermination by helping people to tell their stories for their own purposes to audiences that they have chosen and through technological means consistent with these purposes kutay explains that in each of the cases describe resources developed for the expression of culture she argues that using technology and knowledge transfer for cultural maintenance is multifaceted and may start with the interface design the ontology of the knowledge system and then extend to developing the components she argues that as an expression of selfdetermination this means that eventually communities can be in control of the systems and provide ongoing innovations in this area in the third article of the special section clapham hassan fredericks bessarab kelly harwoood senior longbottom and dale note the importance of indigenous led research arguing that research conducted by outsiders may be problematic for its perpetuation of a colonial mindset of nonindigenous australians leading to failed solutions to aboriginal problems in contrast they propose a methodological focus on potential rather than problems which may include information systems providing an accessible platform for aboriginal voices their purpose is to show how the application of digital tools to existing indigenous research methodologies can support authentic data collection analysis and dissemination they develop these arguments from a case study of aboriginal led community research involving an aboriginal community controlled organisation and the illawara koori mens support group in new south wales the study showed the benefits of community knowledge and involvement in decisionmaking to improved health outcomes they argue that the study australasian journal of information systems osullivan 2021 vol 25 research on indigenous use of special section editorial information and communication technologies also demonstrated digital tools broader applicability to indigenous research methodologies and that digital tools can support many activities in the conduct of research in aboriginal communities enable authentic outcomes to projects which address aboriginal issues and concerns help in the management of aboriginal knowledge and provide a platform for aboriginal voices hasan et al locate their work alongside indigenous scholarship in other disciplines with a similar focus on contextualising and giving substantive effect to the right to selfdetermination they cite education health policy social work and media studies as particular examples more widely still all three articles may also be understood as contributions to indigenous data sovereignty as an emerging field of inquiry data sovereignty is both a precursor to selfdetermination and an expression of an indigenous capacity to know and interpret their own stories and to collect record store and curate information for their own purposes data sovereignty responds to the idea that relying on others to frame how a people should understand itself and be understood by the wider world contributes to colonial stereotypes and to the setting of research and public policy agendas by other people creating negative images of people to justify colonialisms hierarchy of human worth is a phenomenon that data sovereignty challenges the articles in this special section show selfdeterminations alternative potential and its significance for information systems research and practice each of the articles is important beyond its own context because each shows why the information that information systems researchers and practitioners collect curate and use may reflect peoples relative positioning in a social and political order that they may not have chosen or helped to construct the articles provide insights into information systems potential to contribute to the perpetuation of a social order in which selfdetermination is not equally available to all peoples or on the other hand to contribute to the reclamation of indigenous peoples authority over information about themselves and its use collectively the articles show the diversity of data sovereigntys concerns and the scope of the right and capacities of selfdetermination access to knowledge is a measure of social and political inclusion and a measure of cultural independence the articles show how and why and provide useful case studies for the consideration of indigenous data sovereignty scholarship finally we like to acknowledge yeslam alsaggaf daniel cunliffe te taka keegan andrea heather duff anisha fernando lynette russel tristan kennedy kirsten wahlstrom and stuart andrew yeates who served as reviewers

selfdetermination is a social political and cultural right that belongs equally to all peoples the three articles in this special section show how information systems practice may limit this right on the one hand or make significant contributions to its development on the other the ways in which information is collected and curated to diminish the stories that people wish to tell about themselves or to create opportunities is the articles common theme they consider selfdetermination beyond its more usual study as a body of legal and political rights to show its deep cultural significance and to draw out information systems research and practice as inevitably cultural activities

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introduction chronic childhood illnesses require systematic and longterm treatment repeated visits to the hospital at regular basis and a lead to an uncertain future nowadays treatment practices have evolved and the survival of children with neoplasm has increased dramatically the fact remains however that illness and education and by extension1 social exclusion are significantly related to each other undoubtedly the education of children with chronic health problems presents extremely high demands both during their stay in the hospital 2 and when trying to reintegrate them into the everyday life of school after discharge in the context of a wider discussion about hospital education internationally alternative educational practices are considered which mainly concern the stage of childrens recovery and their return to everyday life outside the hospital these are educational practices that take place either at home with home education or during the formal reintegration of children into their classroom environment and are more or less differentiated in various countries of the european union in the netherlands for example hospital schools and hospital teachers were replaced by a counselor for the education of sick pupils this fact allows a better arrangement of the educational needs that arise during the long periods of stay of young patients at home or in the hospital in greece children with chronic diseases fall under a law that refers to people with disabilities and special educational needs among other things the law provides for home schooling theoretical framework 21 school reintegration after hospitalization children suffering from a chronic illness cope with many different issues that determine their daily life in addition to the doctors and daily examinations their institutionalization in the hospital and the sudden disconnection from their ordinary life they are also called to face the problem of reintegration into school which is a major issue for their cognitive development and socialization after the end of the treatment and the period of stay at home until they return to their new everyday life the main request is for them to return to school as we read in bruskeli even immediately after the diagnosis they wonder about when they will return to school it is known that students with chronic diseases face an increased risk of social isolation which is directly linked to the lack of understanding of their condition by their classmates their inclusion in the classroom community is considered a catalyst for recovery from the illness too often parents focus on their childrens health without considering the importance of their school reintegration in research conducted on socially isolated children high levels of cortisol were observed which were directly related to correspondingly high levels of stress also an extremely important parameter during school reintegration is the concern of parents regarding the possibility of rejecting behaviors and discrimination towards their children due to illness and longterm absences during hospitalization in a study carried out at the finnish university hospital turku it was found that a significant percentage of sick students were bullied when they returned to school mainly because of their appearance by classmates who had not received sufficient information about the adventure of their victims 1in general we would say that upon returning to school children survivors from a form of cancer cope with difficulties and limitations in almost all fields of their lives research has shown that time out of school have detrimental effects on childrens mental health wellbeing and educational outcomes they are very likely to present with low energy deficient motor skills and balance problems which limit participation in sports and other activities that require physical endurance thus contributing to their social isolation the situation is even more difficult in the case of children who are ill and come from immigrant families in particular immigrant mothers with limited fluency in the official language of the host country have difficulty communicating and understanding complex medical procedures and treatments resulting in the frequent misinterpretation and exaggeration of the problem in addition they are unable to communicate directly with the school staff in order to request personalized support and a range of services to their sick children therefore for some immigrant parents it seems more practical to keep their sick child at home than to pursue the return to school as soon as possible the role of the teacher in the formal school during reintegration in the context of the reintegration into the classroom of a student who returns after hospitalization the teacher undertakes a particularly demanding role since the need to deal with medical problems that may occur during everyday school life is imperatively added the formal education teacher is usually not trained to academically address or emotionally handle such a challenging role or to develop an academic plan for a child with cancer according to studies teachers are concerned about their lack of knowledge on these issues and are not at all sure about the realistic limits of the expectations they have to meet for each case while at the same time having to worry about more effectively addressing the needs of the other students in general they consider it necessary to be informed about a wide range of medical issues as well as appropriate ways of dealing with school bullying incidents against children who have experienced the painful adventure of a chronic illness mainly due to their appearance after treatment a recent survey of teachers in the formal education system found that participants were unable to adequately respond to issues related to the reintegration of children with chronic diseases into their normal classrooms after a more or less long period of hospitalization finally teachers often receive little information from parents or medical staff and are unaware of life expectancy the severity of the disease or possible medical complications that may occur at school therefore in order to effectively address the issue of reintegration various integration intervention programs have been designed as a bridge for the exchange of information between teachers students parents classmates and medical staff of hospitals relevant reintegration programs should give immediate priority to proper information to the teachers of the standard classes regarding the chronic diseases and their close cooperation with their hospital teacherscolleagues who take care of the children during their hospitalization examples include sachss returntoschool plan in 1980 likewise there is a pilot program with an intent to examine the experiences of children with brain tumors their parents and the collaborating educators in greece there is no official program for the reintegration of children with chronic diseases in formal education teachers are not provided with any educational material to inform and deal with such situations and as a result the child and parents become deeply concerned about what the future holds reintegration programs may provide the opportunity for children who suffer from chronic illness and long academic exclusion to explore their fears concerns and anxieties on their return to school and help them to deal with issues such as selfand bodyimage classmates reactions teachers attitudes and schoolwork thus these school reintegration programs and their development in an official state level has been identified as an important need technology in the service of school reintegration of children with chronic diseases research shows that children with cancer and other chronic diseases although they received instruction during their hospitalization there was a decrease in their school performance upon their return and had difficulty reintegrating into regular school this fact led to the examination of the possibility of offering new educational models and very specific therapeutic protocols to be followed both during hospitalization and after discharge from the hospital online education for example is an important solution in this particular case and perhaps one of the rare cases that is considered in our opinion necessary 1in europe therefore efforts have been made to develop specific software to provide the possibility of the participation of sick children in the everyday life of their classroom throughout their hospitalization we mention for example the project bambi of the hematooncological pediatric department of the hospital silvestrini of perugia a system of recreational and educational applications from a distance during the therapeutic quarantine another interesting project is the monkey in my chair 2 program created by the cure starts now foundation in australia and now established in america and canada this is a program originally developed for preschool children diagnosed with cancer through the program each child is provided with a monkey kit which includes a stuffed monkey that takes their place at school when they cannot be there in addition a book is included to help teachers explain to their students the situation faced by their classmate who is ill finally electronic exchange of images and documents is planned in order to ensure live communication between the sick child and the rest of the class method of research the aim of this study is to investigate the various dimensions of the reintegration of children with chronic illness during their return to formal education after a short or longterm treatment in the hospital the ultimate purpose is the detection of cases of social and educational exclusion of children in this certain category and the repercussions of the lives of all members of their families specific scientific questions constitute whether or not the institution of home education is effective the importance of cooperation of the enmeshed entities the effectiveness of new technologies and the existence or notof the versatility of the present institutional framework while in addition a summarized valuation of their further school career of these children was attempted its a qualitative research conducted on semistructured interviews to fifteen parents and eight teachers of which five serve or have previously served as hospital teachers at the two pedooncology clinics in thessaloniki located at hippocratio and ahepa the other three are practicing teachers who have had experience with children with chronic diseases not only during their return to the regular classes but also in the context of home schooling in the selection of subjects the contribution of parents association with children with neoplastic diseases of n greece called lampsi was decisive the people in charge offered to bring us into contact with parents whose children were patients in the past and survived or notthe illness as well as with teachers who served both within the hospital schools and in the typical schools the research procedure was followed by a convenient sampling with an avalanche of characteristics the context of the interviews after their recording and digitization were analyzed through the method of qualitative content analysis with the subject as a unit of recording as a result of the analysis three basic axes emerged which are composed in a number of thematic categories and subcategories a semistructured interview questionnaire was used as a means of data collection the main axes of which emerged from the overview of the existing literature and from conducting informal interviews in the form of discussion with selected personsinformants during the pilot research 3 the interviews took place either in a prearranged meeting place or through teleconferences last but not least the interviews with the hospital teachers who continue to work in this working place were conducted within the hospitals in order to ensure the possibility of life observation of the school premises and the daily life of children and their teachers discussion from the qualitative content analysis of the interviews conducted with parents and teachers two thematic axes emerged for each of the two categories of research subjects 1 home schooling 2 reentry to the formal education below is a summary table with the main thematic axes and the relevant thematic categories and subcategories that emerged from the qualitative content analysis of the interviews conducted with parents and teachers the inhospital study of children with chronic diseases is generally regarded as a vestibule for their following school course by parents and teachers it is decisive and supportive in terms of their school reintegration and career in standard classes after hospitalization home education we could say is a necessary intermediate stage in the transition of children from healthcare to formal school regarding the reasons why a child should be homeschooled after hospitalization parents focused on the childs safety as childrens viruses can significantly worsen their health condition several times doctors advise parents to keep children at home for a while until their immune systems can cope also the changes in the childrens appearance as a result of the chemotherapy they receive also play an important role which causes intense narcissistic trauma and makes it difficult for them to return to the school classroom 1 needed to be protected from viruses while he was an athlete before his surgery after the surgery we ended up in a wheelchair and had trouble getting around his appearance which had changed terribly as well as his psychological state he was not prepared to face it completely and go to school we had some facial deformities but the main reason were the viruses hospital the specific formal discussions were conducted in the context of our pilot implementation of the draft questionnaire which was further developed and constituted the main data collection tool 1 worchelprevatt et al report that children with chronic illnesses find it difficult to return to school after prolonged absences due to hospitalization‧ this is compounded by low selfconfidence regarding school achievement and narcissistic trauma caused by changes in their appearance that were circulating and shouldnt have because we continued the chemotherapy at home for us the chemotherapy was in the form of pills it was not intravenous and the child had to be protected a lot according to the literature home education is rarely mentioned as an alternative method of educational intervention in official texts concerning educational policies schools do not have a specific plan but instead decide to cover emerging needs based on the situation they are called upon to handle the following are the parents statements about the current framework it was summer when we entered the hospital so in september i was informed that home teaching can be done which of course we never had because while i had done all the necessary paperwork for primary education because then the child would have to attend 5th primary teacher never came we were told it was approved but there were no credits 8 despite the positive assessment of some parents regarding the effectiveness of home education the vast majority of people who participated in our survey stated that the child in home education does not manage to cover neither the learning gaps nor the percentage of the content corresponding to his study class this is confirmed by the research of shaw et al in which it is argued that a major pedagogical barrier to homeschooling is the fact that one hour of instruction at home cannot in any way reflect the educational experience of seven hours of instruction in the typical traditional classroom brown informs us in his research that many families were dissatisfied with the quality and quantity of home teaching their child received before returning to school the following statement from a parent who participated in the research is typical however he didnt lose from the home education by any means in the 5th grade he managed to get a literary prize writing a story that was somehow autobiographical that is in the lessons he was taught he did not fall behind he was left behind in the rest that the school offers he does not have the general education that the school can give you he misses the ideas the opinions that are heard in the classroom managing the time he has in a classroom is completely different similar statements were made by teachers who welcomed their students back to their classes after their illness and hospitalization in addition to the cognitive field that is not served as it should be homeschooling by its very nature fails to provide the child with the right to participate in the classroom and interact with his classmates these are basic psychopedagogical functions which however are not performed with this specific type of education as a teacher and a mother tells us look homeschooling is something that only helps with the learning part in nothing else if a child can be found in the school place then no home teaching offers him the slightest according to brown for home teaching to be considered effective and to facilitate the smooth reintegration of the child into the standard school his academic performance should be maintained at levels comparable to those of their male and female classmates therefore according to boles et al it is important that home education aims at a fruitful interaction both cognitively and socially always based on the learning needs of the sick child as for the transition to the main phase of the childs reintegration into the typical school a series of issues arise that are obviously a continuation of the previous education process he experienced both during hospitalization and later during home education we focus below on the choice of repeating a class a particularly antipedagogical practice as a mother said however when home education stopped and we went to school we had a problem we couldnt read we couldnt stay in class we couldnt do anything so he had to repeat the class but also to be able to cover the learning gap that existed from kindergarten and prekindergarten sic because other children knew how to write1 it is also interesting how the teachers cope with the problem of the hospitalized childs communication with the class and his classmates the introduction and use of new technologies and it systems in schools is seen as particularly useful i was lucky because in 2007 suddenly the school got technological equipment we had internet in the school we had a computer in the classroom a projector and we could make a connection this of course we did only in the first month because it didnt take longer then entered the classroom for good as if he had never been absent nevertheless the use of technology also requires specific skills from hospital and typical education teachers the need for information on the new technological data is another issue that must be addressed immediately by the competent bodies benigno et al after a systematic review of the existing literature point out the great importance of technologies in terms of connecting students with their school during their hospitalization and a possible extension at home the relation between the original school and the hospital one can be supported by an electronic register and through the creation of a personal portfolio with recorded activities of the student however the integration of the technology tool into the teaching of this particular population of students proves to be quite complex for several reasons including the skills required by teachers for their effective use from this research it was also found that the communication of the hospitalized child with his previous school environment is often undermined by the contributors involved thus upsetting practices of confrontation and competition occur between hospital teachers and their typical education colleagues there are also obstacles put up by the medical staff of the hospital the statements of a hospital teacher are indicative this online communication with the regular class is a very important part and it was the first thing i asked when i entered the clinic but everyone and when i say everyone i mean my colleagues and the nurses and the parents of the children they advised me not to have any contact with the school that is there should be no cooperation one reason is that no one is involved with anyone they are another school and we are another school the second reason is that we help the children more in the psychological part and do not focus so much on the lessons so there is no need for a direct connection with the school even parents undermined the whole process in an attempt to completely hide the fact of their childrens illness and hospitalization there were parents who did not accept the situation and said you will not say that i am a parent at lampsi you will say that i am a volunteer and i told her well is this possible the child is seen going to and from the hospital no she says we leave and cover him with caps and scarves it is winter it is night they will not see him hiding the child and his problem under the pretext of protecting him from teasing or bullying are practices that increase the risk of the sufferer slipping into conditions of social exclusion valamoutopoulou valamoutopoulou state that the information of the general public as well as of teachers about the issue of chronic disease continues to be insufficient as the main concern of some families is acceptance from the others obviously this attitude is a reaction to the social stigma that pervades the case of people with chronic diseases however it acts as a feedback loop in the formation of a vicious circle that contributes to the aggravation of their health recovery process the quasiintolerance of some children towards diversity which of course reflects the general attitude of their families often contributes to their adoption of bullying behaviors at school some children who were bothering him due to the illness he was going through he was a little lets say in a bubble we were told to stay away from sports not to participate in gymnastics not to go out in the sun for a long time he was a little guarded because we were afraid about the surgery he had done at some point we noticed acts of violence on him when he was beaten in particular there were two children finally things normalized they left they went to another school and we obtained our peace possible marginalization or a condition of social exclusion has adverse consequences on the academic and psychosocial development of children with cancer in particular given the concerns that children with chronic illnesses face when returning to school coping with similar issues is a central topic of the general discussion within the school community it is considered crucial that schools provide ongoing support to children and their families however in order to enable a similar support for the children during their reintegration into school the cooperation of all involved bodies is considered necessary within the framework of a holistic reintegration plan such programs have been proposed in foreign countries and despite their different approaches they are based on the cooperation of the various participants it is impressive that the hospital educator and academic liaison association and the société internationale d oncologie pédiatrique recommend that school support for students with cancer should begin at the diagnostic stage it is important therefore to offer school reintegration programs and to have uninterrupted and mandatory communication between school and hospital staff however despite the recommendations no standard reintegration plan based on research results has yet been established canter roberts propose a multisystemic model of collaboration underlining the importance of a unified approach when returning the child to school and focusing particularly on the need to utilize the institution of the consultant as a link between the agencies involved the importance of a similar approach can also be seen from the testimony of a class teacher whose pedagogical instinct led her to seek cooperation with her colleague who provided the childs home education while there is absolute convergence with the views of a mother the teacher who goes to the home school who is an extra to us goes with specific material which i will send her today you will do this because in class we will also do it in summary a school reintegration program should take into account a variety of factors such as for example psychologicaltype inhibitions concerning general relationships with classmates and body image accompanying elements of anxiety melancholy or even depression appearance of more general malfunctions the developmental perspective of a reintegration program is an appropriate framework for defining both the content and the nature of interventions consistently taking into account any information about the cognitive capabilities of reintegrated children to the question regarding the provision or not by the ministry to implement a reintegration program the responses of the teachers in the sample are typical what i want to say is that this is a part of education that unfortunately the ministry and our country are dealing with as if we were in the previous century since we have so many incidents i think that the state finally it must bend down and see this problem seriously and not be afraid and not hide as it always hides behind deficit structures such as the integration departments the coteaching meaning the model of parallel teaching support or whatever else this insufficiency is not only observed in greece in a survey conducted in america the results showed similar deficiencies in the implementation of good practices such as the establishment of interdisciplinary school reintegration teams under the guidance of authorized consultants the development of school reintegration systems and the exchange of information with the agencies involved the result of the above shortcomings is the strengthening of a series of prejudices that prove to be particularly burdensome and decisive for the later school career of the children who were ill we mention for example the following of course i have also heard horrible stories there was a child who wanted to return with a hat and the teachers fear was about not to get infected i mean i cant believe in 2019 that there is a person who believes that cancer is contagious in the international literature we find serious misconceptions of healthy classmates about chronic diseases impressive among them is the view on the transmissibility of cancer thus school becomes particularly toxic as the child recovering from the disease finds it difficult to manage on the one hand the various prohibitions related to his health and on the other the frequent negative reactions of his classmates i mean just imagine the gymnast still wanted to make her do gymnastics but she tells him i have an exemption and he wanted her to bring him a notice he didnt think she had a problem and what do you want me to do to show you my leg 1 it is important to note at this point that a potential exclusion or marginalization in the context of the school process contributes to the further burden of the cognitive function research supports this claim providing clear evidence that brain regions associated with executive functions and higherlevel cognitive processes located in the frontal lobes are affected by experiences of social exclusion however possible conditions of marginalization and social exclusion have serious implications in the behavioral domain as well the literature finds rejection hypersensitivity to be associated with higher levels of aggressive behavior and more interpersonal difficulties the following extract is characteristic the child had an adjustment problem he was aggressive to a point he cried easily he didnt hang out with the other kids because he was aggressive he felt marginalized so his reaction was this the role of formal education teachers is undoubtedly crucial since they are not only the ones who first welcome children after hospitalization and confinement at home but also those who help them to obtain a desired academic level however the insecurity of teachers is evident when it comes to interacting with children who have undergone heavy forms of therapy this is observed due to their insufficient training on specific issues1 as well as their unpreparedness regarding the mental domain to respond to such a demanding role and to develop an effective academic plan for their students with cancer below there are extracts from the narratives of parents with completely different experiences with teachers when reintegrating their children we had a lot of psychological support from the school from the teachers and all the educational staff and the principal and even though our child had this teacher for the first time they immediately developed a very special relationship he came to the hospital saw him we had if not daily communication very regularly he was being informed about his health our first grade teacher when the child returned to school considered that childs name was a burden because she needed to take care of him and she didnt want a problem in the classroom on the other hand in the second year another mistake was made his teacher believed that with the arrival of coteaching another teacher that is inside the schoolmaybe the child will be targeted maybe the rest of his classmates considered him dumb stupid whatever so the marginalization would intensify it is worth highlighting at this point the convergences on the part of the teachers so i had to somehow raise awareness among my kids make them a team thats my goal anyway that is to create the community of my class so that they can then welcome childs name through activities aimed at raising childrens awareness of diversity to build social identities that we are all equal in here and we all respect each other another important issue that emerged from the research was the effects on the mental balance and daily life of the rest of the family from the international literature we know that caring for a child with complex needs at home requires multidimensional parental involvement full acceptance of responsibility for problem solving decision making many times teaching managing and coordinating various actions and interventions‧ and of course all of the above unfold in the wider context of family life previous research has compared children with chronic diseases and their siblings in terms of their cognitive skills quality of life and psychosocial development it was found indeed that the children who got sick and were eventually curedhad more cognitive and educational deficits than their siblings in recent studies it was the healthy siblings who presented higher rates of social isolation more posttraumatic stress symptoms and significantly worse school performance than those who suffered from childhood cancer however beyond the contradictory results of some studies it has been observed that the siblings of cancer survivors show an increased frequency of school absences compared to the general population possibly this occurs on the basis of a more general permissiveness or tolerance of parents regarding school absences resulting from their awareness of the painful mental processes that their healthy children face during the hospitalization of their siblings in general we would say that burdening parents with additional obligations in terms of nursing and caring for sick children is a major issue that directly affects the schooling of the familys children it is worth recording a phrase that was said many times during the interviews and by different parents each time when one member of the family gets sick the whole family gets sick very often the home turns into a makeshift hospital and this has direct effects on sick children their siblings and parents as we read during the home care of children with complex needs parents often provide a type of care that corresponds to professionals further aggravating for the already mentally charged parents the factor of the voluntary or more accurately forced abandonment of work by one of the two parents due to their inability to cope with the new increased demands entailed by the recovery of their childrens health parents very often feel that they cannot control the course of the disease which makes them feel helpless sometimes again they feel guilty as they poke their child with the needle and cause him pain other times they are suffocated by the absolute dependence of their sick child all these together are stressful factors that further burden the already burdened everyday life the multiple and daily obligations of parents in terms of planning and organizing the childs life on the basis of strict hospital settings and complex home treatments justify any concerns they have about the possibility of side effects during treatment a fathers statement is indicative our everyday life has also changed we suddenly became nurses we became doctors without knowing anything in the long period of continuous handling at exhausting rates the school is reduced to a serious mechanism of support and optimism there are many parents who will not look for psychological support anywhere else except from the school staff therefore one realizes the importance of trained teachers in matters of school integration of children with chronic health problems this is a necessity that was demonstrated in another part of this work and is highlighted in all the relevant reports of the parents who took part in the research finally it is necessary to say that feedback on the range of attendance and longterm results concerning the general school career of children who suffered from chronic diseases was not possible to obtain due to the fact that most of the children whose parents participated in the research are still at school the fact however of giving them the possibility of admission to tertiary education without the national university entry exams but using a prescribed percentage of the grade if nothing else justifies some optimism obviously restrained since no privilege policy can be a panacea in solving both complex and demanding issues as was evident from all the above the following contradictory passages are typical they have some help in the future to enter the university more easily of course there should be special treatment because we are talking about children who have suffered for many years therefore they cant have the same drive and vitality in any case because they miss too much of their school being in the oncology department i tried to use a lot of this dynamism on some students who were older conclusion in summary we would say that hospital education in greece is still in its infancy as far as the teachers are concerned the absence during the circular studies of training related to teaching in hospitals is a significant aggravating factor and is attributed to the general indifference of the state while also making the curricula of the individual pedagogical departments hollow hospital schools are treated by legislation exactly like other formal education schools in terms of opening hours and the selection of teachers although they are a very different type of educational structure with multiple requirements the poor organization and the almost nonexistent communication between the teachers inside and outside the pediatric clinics raises a more general concern since the adoption of an interdisciplinary cooperation plan of the involved bodies is considered crucial it is found that the maintenance of dividing lines between formal and hospital education does not at all serve the learning and socialization process of children experiencing the case of a chronic disease on the contrary it prevents the correct information and management of the various issues that arise similarly the possibility of online communication with the school both during and after their hospitalization during home education is considered necessary for their more effective reintegration into school and society in general nevertheless from discussions with parents our initial feeling was reinforced about a completely unprepared and unscientific handling of the whole issue by the state thus in a prolonged period of unsuccessful treatment of the pandemic by the greek government where adherence to neoliberal dogma prevented the exercise of a if not radical at least effective social policy the area of public health was underfunded and understaffed the policy was similar in the area of education where the only response to the risk of the spread of the coronavirus was the consecutive closing and opening of schools for a period of approximately 15 years during which distance education alternated periodically with facetoface teaching despite significant and fair objections to the antipedagogical and antisocial character the established educational and socialization costs of this option distance education was imposed on all schools in the country they forgot however to use it in hospital schools and home education in perhaps the only cases where its utility would hardly be disputed we wonder then whether distance education is ultimately another means of social distancing of the population serving the modern social contract recently signed with the neoliberal political instrumentalization of the pandemic rather than being as it should be an alternative teaching practice to overcome situations of lack of communication between burdened groups of the countrys student population finally some common practices of keeping the disease silent from those around children with chronic diseases are considered ineffective and pedagogically unproven while they reinforce other possible adjustment problems when they are reintegrated into the standard school from all the preceding it is certain that children with chronic diseases are hampered by their equal participation in educational processes which negatively affects the general quality of their lives addicting them to a constant flirtation with situations of social exclusion which seem insurmountable any successes in the educational field are due to the efforts of the children themselves and their families and of course to the personal sensitivities and daily sacrifices of their teachers the field of our research is still open for future and more specific research approaches for example the educational trajectory of children recovering from chronic illnesses could be examined in addition a comparative study of the social characteristics of these children in relation to their school outcomes would be of particular interest finally a comparative study of national policies and the corresponding educational practices followed could be undertaken

this research attempts to identify the conditions under which children with chronic diseases are reintegrated into formal education after they have been hospitalized for a long period in addition it attempts to probe the conditions under which the children are being taught during the home schooling period educational inequality is a thorny issue that concerns every education system many important social vulnerabilities affect the equal distribution of educational opportunities but the education of children with chronic illnesses creates a double vulnerability the results of which are most often truly tragic for the affected students and their families the research data was collected after a series of interviews with parents whose children had been hospitalized with a serious illness and teachers who had worked in hospital schools and in formal education the findings of the research show that the reintegration of hospitalized children who have been absent for a long time from school is difficult and often causes anxiety due to the abusive behaviors they receive from their classmates it is also emphasizes that the teachers of the formal education have serious lack of training related to the reintegration of children with chronic diseases as well as a holistic cooperation plan that should prevent the stigmatization related to the disease is necessary

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s ocial gerontologists have shown an interest in the quality of life of older adults since the establishment of the field some of the first studies by these sociologists and psychologists focused on the wellbeing of older adults researchers initially showed an interest in personal characteristics believed to affect an older persons feelings of wellbeing this interest eventually expanded to include social conditions today some researchers have begun considering whether the natural environment and the physical infrastructure surrounding older persons affect their sense of wellbeing one question raised is whether the environment has independent effects on wellbeing after considering personal and social factors the purpose of this article is to address this question by using multilevel regression analysis that simultaneously considers the effects of personal social and environmental characteristics the analysis is limited to rural elderly because the urban and rural chinese have very different environments and the rural elderly make up a significant portion of the elderly population in china provided later is a brief summary of rural chinese development literature review and description of the methods findings and conclusions rural chinese villages in transition in the late 1970s the chinese communist party began changing policy to allow for major political economic and social changes in china reduced central state planning and the development of an increasingly marketled economy that is the emergence of a capitalist china have substantially affected its rural areas many villages have taken the initiative to attract various means of development with mixed results on one hand they have prospered financially with the addition of industry and business on the other hand the lack of enforced environmental regulations has generated a variety of environmental problems such as serious shortages of drinkable water clean air and arable and forested land the marketization of the countryside has been accompanied by the central governments relaxation of restrictions prohibiting ruraltourban migration attracted by the potentially greater opportunities of urban areas substantial numbers of young villagers have moved to these areas creating a major disruption in rural chinese family practices and norms many from the younger generation are unable to perform traditional caregiving roles to their parents and parentsinlaw because they no longer live near them these changes in family structure appear to be having detrimental effects on village elderly environmental social and personal effects on subjective wellbeing the subjective wellbeing of older adults has been studied from a variety of perspectives the earliest studies focused primarily on the effects of personal characteristics these studies eventually grew to include social conditions most recently researchers have begun to consider the effects of the environment research on these is reviewed later following the definition of swb swb defined george conducted an extensive literature review and found that the concept of swb was measured as happiness psychological wellbeing positive affect and morale with these often used interchangeably further george concluded that researchers are largely measuring the same thing individuals subjective perceptions that life as a whole is good on the other hand the world health organization has equated wellbeing to positive mental health thus this article examines two dimensions of swb happiness and mental health happiness is defined as the elderly persons perception of how often shehe feels happy mental health is defined as the older persons level of psychological wellbeing as measured by an index of eight questions environmental conditions affecting swb in the 1960s and 1970s there was heightened interest among social scientists in examining how the environment affects social institutions organizations social groups and individuals this interest did not escape gerontologists as lawton noted in 1977 there has been a strong surge of interest in environment and aging during the past decade more recently the environment has received renewed interest among social gerontologists as they focus on health and swb factors that have been used to characterize the environment include climate and topography pollution and a communitys infrastructure and neighborhood characteristics when considering climate rehdanz and maddison found that temperature and precipitation were significantly related to happiness among persons in 67 countries using the world database of happiness kelly and colleagues examined the univariate relationship between swb and climate and found that droughtrelated worry had a significant association with swb it is also reasonable to suspect that other natural environmental characteristics are associated with swb older adults are more likely to be frail and vulnerable to natural disasters than younger adults and consequently may feel more concerned and stressed about future disasters leading to lower swb finally older adults who are typically less mobile may feel added stress and subsequently lower swb if living in areas where it is difficult to travel such as mountainous areas and conversely feel higher swb if living in easily traveled plains studies examining pollution include that of lim and colleagues who found a positive relationship between pollution and depression in their longitudinal study of 537 older adults similarly welsch examined the relationship between air pollution and life satisfaction among 80 residents from 10 european countries using annual data from 1990 to 1997 he found a negative effect of air pollution on life satisfaction after controlling for per capita income roh and colleagues examined the relationship between neighborhood characteristics and swb measured as mental health their sample included 420 korean american older adults living in the new york city metropolitan area after controlling for the effects of individual level variables they found that neighborhood environment had a direct effect on the older adults satisfaction and depressive symptoms other studies have reported significant effects when examining factors such as neighborhood wealth stability safety and social cohesion a review of the literature by mair diez and galea found that 37 of 45 studies found support for an association between neighborhood characteristics and depression or depressive symptoms with six of seven longitudinal studies finding significant effects further lou and gui found community programs and services to have a positive effect on swb and muramatsu yin and hedeker found similar results finally lawton emphasized the importance of transportation to the swb of elderly residents particularly as it provides a means of access to lifesupporting and lifeenriching facilities it is important to note that not all studies examining the relationship between the environment and swb have found significant effects as noted earlier kelly and colleagues surveyed a stratified random sample of 2639 adult australian respondents and found droughtrelated worries to affect swb however once controlling for individuallevel factors they found that the environmental effects became insignificant and concluded that most of the explanation for respondents swb was at the individual level social conditions affecting swb researchers have examined the relationship between an individuals social conditions and swb with a primary focus on informal relationships social supports social activities and social organizations informal relationships include those with a spouse family members and friends studies have found that married persons tend to report higher swb than widowswidowers and those living alone in addition pei and pillai found in their study of the chinese elderly that the number of children was positively related to swb measured in terms of happiness closely related to informal relationships are social supports with research showing that swb is higher among persons who believe they have social supports available if needed research examining swb and participation in social activities has also found positive effects other studies have focused more specifically on participation in social organizations and volunteering and found positive effects similarly research reviewed by huppert and brown nesse vinokur and smith suggests that providing care to others may have positive effects on swb personal characteristics affecting swb personal characteristics have received the most attention when attempting to explain swb these include health physical activity wealth psychological resources education gender and age perhaps the most important of these has been health george in her review of the literature on swb noted health is an important predictor of swb at all ages and the strongest predictor of swb during late life pinquart and sorensen came to similar conclusions in their metaanalysis of 286 studies closely related to health is physical activity such as walking in a park horse riding and boating it was found to positively affect swb among 263 respondents in the uk several studies have focused on personal wealth and swb measured as happiness or life satisfaction for example pei and pillai in their study of the chinese elderly found pensions to be positively related to swb on the other hand some studies suggest this relationship is less than clear somewhat related and specific to china is hukou status all chinese residents have a hs that is linked to a rural or urban location hs is typically obtained from ones village or city of birth but can be transferred to a different village to a city or from a city to a village with government approval urban hs has historically been associated with greater privileges and available resources than rural hs and thus may have positive effects on swb method data collection design and procedures data collected from the chinese health and retirement longitudinal survey pilot study were used to examine the relationship between the environment and swb of chinese rural elderly while controlling for social and personal characteristics the design and data collection procedures for the charls are described in detail by zhao strauss and sun and are only briefly summarized here the survey instruments and procedures were developed by a team of researchers from peking university the university of southern california and oxford university persons aged 45 and older were randomly selected from two chinese provinces between july and september 2008 multiple visits were made by the charls team to interview each respondent and a local official of the village or community where the respondent resided in order to obtain environmental characteristics although spouses of elderly respondents were included in the pilot study we limited our analysis to the person in each household who was initially randomly selected for the study in addition as noted earlier we limited our analysis to respondents living in rural areas the sampling procedure used probability proportionate to size techniques sampling occurred at four stages with the primary sampling units being rural villages and urban communities the number of households sampled from each unit ranged from 5 to 24 with one or two individuals in each household interviewed depending on marital status in the household the two provinces surveyed included gansu and zhejiang gansu is the poorest and one of the most rural provinces located in the north central to western part of the country zhejiang is a wealthy province with a strong and relatively large private sector located on the central east coast of china because analyses indicated no substantive differences in the effects of the factors considered on swb by province the rural village elderly from these two provinces were treated as a single group in the results the total number of respondents living in a village was 1267 representing 73 villages 37 in zhejiang and 36 in gansu however interviewers were instructed to administer the cognition section of the questionnaire where the swb items were located only to respondents who had little or no help with answering questions in the preceding health status section of the questionnaire accordingly the number of respondents eligible for our analysis dropped to 930 listwise deletion of cases due to missing values further reduced the sample for example four villages with a total of 39 respondents were missing one or more villagelevel characteristics another village was excluded because only one respondent remained final sample size was 850 respondents in 68 villages with a range of 421 and an average of 125 respondents in a village dependent and independent variables the dependent variable swb has been measured in many different ways the charls data allow for two different measures of swb happiness and an index of depressive symptoms each of these was constructed from the respondents report of how often an experience occurred in the last week for example happiness was measured with the statement in the last week i was happy rarely or none of the time some or a little of the time occasionally or a moderate amount of the time or most or all of the time to better reflect the distribution of responses and to assist with substantive interpretation happiness was recoded 1 for those who responded most or all of the time and 0 for those who responded with one of the remaining three categories the eight experiences used for the index of depressive symptoms were i was bothered by things that dont usually bother me i had trouble keeping my mind on what i was doing i felt depressed i felt everything i did was an effort i felt fearful my sleep was restless i felt lonely and i could not get going a factor analysis indicated that the eight depressive symptoms items measured a single factor hence the respondents responses to each of the depressive symptoms items were summed to create an index ranging from 8 indicating that he or she experienced all eight symptoms rarely or none of the time in the last week to 32 indicating that he or she experienced all eight symptoms most or all of the time in the last week the independent variables in our analysis included personal characteristics social conditions and environmental conditions of the seven personal characteristics considered four were coded as dummy variables to better reflect their distribution in the sample and to assist with substantive interpretation of their effects these included sex place of birth education and hs age was measured by a single question asking date of birth following previous studies of china and other developing countries the respondents wealth was measured by expenditures specifically the natural logarithm of his or her households expenditures per member in 2007 because six households in the sample reported 0 expenditures in 2007 a 1 was added to the variable before it was logged finally number of iadlfunctional limitations was measured by creating a count variable respondents were asked if they had difficulty with five instrumental activities of daily living including household chores preparing hot meals shopping for groceries managing money and taking medications they were also asked about difficulties with seven other functional activities running or jogging about 1 km getting up from a chair after sitting for a long period climbing several flights of stairs without resting stooping kneeling or crouching reaching or extending arms above shoulder level lifting or carrying a weight and picking up a small coin from a table the original response set for each of the items included no i dont have any difficulty yes i have difficulty and i cannot do it responses were recoded 0 for no i dont have any difficulty and 1 for yes i have difficulty or i cannot do it these responses were then summed to construct the variable with a range of 0 indicating no iadlfunctional limitations to 12 indicating difficulty performing all 12 activities four social conditions were included in the analysis all were coded as dummy variables marital status received help from others last year provided help to others last year and perception of future help environmental conditions encompassed both the villages natural habitat and its infrastructure the natural environment was measured by village located in the plains village had a natural disaster in past 5 years and number of rainy days in the village last year infrastructure was measured by type of roads coal used for heating andor cooking in the respondents household sewer system in village and a measure of village wealth the natural logarithm of village net income per capita in 2007 although village wealth varied by province it was nevertheless highly correlated with being in zhejiang province thus as we could not include both village wealth and province in the same model for substantive reasons we chose to include only village wealth however when province was substituted for the village wealth variable in sensitivity analyses the effects of the other variables in the model did not change the final infrastructure variable number of social amenitiesprogram for seniors in the village indicated how many of a variety of 12 opportunities were provided by the village including an activity center for the elderly an elderly association rooms for card games and ping pong and other entertainment facilities and assorted exercising facilities analytical strategy multilevel regression analyses with a random intercept were used to estimate the effects of individual social and environmental characteristics on swb multilevel logistic regression results are presented for the happiness measure of swb whereas multilevel linear regression results are presented for the depressive symptoms index more specifically for happiness stata 11s multilevel logistic regression procedure xtlogit was used for the depressive symptoms index stata 11s multilevel linear regression procedure xtreg was used these techniques account for the clustering of respondents within village tolerance checks revealed no problems with multicollinearity the linear regression results include unstandardized coefficient estimates we did not present standardized estimates because those associated with dichotomous variables are not interpretable and our analysis included a large number of dichotomous variables for both the logistic and linear regressions performed model 1 examines the effects of the villagers personal characteristics model 2 adds social conditions and model 3 adds environmental conditions the goodnessoffit of the different models was compared using deviance or likelihood ratio tests and akaikes information criterion the difference in deviance of two nested models had a χ 2 distribution with degrees of freedom equal to the additional number of predictors in the larger model aic is an alternative measure of fit that corrects for model complexity twotailed p values are reported to reflect significance of the independent variables a baseline or interceptonly model was examined to assess the extent of the dependent variables variation between villages and the advisability of using a multilevel modeling strategy according to the results of these preliminary analyses the intraclass correlation coefficient for the depressive symptoms index was 0170 indicating that about 17 of the variation in symptoms was associated with differences between villages further based on a likelihood ratio test the null hypothesis that this variation is zero is rejected the results for the happiness variable were similar results an examination of the descriptive statistics for our sample of older chinese villagers shows that 34 of the sample was happy most days and scored on average 14 out of a possible 32 on the depressive symptoms index the sample was fairly evenly split on sex and education 52 of the respondents were male and 56 had at least some formal education although only a slight majority of the sample lived in the same village in which they were born an overwhelming majority had rural hs the sample was relatively young and physically healthy averaging 59 years of age and 2 out of a possible 12 functionaliadl limitations overall the villagers economic situation tended to be relatively poor they lived in households with an average annual expenditure per member of only 6200 yuan in 2007 when considering the villagers social conditions they were quite varied about three fourths were married and nearly two thirds indicated that they had received financialother support from others in the last year thus it is not surprising that most believed that help would be available to them in the future if needed however fewer of the villagers reported providing financialother support to others in the last year the natural environment of the sample was also quite varied the number of rainy days experienced by villagers in the year before they were interviewed ranged from 8 to 160 and averaged 62 about 61 of the villagers lived in hilly or mountainous areas one fourth lived in an area that had experienced a recent natural disaster many of the respondents lived in villages with relatively poor infrastructure for example nearly one half lived in villages that had no major paved road and more than two thirds lived in villages that had no sewer system over one third used coal for heating or cooking in their household the average village provided only 3 out of the 12 social amenitiesprograms for elderly that were considered finally the typical village was relatively poor averaging only about 4771 yuan in net income per capita in 2007 the multilevel logistic regression analysis of happiness shows that when considering the personal characteristics four had significant effects place of birth hs household expenditures and number of iadlfunctional limitations somewhat surprising respondents living in their birth village were 38 less likely than those living elsewhere to feel happy most days as expected however respondents with rural hs which historically has been associated with fewer privileges were 50 less likely than those with urban status to feel happy most days also as expected poor health had a negative effect the odds of feeling happy most days were reduced 18 with each additional physical limitation experienced household wealth had the predicted positive effect adding the social conditions to the personal characteristics shows that hs and household wealth lost significance but with the addition of the social variables the fit of the model for happiness was significantly improved contrary to expectations the social variables marital status and receiving help from others in the last year had no significant effects on happiness believing help would be available in the future if needed was significant those that held this belief were 72 more likely to feel happy most days likewise respondents who provided help to others in the last year were 64 more likely to feel happy most days with the addition of the environmental variables little change occurred regarding the effects of the personal and social variables on happiness the fit of the model also remained essentially the same nevertheless two of the environmental variables had effects on happiness worth noting specifically as expected the odds of feeling happy most days were 45 lower in villages that had recently experienced a natural disaster and 45 higher in villages with a sewer system the multilevel linear regression analysis of the depressive symptoms index shows that when considering personal characteristics alone 24 of the variation in level of depression was explained the effects of household wealth and physical limitations on depressive symptoms were consistent with their effects on happiness as expected household wealth decreased depression and physical limitations increased it age was found to have a negative effect the addition of social conditions significantly improved the fit of the model and increased the variation in level of notes descriptive statistics for the independent variables are taken from the largest sample iadl instrumental activities of daily living ln natural logarithm six households reported 0 expenditures in 2007 thus for the ln calculation a value of 1 was added for all households sd standard deviation a percentage of older adults scoring 1 on the variable b exchange rate was roughly 65 yuan to one us dollar depression explained to 26 although the personal characteristic household wealth lost significance with the addition of social conditions the effects of physical limitations and age persisted further three of the four social conditions had significant effects and two of these had consistent effects across both the happiness and depression results respondents who provided help to others and those who believed that help would be available when they needed it tended to feel happy most days and be less depressed in contrast although being married had no effect on happiness it had the expected negative effect on depressive symptoms the effects of the personal and social variables did not change much with the addition of the environmental variables further three of the environmental variables had significant effects that were not found for happiness specifically depressive symptoms tended to increase with the number of rainy days and the use of coal in the household and tended to decrease with village wealth adding the environmental variables to the personal and social variables significantly improved the fit of the model and increased the variation in level of depression explained to 31 discussion a review of the literature showed that historically the majority of research on swb has focused on personal characteristics if a social scientist chose to consider only personal characteristics for explaining swb our analysis suggests a host of significant variables would be identified more specifically happiness increased as the respondents number of physical limitations decreased the respondent had urban hs the respondent was not living in the village where shehe was born and the respondent had relatively high household expenditures depressive symptoms decreased as physical limitations decreased and as income and age increased further 24 of the variation in depressive systems was attributed to personal characteristics alone social conditions have not received the same amount of attention among researchers nevertheless a great deal of research has focused on informal relationships social supports social activities and social organizations our examination of chinese village elderly supports the emphasis on social conditions even after controlling for personal characteristics respondents were more likely to feel happy and were less likely to have depressive symptoms if they believed someone was available to help them if needed and also if they had provided help to others in the past year those who were married also had fewer depressive symptoms and the variation explained for depressive symptoms when considering both social and personal characteristics increased the least amount of research has focused on the relationship between swb and environmental conditions such as the natural environment and community infrastructure conditions receiving the most attention have been residential characteristics such as neighborhood safety and residential stability the purpose of our study was to examine the proposition that environmental conditions affect an older persons swb after holding constant personal and social variables the proposition was supported five of the eight environmental variables were associated with at least one of the two dimensions of swb it is not surprising that those who have experienced a natural disaster in the past 5 years were less likely to be happy similarly rainy days were generally associated with more depressive feelings this supports the work of rehdanz and maddison who found climate to be significantly related to happiness with climate characteristics including temperature and precipitation no literature was identified that examined the relationship between village wealth and swb however the findings indicate that those in wealthier villages experienced fewer depressive symptoms perhaps the village had the resources to provide elderly villagers with what they needed to maintain good mental health and subsequently swb a second possible explanation is that the elderly in wealthier villages may have felt more confident that the village could help them if needed alternatively those in poorer villages may have been more concerned that their village could not adequately support their needs an examination of air pollution via the use of coal in the household found a significant positive association between its use and depressive symptoms one explanation is that breathing contaminants in the air resulted in negative physical reactions including feelings of depression this explanation is supported by the work of lim and colleagues who found pollutants in the air to be significantly associated with depressive symptoms among an elderly population in korea and provides support for the work of welsch who found a negative effect of air pollution on life satisfaction an additional explanation is that the use of coal may have served as a reflection of the older villagers general living environment those who had been unable to convert from coal to cleaner energy sources such as gas and electricity may have been living in what was considered a less desirable situation which contributed to feelings of depression also significant was a positive association between the existence of a village sewage system and feelings of happiness here again this may reflect the general living environment with those having a sewage system feeling better about their situation and subsequently feeling happier these explanations have been used by roh and colleagues in their examination of the relationship between mental health and neighborhood characteristics they concluded that individuals who were less satisfied with their overall neighborhood environment were more likely to have depressive symptoms those personal social and environmental variables having the most consistent associations with swb that is with both happiness and depressive symptoms included health perception that help is available when needed and giving help to others these associations support the previous research noted earlierpeople are happier and have fewer depressive symptoms when they are healthier believe they have help available when needed and provide help to others interestingly the data do not support previous research regarding several of the personal characteristics once controlling for social and environmental conditions men were not found to be happier and with fewer depressive symptoms than women although effects are in the directions expected likewise education and income had no effects on happiness or depressive symptoms once controlling for social and environmental factors these findings support those of lou and gui who concluded that income appears to be less important than factors such as social attitudes and health among the rural elderly a second possible explanation is that chinese rural elderly are not accustomed to having large sums of income or expenditures so having small expenditures do not reduce their swb in sum we proposed that environmental factors are important to the swb of chinese rural elderly the findings show that five of the eight environmental variables affected happiness or depressive symptoms after controlling for personal and social characteristics on the other hand the variation explained in depressive symptoms beyond personal and social factors was modest further the most consistent factors associated with swb were two social conditions help available if needed and provided help to others and a single personal characteristic health a major limitation of the study was the lack of longitudinal data any suggestions or references to causal effects can only be hypothetical a second limitation was the use of a village leader to obtain seven of the environmental conditions chinese village leaders were required to provide these types of information to government township offices unfortunately the specific methods used by village leaders to collect these data are unclear therefore it is unclear how accurate or unbiased these data are and so they must be considered cautiously a third limitation was the inability to control effectively for the amount of outmigration that occurred from villages to urban communities it is reasonable to suspect that villages with a large amount of outmigration may have been different in some ways from those that experienced little outmigration and these differences may have affected swb finally making the connection between environmental characteristics and swb is a relatively new one consequently there has been relatively little conceptual development or studies examining these relationships this can make the research process more challenging to the extent that important factors have yet to be identified andor are not measured during data collection implications for social policy there are several findings that standout with regard to social policy in china the use of coal in the home and the lack of a sewage system were found to be negatively associated with swb thus the establishment of village sewage systems and the reduction of coal use may increase swb health was also found to be important to the elderly villagers swb programs designed to help older villagers maintain or improve their health such as chinas new cooperative medical scheme which is intended to provide universal health coverage may result in improved swb of elders finally programs that assure elders that help is available if needed may create higher feelings of wellbeing as may programs that are designed to help elders help others funding collection of the data was supported by the us national institute on aging the china national natural science foundation and the world bank china

the purpose of this study was to examine the effects of environment on the subjective wellbeing swb of older chinese villagers after controlling for personal and social characteristics method data collected from the chinese health and retirement longitudinal survey pilot study were used to examine the relationship between a swb ie happiness and depressive symptoms of chinese rural elderly and b environmental characteristics controlling for personal and social characteristics a total of 850 older villagers from 2 chinese provinces were analyzed using multilevel regression models results five of the 8 environmental variables had significant effects on swb a natural disaster in the past 5 years rainy days and use of coal in the home were associated with lower swb whereas village wealth and sewer system were associated with higher swb personal and social characteristics of importance included health age place of birth perception that future help is available if needed and providing help to others discussion the proposition that the environment of older chinese villagers is associated with their swb was supported after accounting for personal and social characteristics swb may be improved by improving environments as well as by changes to personal and social conditions

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bmj global health the role of precarity as a contextual factor shaping patients healthcareseeking behaviour with reference to amr one key domain of demandside responses to amr is population behaviour change towards a more targeted use of antimicrobials such as antibiotics 5 with education and awareness campaigns being key policy instruments 5 6 the behaviour change approach in amr assumes that the main drivers of behaviour are patient misconceptions and a lack of knowledge 7 8 9 10 however the link between antibiotic use and peoples awareness of drug resistance is more complicated than is often assumed in amr policy documents 11 12 13 14 15 in addition an approach that foregrounds awareness and education also implicitly prioritises individual over contextual factors of healthcareseeking behavioursuch as precarity in a growing and interdisciplinary body of literature precarity has been receiving attention as a social determinant of health 16 17 linked especially to employment and working conditions 3 18 19 driven by stress and economic insecurity it is argued that workrelated precarity contributes to physical and mental illness and ultimately to premature mortality 1 3 17 outside of public health butler 20 describes precarity as the unfair distribution of social economic and political structures that could protect people from disease poverty starvation displacement and exposure to violence 20 examples of precarityinducing circumstances defined thus include oppressive gender norms and experiences of disempowerment 21 22 patients in such circumstances could find themselves pressured into detrimental patterns of selfmedication and delayed healthcare access consequently quick fix solutions such as selfmedication or antibiotic purchase without prescriptions can be interpreted as default strategies to cope with adversity 23 24 25 or perhaps even as performance enhancers 26 precarity could therefore challenge the underlying assumptions and ultimately the effectiveness of public awareness campaigns that form the backbone of global amr strategies 4 8 27 however and despite the growing body of work evidence evaluating contextual factors leading to precarity against the backdrop of amr is limited in response we investigated two research questions against the backdrop of amr what is the impact of precarity marginalisation and clinical presentation on healthcareseeking behaviour we subsequently explored whether these patterns of healthcareseeking behaviour are justified in light of patients clinical presentation do patients experiencing precarious livelihoods have clinically less advisable healthcareseeking behaviour we situated our research in rural thailand and lao peoples democratic republic considering that southeast asia is an epicentre for antibiotic resistance 31 32 33 34 rural settings are of particular relevance because their health systems face heightened infrastructural human resource and financial challenges and a high burden of communicable diseases 35 36 37 38 precarity in various forms has been highlighted in the region as well 39 40 whereby large parts of working populations remain excluded from social welfare schemes informal agricultural work alternates with offseason casual labour and gradual environmental degradation and the expanded presence of industry and international companies exacerbate precarious livelihoods 41 42 43 44 these circumstances have been associated with potentially detrimental forms of healthcareseeking behaviour such as unsupervised selfmedication 45 methods study sites and population compared with lao pdr thailand exhibited a more advanced economic and health system context evidenced by virtually zero extreme monetary poverty at us 190 day government healthcare expenditure of 15 of total government expenditure and an expected life expectancy at birth of 75 years thailand also had a more established amr strategy which was evident in a national action plan on amr together with a network of 74 surveillance sitesneither of which existed in lao pdr at the time of this research 34 our study population was the general adult population of rural chiang rai province thailand and salavan province lao pdr the specific study sites comprised five villages which were selected in consultation with local stakeholders guiding selection criteria were village size and structure remoteness villagelevel infrastructure ethnic composition and available health facilities key questions what do the new findings imply bmj global health the villages had an estimated population between 339 and 1462 residents representing 3331 villagers in total patient and public involvement this project was based on preceding qualitative research with local northern thai patients and the general public 47 48 which revealed the need for sociomedical research on patient experiences of illness in context bmj global health in this particular project members of the thai and lao public were involved through cognitive interviewing to inform the survey design and through local workshops to improve our understanding of local medicine uses and healthcareseeking behaviour survey design and implementation we implemented tworound individuallevel census surveys in the five purposively selected villages between november 2017 and may 2018 within the selected communities all households were enumerated using a satelliteaided sampling approach 49 and all adults were invited to participate our household definition was based on a shared kitchen and previous residence of at least 6 months in the survey village the household response rate in the first survey round was 979 and 991 in the second survey round a total of 2066 adult villagers were interviewed whereby 888 of the firstround participants could be reinterviewed we chose an oral consent procedure to not alienate and discriminate against illiterate or unregistered participants of the 3744 responses across the two survey rounds we did not receive consent for data sharing in four instances which constitutes the main difference between the data analysed here and the publicly available data set of our project 50 the recruitment and data collection processes were monitored in the field through the survey supervisors a research officer and digital survey monitoring tools 150 of all interview sessions were monitored by a survey supervisor based on the complete village census we identified as patients those respondents who had an acute illness and injury in the 2 months preceding the survey survey instrument our survey instrument was a 45min facetoface questionnaire administered on tablet computers using surveycto 51 the locally recruited field teams received 5 days of fulltime classroom and field training the questionnaire was piloted in rural chiang rai and salavan with 50 cognitive interviews supporting the questionnaire development and revision as well as the contextualisation of the survey data 52 the questionnaire was codeveloped with the local research team in english thai and lao administered in the local language and translation difficulties with ethnic minority languages were resolved by recruiting local translators within the survey villages the questionnaire modules included basic demographic and socioeconomic information social network structures antibioticrelated knowledge and attitudes and healthcareseeking behaviour during acute illnesses and accidentrelated injuries this study used in particular modules 1 and 4 whereby 608 of the participants volunteered information about at least one recent illness episode experienced by themselves or a child under their supervision within the 2 months preceding the survey yielding a total of 1887 illness episodes captured by the community census surveys the healthcareseeking data included selfreported symptoms and recalled diagnosis of the condition as well as detailed information about each step of the illness episode from the moment a discomfort was detected until the condition was resolved or the symptoms otherwise disappeared for every step the type of treatment was recorded together with the type of received medication as bmj global health recalled by respondent and supplementary information about the process this information formed the basis for our analysis of healthcareseeking behaviour on the one hand these data documented revealed healthcareseeking behaviour during the course of an illness episode on the other hand the rich information on selfdescribed symptoms and recalled diagnoses permitted a broad categorisation of clinical presentation andtogether with information on disease severity duration and recurrence alongside the revealed healthcareseeking behaviour of the patientenabled a basic clinical evaluation by our medically qualified research team member considering the importance of antibiotics for our research question we focused on cases where we could establish antibiotic use with a high degree of confidence we manually coded freetext responses of reported medicines and treatments based on pharmaceuticals in local circulation and triangulated ambiguous responses based on respondents reports as to how they colloquially refer to antibiotics in module 3 of the survey questionnaire of all 4611 recorded medicine use episodes 135 involved an antibiotic with a high degree of confidence determinants of healthcareseeking behaviour the key independent variables comprise clinical determinants and composite indexes of precarity marginalisation and situational facilitation we explain these variables below and provide variable summaries in online supplemental table 2 clinical determinants the impact of each clinical determinants their duration severity and frequency over the past 6 months was evaluated on healthcareseeking behaviour the nine clinical determinants were based on respondents reported symptoms and recalled diagnosis during medical encounters and included presence of an infection fever respiratory tract symptoms bmj global health common cold digestive symptoms urogynaecological symptoms neurological symptoms traumatism and other symptoms for full disclosure the complete list of symptoms and their coding into clinical presentation is provided in online supplemental table 1 precarity the health impact of precarity is often framed in similar terms as problematic employment conditions poverty marginalisation or stress 1 3 17 53 54 based on our definition however we argue that precarity is a phenomenon with distinct behavioural implications precarity differs from poverty and marginalisation because it can be experienced regardless of wealth level 55 56 57 58 59 and it may have different impacts on healthcareseeking behaviour than the barriers created by marginalisation in relation to stress bmj global health it is important to note that the behavioural influence of precarity only partly overlaps with stress experienced in problematic employment or under conditions of poverty 61 62 more broadly the behavioural impact of precarity may be better described as a loss of control and flexibility over healthrelated decisions which extends beyond employment and also involves for instance communitylevel social support 21 25 63 in order to represent the distinct circumstances under which precarity could militate against healthcareseeking behaviour we considered six indicators along occupational social and logistical dimensions the occupational dimension clearly cannot be ignored in a study of precarity and evaluated whether peoples income was erratic and whether the structure of the work restricted peoples flexibility when responding to illnesses 25 30 the social dimension of precarity was evaluated through the absence of other adults in the households and the lack of a healthrelated social network lastly logistical indicators comprised the absence of solutions to flexibly address health problems namely no household mobile phone and no motor transport option within the household marginalisation marginalisation was evaluated in terms of education wealth and ethnicity 60 67 the respondent had not received any formal education belonged to the lowest household asset quintile among the rural population in their province and did not belong to the majority thailao loum ethnic groups in their field sites although spatial marginalisation would also be an important dimension to consider we chose not to include it into the index considering that distances to health facilities were similar and clustered at the village level the respondents distance to the nearest formal health facility was thus included as a separate control variable 38 67 alongside other controls including the sex of the respondent and whether the reported illness episode was experienced by the respondent themselves or a child under their supervision 21 67 facilitation in addition to the indicators above situations and practical means may arise situationallythat is revealed during the course of an illnesswhich enable patients to respond to crisis and escape the structural conditions of precarity and marginalisation 21 68 our survey detected such situational facilitators in the form of tools and support sources that become visible during an illness episode support received from other people during the illness episode healthrelated phone use during the illness and the use of a car or taxi during the illness these situational facilitators could help mitigate structural conditions of precarity as a result of which we analyse them separately and in interaction with our precarity index behavioural outcomes outcome variables considered in this study comprised different forms of access to healthcare and antibiotic use to represent healthcareseeking behaviour reflecting the pluralistic health systems of southeast asia 69 healthcare access included formal healthcare providers and informal sources of care antibiotic use captured whether any antibiotic was received at any point during the illness episode we complemented the analysis of healthcareseeking behaviour with an evaluation of clinically inadvisable antibiotic use and healthcare access these evaluations used the comprehensive survey data surrounding patient clinical presentation which enabled us to identify cases in which healthcare access and antibiotic use appeared clinically advisable but was not pursued given the nature of the selfreported data we did not flag behaviours as inadvisable where the clinical indication was unclear the evaluation was carried out by a medically qualified coauthor with research experience in the field sites in correspondence with the local research teams specifically the first clinical indicator evaluated the rationale for seeking no formal treatment despite a clear indication for care and vice versa the second clinical indicator evaluated the rationale for antibiotic use whereby our focus was on identifying situations with a clear indication to not use an antibiotic namely scrub typhus leptospirosis cholera and malaria we also flagged as inadvisable where patients used antibiotics despite the absence of a clear indication for an antibiotic and when patients accessed antibiotics stored at home from friends traditional healers and other unregulated sources of healthcare note that these evaluations are strictly from a clinical perspective and do not entail judging villagers behaviour as unreasonableour argument rather is that people have good reasons and structural determinants for behaving the way they do and that this behaviour might analytical strategy the analysis took place on the illness level whereby we analysed the pooled sample of all completed illness episodes across the two survey rounds we proceeded in four steps ► step 1 descriptive analysis of the healthcareseeking behaviour precarity and marginalisation among the study population ► step 2 contribution of the clinical determinants on healthcareseeking behaviour ► step 3 contribution of precarity and marginalisation on healthcareseeking behaviour ► step 4 the role of precarity as contributor to clinically inadvisable healthcare access and antibiotic use step 1 was based on descriptive statistical analysis to describe and contrast the survey results across the two field sites we compared the samples on the illness level using χ 2 tests for binary and wilcoxon ranksum tests for nonnormally distributed variables to test for differences across sites 70 71 we conducted univariate and multivariate regression analyses for steps 24 for step 2 we focused on the contribution of the clinical presentation to the healthcareseeking outcomes for each outcome we separately estimated the contribution of the eight clinical presentations controlling for symptom duration severity and illness frequency as well as other confounding variables step 3 assessed the relative contribution of precarity facilitation and marginalisation to the outcomes of healthcare access and antibiotic use in step 4 we analysed whether precarity in isolation or moderated by situational facilitators contributes to healthcareseeking behaviour that appears clinically less desirable again controlling for clinical determinants and other control variables for all analyses in steps 24 we first conducted univariate analyses followed by multivariate analyses adjusted by confounders we initially chose multilevel logistic regression models with a site random effect 72 however in several instances the maximum likelihood estimation of the multilevel models failed to converge and to produce se estimates 73 as a result of which we limited the presentation of the main results to singlelevel models with a site dummy we also conducted the multivariate analysis with an interaction effect between precarity index and facilitation index to consider the potential moderating effect of the situational facilitators we compared model fitness between the interacting and noninteracting models based on the significance levels of the parameter estimate for the interaction term and the akaike information criterion reporting interacting models where the interaction term was statistically significant and aic was smaller than the noninteracted model our robustness checks included comparisons between the singlelevel and multilevel models and estimations using nested models and including patients symptoms as additional determinants of health behaviour the robustness checks did not substantively influence the main results nor the conclusions of this paper we used the statistical software stata v15 throughout the results we indicated significance levels below 01 005 and 001 with and respectively and considered the 5 level as statistically significant results step 1 patterns of illness precarity and marginalisation across the 1421 illness episodes in the sample the most commonly reported illness was the presence of any infection with 646 of all cases while the term fever was cited in 257 of all cases respiratory tract symptoms were the second most reported complaint of which common cold represented 56 median duration of symptoms was 5 days with a moderate severity 792 of illnesses involved access to healthcare and antibiotic intake was declared in 287 of all cases the results of the descriptive statistical comparison of the two field sites are presented in table 1 the comparison indicated that illness episodes were statistically significantly more likely to involve healthcare access and antibiotic use in salavan where healthcareseeking behaviour was also more commonly misaligned with patients clinical presentation the most common forms of clinical presentation in both sites were the presence of an infection followed by respiratory tract symptoms and the declaration of fever furthermore precarity and marginalisation were more concentrated among the patients in chiang rai as indicated by the relatively higher average precarity scores and marginalisation scores while not necessarily representative of the overall provincial population 15 these statistics reflect the living conditions of the specific field site communities step 2 clinical determinants and healthcareseeking behaviour in the multivariate analysis of clinical determinants the common cold was the only clinical presentation significantly associated with healthcare access of all common cold episodes adjusted or bmj global health 163 however antibiotic intake for common cold was not significantly greater than other clinical presentations whereas the presence of an infection was significantly associated with antibiotic intake as was respiratory tract infection the presence of digestive symptoms was significantly associated with antibiotic withholding the association between clinical determinants and outcomes is illustrated in figure 1 with detailed results provided in online supplemental tables 3 and 4 step 3 marginalisation and precarity as determinants of healthcareseeking behaviour table 2 presents the results of the regression analysis controlling in all cases for a reduced set of clinical determinants and considering the potential moderating role of situational facilitators in the interaction models the interaction terms were not statistically significant for healthcare access and antibiotic use instead facilitation presented a strong and statistically significant positive association with healthcare access and antibiotic use independently of precarity the marginalisation index was associated with antibiotic withholding at the 1 level whereas the precarity index was not statistically significantly associated with healthcare access or antibiotic use among other control variables illnesses involving children those with a higher severity rating and illnesses with a duration between 7 and 30 days were significantly more likely to involve healthcare access and antibiotic use step 4 precarity and clinically inadvisable healthcareseeking behaviour this final step assessed the factors contributing to clinically advisable healthcareseeking behaviour the interaction term was statistically significant at the fivepercent level for the antibiotic use model no statistically significant association existed between marginalisation and the dependent variables whereas a significant association existed between precarity and inadvisableantibiotic through the interaction term the statistically significant interaction term suggests that the association between precarity and inadvisable antibiotic use increased with higher levels of facilitation facilitation was also associated with more advisable patterns of healthcare access figure 2 summarises the key findings from this analysis and illustrates that in the absence of situational facilitators higher degrees of precarity were predicted to link to more appropriate antibiotic access patterns simultaneously patients exhibiting facilitation through mobile phones motor transport or human support were predicted to be at higher risk of clinically inadvisable antibiotic use when being in otherwise precarious circumstances for the highest levels of the precarity the predicted difference between patients with and without facilitation in inadvisable antibiotic use was 449 points in contrast patients with a precarity index of zero were 103 points less likely to misuse antibiotic if they experienced the full range of facilitators captured in our survey discussion our research focused on the clinical and socioeconomic determinants of healthcareseeking behaviour we drew on a uniquely detailed health behaviour census survey from five villages across northern thailand and southern lao pdr as part of a broader healthcareseeking behaviour research project 35 data from 2066 villagers across five communities included 1421 completed episodes of acute illnesses and injuries over the period of 6 months our fourstep analysis offered the following interpretations 1 patients commonly exhibited respiratory tract symptoms presence of an infection and fever precarious livelihoods were common in both sites whereas indication of marginalisation was less widespread and more concentrated in chiang rai 2 the common cold was positively associated with healthcare access whereas presence of an infection and respiratory tract symptoms were positively associated with antibiotic use the surprisingly minor link between clinical presentation and antibiotic use pointed towards the importance of other social determinants of healthcareseeking behaviour such as precarity and marginalisation 3 we analysed the contribution of marginalisation and precarity to healthcareseeking behaviour and found that situational facilitators were associated positively with healthcare access and antibiotic use but no moderating effect of facilitation on precarity materialised marginalisation was negatively associated with antibiotic use however overall rates of healthcare access and antibiotic use could mask clinical justifications for the observed behaviour 4 an evaluation of clinically inadvisable healthcare access and antibiotic use showed that facilitation independently linked to more appropriate healthcare access in addition controlling for other determinants of health behaviour patients in otherwise precarious circumstances were significantly more likely to misuse antibiotics in the presence of situational facilitators to the best of our knowledge this is the first study that examined quantitatively the relationship between precarity and amrrelated healthcareseeking behaviour a key strength of our study is the original microlevel behavioural data set which enabled us to disentangle key limitations in this study pertain to the nature of the study sample which reflects living conditions in selected rural communities of chiang rai and lao pdr rather than broader rural populations of lowincome and middleincome countries more extensive and systematic health behaviour surveys based on our indepth survey instrument would be necessary to understand the broader variability of common healthcareseeking behaviours and their socioeconomic drivers in addition observational survey data on healthcareseeking behaviour are subject to recall biases that could amplify the perspectives of relatively more privileged groups 75 however considering complex behaviours in pluralistic health systems 76 77 78 communitylevel studies of this kind are essential to complement amr research in clinical settings lastly although our indicators of patients precarity and marginalisation were literature based more extensive ethnographic research is necessary to identify their locally specific expressions and to map out their links to healthcareseeking behaviour and antimicrobial use conclusions the increasing health policy interest in the 2030 sustainable development agenda 79 and its relationship to global health priority issues such as amr 6 underlines the importance of the social determinants of health we therefore studied precarity and marginalisation alongside clinical indication as determinants of healthcare access and antibiotic use using finegrained health behaviour survey data from five rural communities our study has two main implications on the one hand global health interventions must move beyond patientcentric and diseasecentric approaches acknowledging and responding to contextual factors that shape how people cope with illness interventions based on this logic could for instance aim at improving work environments supporting social support structures and fostering community building on the other hand our study emphasises that localised forms of hardship could influence the effectiveness of clinical interventions to tackle amran issue that is often overlooked in global health practice 80 81 82 public health research and policy therefore require urgent collaboration with lowand middleincome country researchers and social scientists to appreciate the contextual drivers of global health challenges such as amr marco j haenssgen orcid org 0000000258497131 nutcha charoenboon orcid org 0000000269753524 thomas althaus orcid org 0000000269973877 competing interests none declared patient consent for publication not required ethics approval

background the social determinants of health are a decisive yet persistently understudied area for tackling global health challenges like antimicrobial resistance amr precarity is one determinant whose importance is increasingly recognised which we define here as a form of pernicious selfdependence that undermines individuals control over their own lives and limits their ability to flexibly respond to crises we aimed to assess the relationship between precarity other forms of deprivation and healthcareseeking behaviour by asking what is the impact of precarity marginalisation and clinical presentation on healthcareseeking behaviour and do patients experiencing precarious livelihoods have clinically less advisable healthcareseeking behaviour methods we used healthcareseeking behaviour census survey data from rural thailand and laos wherein five rural communities were surveyed two times over a period of 3 months 2month recall period using descriptive statistical and multivariate logistic regression analysis on the illness level we studied precarity alongside clinical presentation marginalisation and facilitating solutions during an illness eg healthrelated phone use as determinants of healthcareseeking behaviour in the form of healthcare access and antibiotic usethe data included 1421 illness episodes from 2066 villagers patients in precarious circumstances were up to 449 percentage points more likely to misuse antibiotics in the presence of situational facilitators predicted antibiotic misuse 62 95 ci 09 to 114 vs 511 95 ci 166 to 855 for precarious circumstances withwithout facilitation marginalisation was linked to lower antibiotic use but this did not translate into clinically more advisable behaviour clinical presentation played only a minor role in determining healthcare access and antibiotic use conclusions this study underlines the importance of context and local livelihoods in tackling drug resistance while supporting the growing emphasis on amrsensitive development policy we call for future research to study systematically the healthcareseeking behaviour impact of precarious livelihoods social policy and community development initiatives trial registration number nct03241316global health research and practice have become increasingly sensitive to nonclinical factors that influence health outcomes this recognition has been driven by the concepts of the social determinants of health and diseases of poverty 13 which draw attention to the role of the local context in the response to global health priorities antimicrobial resistance amr is one of these priorities feared to become one of the leading global causes of death by 2050 4 and we here studywhat is already known ► precarity is an important social determinant of health with demonstrated physical and mental health consequences which affects people in lowincome middleincome and highincome contexts ► the response to antimicrobial resistance amr in human use focuses heavily on individual behaviour change neglecting the critical role that contextual determinants play in behaviours of individuals ► the behavioural impact of precarious livelihoods is hypothesised to contribute to clinically inadvisable antibiotic use and therefore potentially to amr what are the new findings ► we used an original microlevel behavioural data set from thailand and lao peoples democratic republic which enabled us to disentangle clinical presentation marginalisation and precarity as separate drivers of healthcareseeking behaviour ► the link between clinical presentation and antibiotic use was surprisingly weak instead patients in precarious circumstances were significantly more likely to misuse antibiotics in the presence of situational facilitators eg mobile phones and social support activated during an illness ► this is the first study that examined quantitatively the relationship between precarity and amrrelated healthcareseeking behaviour

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introduction an estimated 40 of the population of bangladesh lives in extreme poverty defined as living on less than 125day with an estimated population of 1585 million the country also has one of the highest population densities worldwide the traditional culture within the population is of a patriarchal social system whereby brides move to live with the grooms family upon marriage and dowry payments are a necessary adjunct to any marriage arrangement among poor households parents may incur longterm financial debts in order to make a dowry payment patrilocal residence after marriage also means that daughters move away from their natal home upon marriage and the children reside with the husbands family in contrast sons bring the benefit of a dowry payment to the household upon marriage the acquisition of a daughterinlaw and subsequent grandchildren these factors in turn bring about enhanced social status to the husbands extended family a womans status in her marital home however is often low throughout the 1980s and 1990s a substantial body of evidence demonstrated associations between the social and cultural preference for sons with unequal health practices and health outcomes for boys and girls in bangladesh such behaviours included feeding male household members before women and girls which in turn meant that boys might receive better quality and quantity of food than girls greater likelihood of seeking medical attention and purchasing treatments for sons than daughters and among poor households better growth and nutritional status of preschool boys compared to girls ultimately these practices led to an excess mortality of girls compared to boys throughout the first five years of life in bangladesh over the last 20 years evidence from national surveys in bangladesh points to a sea change in the disparities in health between males and females there have been dramatic reductions in maternal mortality such that bangladesh is close to meeting the millennium development goal 5 as well as notable j u s t a c c e p t e d progress towards the reduction in mortality rates of children under 5 years old in line with the millennium development goal 4 most striking however has been the reversal of the excess mortality of girls relative to boys since the 1990s in all populations girls are more likely to survive the first 5 years of life than boys this stems from an innate vulnerability of males leading to higher mortality but is offset by the higher number of male infants conceived and born compared to females such that by adulthood the ratio of males to females is approximately equal the expected male female mortality ratio for under5s has been estimated to be 117 per 1000 that is 117 male deaths for every 100 female deaths due to expected excess mortality in males in all populations in bangladesh under5 mortality in 199394 was equal in males and females which equates to significantly higher than expected mortality of females by 2011 as well as a significant reduction in overall mortality the gender imbalance had reversed and male mortality was significantly higher than females in line with expected ratios figure 1 shows that child mortality has also reduced from a ratio of 75 per 1000 in 19934 to 87 per 1000 in 2011 this has not yet reached the expected mortality ratio in 15 year olds of 117 male deaths to 100 female deaths per 1000 but the excess mortality of female children has been greatly reduced similarly the gap in nutritional status of male and female children has narrowed greatly the most recent bangladesh demographic and health survey reported that among under 5 year olds in bangladesh stunting was only slightly higher in girls than boys wasting was slightly higher in boys than girls and underweight was higher in girls than boys this demonstrates that although undernutrition is common the prevalence is similar in male and female children the rapid progress towards millennium development goals and the near reversal of the mortality and nutritional status differentials of male and female children are the aim of this study was to examine the health status of female children and adolescents in bangladesh in a particularly impoverished region of bangladesh the specific aims were to compare the nutritional status of school children during late childhood and early adolescence since this age group has been less well studied in low and middle income countries and to examine the association between poverty and gender inequalities in health by comparing males and females among the poorest households compared to less poor households a further aim was to look at the composition of siblings within households to examine whether reproductive decisions were influenced by the gender of existing children j u s t a c c e p t e d background and methods as part of a baseline survey data were collected from meherpur district khulna division south west bangladesh via schools within the save the children school health programme the agency conducts routine surveys of the health and anthropometric status of school age children to identify health and nutrition interventions for school health programmes the school survey covered all 18 unions of meherpur district including two schools in each union a target sample of twentyfive children from each school was adopted using stratified random sampling by age and sex child ages were extracted from school registers exact dates of birth were not commonly held on file therefore child age was recorded to the midpoint of the nearest whole year with the age of the sample ranging from 65 to 135 years weight and height were measured using standardised techniques in the field the height of each child was measured with the use of a portable stadiometer to a precision of 01 cm weight was measured with the use of a digital electronic scale with the childadolescent wearing light clothing and no shoes to a precision of 01 kg z scores of heightforage and bmiforage were calculated using the who growth references and the anthropometric standards software weightforage zscores were not estimated as these can only be calculated for children less than 10 years of age statistical analyses were carried out using ibm spss version 22 inc participants with zscores exceeding the following values were excluded from the analysis heightforage of 60 sd or 60 sd and bmiforage of 50 sd or 50 sd children with a heightforage or bmiforage zscore of 20 were classified as stunted or thin respectively heightforage and bmiforage zscores below 30 were classified as severely stunted and severely thin an intervieweradministered questionnaire was completed for all children including information on household structure the number of older and younger siblings and the possession of household items a possession index was calculated based upon responses to the questionnaire about household ownership of electricity a motorcycle radio or television this followed a previously validated possession score except that the present study asked about the possession of a motorcycle whereas mohsena et al included the possession of a bicycle this possession score has been shown to be a better predictor of undernutrition among under 5 year old children in bangladesh than the poverty index each item was given a score of one such that the total possession score ranged from 04 possession score values of 3 and 4 were merged as only 13 individuals had a possession score of 4 j u s t a c c e p t e d index results 900 children participated in the school health survey of these 471 had electricity in the house 219 reported ownership of a radio 260 owned a television and 33 owned a motorcycle table 1 summarises the ownership of household items among male and female school children children reported their parents occupation almost all mothers were reported to stay in the home the most common occupations of fathers were as farmers daily labourers or working abroad with other listed occupations being skilled labourer shop owner rickshaw puller office worker and teacher undernutrition was a significant health problem in the school population of meherpur but this was the same for both males and females table 1 shows the mean heightforage and bmiforage of male and female school children by age categories there was a slight worsening of nutritional status with increasing age of individuals in the study relative to the who growth references there were no significant differences in heightforage zscores of male and female school children in any age category for bmiforage zscores there were no significant differences in most age categories other than females had lower bmiforage than males at age 75 years and males had a lower bmiforage than females at age 12 years however there were no consistent differences between males and females across ages and the overall nutritional status of males and females for all ages pooled was not significant for either heightforage or bmiforage table 1 also shows that the prevalence of stunting was 368 in males and 346 in females and the prevalence of thinness was 443 in males and 406 in females the prevalence of severe stunting and severe thinness was also the same in males and females j u s t a c c e p t e d table 2 shows a breakdown of household ownership of electricity television radio and motorcycle the proportion of children who owned individual items was the same for males and females there was no significant association with the possession of an individual household item and the heightforage or bmiofage of children together or boys and girls separately the possession score was therefore calculated as a cumulative measure to provide an indicator of relative socioeconomic status within the sample table 2 also shows the total number of siblings and the number of older and younger siblings for male and female children in the study the total number of siblings was the same for boys and girls however girls had on average significantly more younger siblings than boys whereas boys had significantly more older siblings than girls the prevalence of undernutrition in male and female children was analysed across the four possession score groups in order to examine whether gender differences in nutritional status were apparent in the poorest households in the study table 3 shows no significant difference between the mean heightforage zscores or bmiforage zscore according to possession score or sex analysis of variance was performed to assess the effects of relative poverty on the number of siblings in the household the total number of siblings was significantly different according to possession score whereby households with no possessions had significantly more siblings than those in possession groups one and three finally the mean number of older and younger siblings was examined according to possession score and sex to determine whether sibling composition was influenced by relative poverty and the sex of the index child figure 3 shows that the same pattern was observed in all possession score categories whereby gender was associated with the number of older siblings but the possession score was not associated with the number of older siblings f277 p 001 main effects for sex of the index child j u s t a c c e p t e d p 0 005 possession score pns figure 4 shows that both gender and possession score were significantly associated with the mean number of younger siblings such that girls and poorer households had a significantly higher mean number of younger siblings than boys discussion the survey of school pupils in meherpur provides evidence of equality of nutritional status among male and female children and adolescents even among the poorest households however the prevalence of undernutrition was very high 353 of the children and adolescents were stunted and 424 were thin the effect of relative poverty on gender inequalities in undernutrition was examined by partitioning the sample according to the household possession score a measure of household socioeconomic status that has been previously validated as a predictor of child undernutrition in bangladesh the results showed no gender inequalities in health across the different possession score groups and a similar level of nutritional status across all possession score groups this might be expected given that the population as a whole had been identified as being disadvantaged as such this sample reflected a relatively low socioeconomic group with 44 of households having no possessions and only 12 having three or more possessions while there is no evidence of gender inequalities in nutritional status in this sample there is a suggestion of a desire to have a male child as evidenced from the pattern of older and younger siblings within a household the fact that boys had on average a greater number of older siblings suggests that households continued to have children until a son was born the fact that daughters had a greater number of younger siblings is a corollary of the above in that households had further offspring in order to conceive a son this is a relatively small effect given that the average number of total siblings was 154 and ranged from 171 siblings in the lowest possession score group to 134 siblings in the highest group the findings of the analysis of siblings suggests that wealthier households desire a smaller number of j u s t a c c e p t e d offspring but the decisions on the total number of offspring may be influenced over and above this by the presence of a son or daughter interestingly although the poorest households had on average more children than the households with a higher possession score the nutritional status of children across each of the possession scores was not significantly different in this sample certain limitations of the study must be recognised in that the sample comprised children who were attending school who may not be representative of the total population of children in the area school attendance up to the age of 14 years is reasonably high in bangladesh both for boys and girls nationally 77 of children aged 610 years are estimated to be attending primary school with the highest proportion of outofschool children being among 6 year olds attendance of girls in particular has been greatly increased due to the secondary school stipend nationally school attendance rates for secondary education are estimated at 802 for females and 722 for males from a national perspective the successful reductions in gender inequalities in nutritional status among children and adolescents in bangladesh have been achieved through a number of communitybased low cost health interventions for example bangladesh made a commitment to universal vaccination coverage with the extended programme for immunisation in 1985 and within 10 years the gender differential in immunisation rates had disappeared this success came about through a national network of community health workers alongside outreach sites and satellite clinics with knowledge of individual households even in the most disadvantaged areas analysis of national immunisation data shows that coverage rates greatly improved in the lowest socioeconomic status quintiles compared to the highest ses quintile from 49 in 1994 to 80 covered in 2005 another key policy to have made an impact on the status of women and girls is the female education subsidy the female secondary stipend programme was introduced in 1994 as a conditional cash transfer scheme that provided a stipend to subsidise the cost of secondary school for girls and paid for tuition fees in rural areas to qualify for the stipend girls had to attend j u s t a c c e p t e d school for at least 75 of the school year obtain at least 45 in the final examinations and remain unmarried until completion of secondary education the scheme undoubtedly contributes to the increased enrolment in secondary schools among girls but it has been argued that steps may need to be taken to increase male enrolment in secondary school future challenges for the health of adolescent girls and women bangladesh has had very successful family planning programmes evidenced by marked declines in fertility total fertility rates declined from 63 in the early 1970s to 25 in 2010 the practice of early marriage and childbearing for adolescent girls however remains a challenge for bangladesh because of the detrimental effects on maternal and infant mortality as well as the social and economic disadvantages caused by lower educational attainment associated with early marriage while the median age of marriage in bangladesh has been raised from 142 years in 19967 to 158 years in 2011 a large proportion of marriages still take place during adolescence in 2001 375 of females aged 1519 years were married by 2011 this declined to 325 this represents a high proportion of females who are married during adolescence within the country there is considerable geographical variation in the rates of teenage marriage with an eastwest trend teenage marriage rates are highest in the western districts of bangladesh and lowest in the northeast districts in particular meherpur district the area of the school health survey above had the highest rate of teenage marriage in the country in 2011 537 of marriages in meherpur were of girls aged 1519 years early marriage has social and economic influences on later life prospects girls are more likely to leave education as soon as they are married and lower educational attainment leads to disadvantages in health female autonomy and economic status in addition early age at first birth is associated with significant adverse health effects on both the mother and infant a global study across 23 low and j u s t a c c e p t e d middle income countries found higher risks of low birthweight and preterm birth among adolescents aged 16 17 18 19 adjusted or 116respectively and ≤15 years compared to women aged 2024 years furthermore female educational attainment has been associated with gender disparities in child mortality an analysis of demographic and health survey data from south asian countries showed that male female child mortality ratios varied significantly according to the educational attainment of the mother among under5 year olds the m f mortality rate varied from 088 among women with no education to 110 for women with primary education and 113 for women with secondary education compared to the expected m f mortality ratio of 117 the extent of the bias was even greater among 15 year olds such that the m f mortality of children born to women with no education was 058 representing a significant excess of female deaths the factors leading to early age at marriage and first birth are important areas for further research currently there is weak legal governance surrounding the minimum age at marriage dowry payments and the rights of children and these may hinder progress in making improvements in women and child health female autonomy and empowerment womens empowerment has been flagged as an integral component of international development programmes particularly in order to reduce gender inequities womens empowerment in the household has been associated with child nutritional status across south asia in general terms but the nature of the relationship is variable bangladesh has been at the forefront of development programmes that target the extreme poor and also target women this is considered to be one of the key drivers of the success in reducing health inequalities one such development initiative targeting women has been the microcredit schemes such j u s t a c c e p t e d schemes are targeted at poor families giving them access to small collateralfree loans usually initiated and held by the female head of household and thereby encourage female empowerment various health benefits have been suggested to have resulted from microcredit schemes such as improvements in child mortality and womens health status through the indirect processes of social and economic empowerment in 2010 the number of women members of microfinance institutions reached an estimated 33 million however there are many different elements to female empowerment including social support educational attainment decisionmaking within the household as well as financial autonomy more research is therefore needed on the subdomains of empowerment and which components are the greatest determinants of child health outcomes although the proportion of women in employment in bangladesh has been low historically there have been considerable increases in the number of women in the workforce particularly in urban areas the female labour force has increased from 8 of women in 198384 to 33 in 2010 some of the largest employers of women are in the garment industry and construction work where conditions of work are typically very poor while greater employment and participation in the workforce confers greater female autonomy and power women still experience discrimination violence and unequal pay in the workforce it is estimated that 87 of women who are working are employed in the informal sector and these are frequently low status low pay jobs sought by the poorest women the construction industry is an area where participation of women in informal employment has increased and these women are exposed in particular to hazardous work environments as well as harassment and negative social perceptions of their roles early betrothal and age at marriage also impact upon female autonomy because marriage arrangements often lead to a withdrawal from school or further study as well as relocating to the home of the groom the early period of being a daughterinlaw is typically associated with low autonomy and a high level of dependence on other members of the household members j u s t a c c e p t e d conclusion this paper has examined gender differences in nutritional status and the number of siblings in the family according to relative poverty in meherpur a district of bangladesh with high levels of disadvantage and with one of the highest rates of teenage marriage in the country the findings show that boys and girls in late childhood and early adolescence experienced the same prevalence of stunting and thinness with no apparent gender bias in nutritional status across any of the socioeconomic groups there is some evidence that reproductive behaviours in families are influenced by the presence or absence of a son this leads to small but statistically significant differences in the mean number of older and younger siblings but is not associated with significant differences in the nutritional status of boys and girls the study in meherpur district is in line with national data demonstrating significant improvements in the health of girls and women bangladesh has made remarkable progress towards the millennium goals 4 and 5 as well as achieving gender parity in immunisation rates nationally and closing the gap in male female child mortality ratios bangladesh has made some of the greatest progress compared to other countries in the region among the south asian association for regional cooperation countries bangladesh has the highest annual rate of reduction of the under 5 mortality rate for the size of population a key to the success of health improvements and reductions in health inequalities is the strong community based health programme the use of community health workers to deliver low cost interventions and the early and rapid adoption of health innovations these improvements have taken place against a continuing backdrop of poverty however there are still health challenges for women and girls in bangladesh with the need to identify the determinants of early marriage and childbearing improve employment and working conditions of women and identify the important components of female autonomy in order to improve the health of future generations legends to figures figure 1 bangladesh national child mortality rates per 1000 for males and females in 1993 and 2011

background bangladesh has made dramatic improvements in the health of girls and women in the last 20 years this paper examines whether gender inequalities in health are evident among older children and adolescents among extremely poor households and identifies future health challenges for improving the health of girls and women method gender inequalities in health were examined using data from a school health survey of school children and adolescents n900 65135 years anthropometric status household possessions and number of siblings were measured undernutrition was assessed as stunting heightforage zscore and thinness bmiforage zscore results the prevalence of undernutrition was high 353 stunting 424 thinness but there were no significant differences according to gender or socioeconomic indicators via possession score girls had more younger siblings p 005 while boys had more older siblings p 005 conclusions these findings accord with the national picture of successful reductions in gender inequalities in health through low cost communitybased health programmes and education policies targeting the poorest sectors the prevalence of undernutrition however remains high reproductive behaviours may still be influenced by poverty and the gender of existing offspring future challenges lie in reducing the adverse health consequences to women and their infants associated with early age at marriage and childbirth

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background since the turn of the century the number of malaria deaths has been reduced by nearly half 1 this progress in the fight against malaria has been made in part due to the increased distribution and use of longlasting insecticidal nets llin have proven to be one of the most effective tools to combat the disease providing both individual and communal benefits 1 2 3 mass distribution campaigns and clinicbased distributions are the most commonly used strategies to deliver llin to communities yet ownership and usage rates remain well below the targeted ratio of 1 bed net per 2 persons 4 this shortcoming is especially pronounced in vulnerable and atrisk populations notably children and pregnant women 5 6 7 adoption of llin usage is particularly important for pregnant women pregnant women are more vulnerable to malaria and severe outcomes for multiple reasons enhanced attractiveness to the mosquito due to increased respiratory volume and skin temperature suppression of the immune system and the sequestration of the malaria parasite in the placenta 89 the unborn child is subsequently at increased risk for spontaneous abortion stillbirth low birthweight and prematurity 2 despite the increased risks and the prioritization of pregnant women in itn campaigns bed net usage among pregnant women in malaria transmission zones has plateaued in the recent years and ranges from as low as 16 to 74 across subsaharan african countries that have high rates of malaria transmission most countries hover around 50 11011 malaria in ghana is still highly endemic an estimated 58000011000000 cases of malaria occurred in 2013 and the entire country is classified as high transmission free distribution of itn llin was instituted in 2004 and largescale rollouts of bed nets have been conducted since 2007 with expansion to all age groups in 2010 1213 antenatal carebased distributions have been established as a key strategy to improve access to bed nets for pregnant women although gaps in coverage persist 14 in 2011 only 35 of pregnant women between the ages of 15 and 49 in the ghana demographic and health survey reported sleeping under a bed net and even fewer slept under a llin the night prior to survey 15 new approaches to understand these gaps and to reach the universal coverage goals laid out by the roll back malaria partnership are needed while the body of literature has grown on social and communal factors affecting bed net use little has been published on the role of interpersonal influences in the uptake of bed nets 1617 interpersonal influence which is comprised of social support social norms and role models is a key component of the health promotion model and could be expected to be a factor in the decision to own or use a bed net 18 interpersonal influences have been found to be critically important in the adoption of health promoting behaviors in other contexts 18 19 20 21 22 the larger concept of ideation which includes beliefs and values social norms emotional responses and social support and influence about a particular subject has been demonstrated to be correlated with household itn use in tanzania 23 understanding the role of interpersonal influence on the decision to obtain or use bed nets could lead to improvements in their promotion the primary objective of this study therefore was to determine whether interpersonal influences were associated with ownership and or use of bed nets in pregnant women attending antenatal care in kumasi ghana simple measures of interpersonal influence were collected for selfreported advisors to pregnant women in kumasi ghana and modelled into a single influence score this influence score was then related to the bed net practices of the pregnant women themselves methods study setting and design cross sectional data were collected from pregnant women seeking antenatal care at kumasi south hospital in kumasi ghana data were collected as part of a wider survey investigating bed net use and malaria prevention strategies among pregnant women in 2014 all questions were translated by locals to ensure cultural compatibility and acceptability kumasi south hospital is a primary care hospital in southcentral ghana 24 ksh is located between three cities in the ashanti region of ghana and provides services to 56 communities which consist of approximately 400000 people 25 kumasi along with the rest of ghana is considered a highmalaria transmission zone by the world health organization though the prevalence of malaria in urban areas in ghana is significantly lower than in equivalent rural communities 26 27 28 there have been mass distribution campaigns to increase bed net usage in the ashanti region including subsidization of bed net purchases until 2010 and then doortodoor distribution of bed nets through 2012 15 according to the 2014 ghana demographic and health survey 862 of bed nets in the ashanti region were acquired for free and 823 came from the public sector although this information may have been collected after the study survey was administered 29 in march 2014 which represents the beginning of the first rainy season in kumasi a systematic sample of women attending the clinic for antenatal care were identified and interviewed onsite women were selected by retrieving the last file in the stack of charts that were placed in order of appointment on the desk of the hospital from clinic open to close mondayfriday after an interview was conducted another chart was selected this process minimized bias by selecting women throughout the day and week in addition selecting the chart from the bottom of the pile provided enough time between selection and clinic appointment to conduct the interview the inperson survey was conducted with trained personnel to determine knowledge attitudes and practices surrounding bed nets and other malaria prevention strategies variables the exposure of interest was interpersonal influence this was determined by asking participants to provide information for up to three advisors outside of medical personnel who they sought advice from during pregnancy for each selfreported advisor the women were asked whether the advisor uses a bed net whether the advisor had talked with the participant about malaria and how often the participant followed the advisors advice the advisors were also ranked by whom the women went to first second and third the advisor score for each participant was transformed into a single score with the formula where j the number of advisors r j weight of the jth advisors influence by rank u j bed net use by the jth advisor t j talk with jth advisor about malaria during pregnancy i j how often the jth advisors advice is followed influence scores could range from 45 for a participant who received strong interpersonal influence towards using a bed net to 225 for a participant who received no interpersonal influence towards using a bed net the outcomes of interest were selfreported ownership and use of a bed net given there were still some untreated bed nets in circulation at the time all bed nets were treated equally and dichotomized into usenonuse and ownershipnonownership bed net use was assigned on reported use the night prior to the survey per who guidelines 3031 in addition another question was asked about bed net use to conduct a sensitivity analysis namely do you use a mosquito net the bed net influence score j j1 r j u j t j i j ownership analysis was performed on all of the women sampled while the bed net use analysis was performed only on the subset of the women that owned a bed net other variables included in the analyses were the participants ages education levels marital statuses malaria perceptions and knowledge and perceived availability of bed nets in the community age education level and marital status were included on face validity perceptions and knowledge of a disease are crucial aspects of the health promotion model and are likely associated with bed net ownership and use they were included in the adjusted models as potential explanatory factors of the association between interpersonal influence and bed net ownership and use 22 aspects of the perceived risk of malaria perceived severity of malaria and knowledge of malaria prevention were determined using the questions listed in table 1 each question was treated as an individual variable perceived bed net availability was included in the adjusted models as availability of bed nets in the community may confound the relationship between influence score and bed net ownership by the participants perceived availability was measured by the question is it easy to obtain a mosquito net during pregnancy analysis a preliminary assessment of the population was performed using the measured and derived variables twosample t tests for the continuous variables and chi square tests for the categorical variables were used to detect differences across the outcomes categorical variables were assessed for sparse data variables with categories that contained less than 5 of the total number of observations were excluded from the model or recategorized the primary analysis consisted of a logistic regression model between influence score and the binary outcomes bed net ownership and bed net use for each outcome three models were constructed a crude model with only the influence score adjusted a with influence score age marital status and education level and adjusted b with the perceived availability of bed nets and malaria perception and knowledge variables in table 1 in addition to the variables in adjusted a odds ratios for the influence scores were calculated as the measure of association area under the receiver operating characteristic curve values were calculated to determine the ability of the influence score to predict bed net ownership and use ie model fit age and influence score were assessed for linearity against the logit of the probability of the outcomes and were transformed or categorized if linearity was not observed observations with missing values for any variable were excluded from the analysis all analysis was performed using sas 94 sensitivity analyses the method of aggregation of the variables into the influence score was tested by comparing the score outlined above with two alternative scoring systems an influence score unweighted by advisor ranking influence score j j1 u j t j i j and a simple sum of the number of reported advisors who used bed nets influence score j j1 the odds ratios of the influence scores significance of the influence scores and auc values of new models were compared to the original in addition comparisons were made between the who recommended method of determining bed net usage and an alternative question regarding overall bed net use the net use model using this new question was compared to the original a further model that assigned bed net use only when a participant answered yes to both questions was also compared to the original results of the 300 women sampled 294 provided complete survey information and were included in the analysis the six women not included did not provide information about their advisors during pregnancy of the 294 women included in analysis 229 reported owning bed nets of these bed net owners 139 reported having used a bed net the previous night for an overall estimate of 47 of pregnant women sleeping under a bed net age education level and malaria knowledge and perceptions were similar across all outcomes a significantly higher proportion of net users were married as compared to nonnet users though no difference was detected between net owners and nonnet owners bed net owners were more likely to perceive bed nets as easy to get than nonbed net owners though no difference was detected between net users and nonusers influence scores differed across the outcome of bed net ownership though not significantly bed net owners had a mean score of 123 standard deviation 167 and nonowners had a mean score of 085 across bed net use the difference was significant bed net users had a mean score of 151 while nonusers had a mean score of 080 advisor characteristics there were 692 advisors of the pregnant women in the sample among the advisors whose gender could be determined from the information in the survey the majority were female the average advisor age reported by the pregnant women was 435 the most common advisors were the pregnant womans mother the pregnant womans sister and the pregnant womans husband there was a significant difference in gender categories between the advisors of bed net users and nonusers no other differences were found in age or relationship across either category or gender across bed net ownership there were differences in advisor characteristics across outcomes with a significantly higher proportion of the advisors of net owners using bed nets than the advisors of nonowners a similar difference was seen across net use categories the frequencies of having had discussions about malaria during pregnancy and of following advice were not significantly different across outcomes for ownership groups or use groups the differences seen in influence score across the outcomes for the pregnant women was mirrored in their advisors advisors of bed net owners had higher mean influence score than advisors of nonbed net owners but not significantly the mean influence score for advisors of net users was significantly higher than those of nonnet users was models age and influence score were found to be nonlinear with respect to the logit of the probability of bed net ownership and were categorized age was categorized into quartiles the influence score was categorized into standard deviations from the mean to maximize the interpretability of the findings crude and adjusted logistic regression models were constructed and odds ratios were calculated as the odds of using or owning a net with the lowest categories of influence score and age as references the results of the crude adjusted a and adjusted b models were similar participants with a higher influence score were more likely to own a bed net in the adjusted b model as compared to the reference category participants with an influence score within one sd below the mean had an odds ratio of 139 95 ci participants with an influence score within one sd above the mean had an odds ratio of 289 95 ci and participants with an influence score greater than one sd above the mean had an odds ratio of 237 95 ci the area under the roc curve of the crude bed net ownership model was 0588 the same trend was seen in net use using the lowest category of influence score as the reference category participants with an influence score within one sd below the mean had an odds ratio of 228 95 ci participants with an influence score within one sd above the mean had an odds ratio of 276 95 ci and participants with an influence score greater than one sd above the mean had an odds ratio of 538 95 ci in the adjusted b model the area under the roc curve of the crude bed net use model was 0620 sensitivity analyses separate analyses were performed using the alternative influence score formulas the original influence score unweighted by advisor rank influence score j j1 u j t j i j and the number of advisors using nets influence score j j1 the analysis using the influence score unweighted by advisor rank yielded odds ratios and areas under the receiver operating characteristic curve similar to the primary models notable was the similarity of the analysis that used solely the number of advisors using bed nets to calculate the influence score this analysis yielded similar trends in the odds ratios significance of the exposure terms and auc values to the primary models as the number of advisors using bed nets increased the odds ratios for bed net ownership and use also increased with 0 advisors using a bed net as the reference category the odds of owning a bed net were 112 times higher with 1 advisor 95 ci 198 times higher with 2 advisors 95 ci and 245 times higher with 3 advisors 95 ci the odds of using a bed net were 094 times higher with 1 advisor 95 ci 188 times higher with 2 advisors 95 ci and 429 times higher with 3 advisors 95 ci the areas under the roc curves were 0563 for the crude ownership model and 0590 for the crude use model no relationship was seen between the other terms of the influence score and the outcomes the more general question about bed net use do you use a mosquito net included a larger percentage of women in the bed net use category than did the original who question the more sensitive definition of bed net use was associated with the influence terms at a level severalfold higher than the who definition for the most adjusted model using the lowest category of influence score as the reference category participants with an influence score within one sd below the mean had an odds ratio of 278 95 ci participants with an influence score within one sd above the mean had an odds ratio of 557 95 ci and participants with an influence score greater than one sd above the mean had an odds ratio of 1091 95 ci the results of these models suggests that the who recommended question for bed net use is appropriate as a conservative measure of bed net usage discussion pregnant women reporting to kumasi south hospital for antenatal care that owned and used bed nets were more likely to have a higher reported number of advisors that also used bed nets a doseresponse was seen between the influence score and both bed net ownership and bed net use this analysis suggests that when a pregnant woman receives advice from a social network that includes other individuals who use bed nets it may how often is advice followed n very often 448 educators who are from and work within communities to actively engage families about malaria prevention and control were found to have modestly influenced householdlevel universal coverage targets through its influence on net ideation 23 there is however relative consistency in the associations between social factors such as education income and bed net ownership and use among both pregnant women and the general population 71722 further investigation into the associations between interpersonal influence on bed net ownership and use should be undertaken in a larger and more diverse sample to determine the robustness and generalizability of the findings though these findings are unique when examining determinants of bed net ownership and use the influence of interpersonal relationships on health behaviors is not without precedent it is wellestablished that both peers and family members influence the uptake of both healthy and unhealthy habits 193536 in the realm of womens reproductive health a systematic review of factors associated with accessing antenatal care identified the importance of social support 37 a qualitative study in three countries in subsaharan africa indicates that the support of friends and relatives is influential in seeking antenatal care particularly if they have a role in healthcare 38 in ghana antenatal care was associated with the level of antenatal care in the neighboring community as an indicator of social norms 39 social support is adjacent to the explicit modelled practices of a 36 which found that the number of friends or family members who had gotten vaccinated was a significant predictor of a person getting a vaccine themselves acceptability of the hpv vaccine was also found to be highest when when people believed that important others wanted them to be vaccinated or held favorable beliefs toward the vaccine 40 social network theory as applied to public health is a means by which knowledge of and attitudes towards a health behavior can be formed 41 in this case the use of bed nets may be influenced by the individuals whom the pregnant women seek advice from during their pregnancy the similar auc values and odds ratio trends seen in the models using only the number of advisors using nets suggest that this effect is independent of the reported amount of communication with the advisors about malaria and how often the advisors advice is perceived to be followed despite these results the modest auc values of the ownership models suggest that there are strong competing factors other than interpersonal influence on ownership of a bed net these could be things such as availability educational level cost and perceived risk which as noted previously have been associated with bed net ownership in other studies and may have been responsible for the higher auc values in the adjusted models 7161728 the larger auc values for the net use models suggest that once owned the decision to use a net may be more dependent on interpersonal influence limitations this study has several limitations the sample size is relatively small with only 67 women not owning bed nets and 90 women not using bed nets this opens the possibility that some of the analyses could have been underpowered given the conditions of the study an or of 245 for net ownership and 239 for net use were the minimum effect sizes that could be distinguished from chance 42 while lower effect sizes would not be reliably estimated this does not diminish the association that was determined between advisor bed net use and the bed net use by pregnant women in this study the study is also limited by the nature of measures used to determine the social influence though it nonetheless provides strong evidence that more studies should be conducted to examine the relationship between social influence and bed net ownership and use the overall generalizability of these results to all pregnant women is limited by recruitment at an antenatal clinic reported rates of bed net use and ownership in this survey are very similar to what was determined in the communitybased dhs survey of 2014 in the broader ashanti region in which household level mosquito net ownership was 71 and 44 of pregnant women reported sleeping under any mosquito net the night before survey those individuals who access health care may overrepresent women who are further in their pregnancies or women at a higher education or income level although the 2014 dhs data indicate that in the ashanti region 988 of women sought antenatal care 7 in addition a residual concern exists with the accuracy of selfreported bed net usage though an attempt was made to address this in the sensitivity analyses using responses from multiple bed net use questions and results were consistent the findings of this study would be useful in the context of efforts to increase bed net usage as they suggest that each additional person who uses a bed net has a positive effect on the usage of people around them this has implications for the planning and modelling of intervention strategies and any context where the marginal benefits of bed net distribution and education are being considered conclusions the results of this study suggest that there is an association between the decision by pregnant women to use or own bed nets and the use of bed nets by the people they go to for pregnancy advice in kumasi ghana although the crosssectional design of this investigation prevents the establishment of a causal relationship similar findings in other disease prevention settings suggest that interpersonal influence could be an important factor in the uptake of bed net use further research into the relationship between social influence and bed net use is warranted as interventions could capitalize on interpersonal relationships to raise bed net ownership and usage rates in ghana and worldwide planning and execution of the study je provided guidance on the study and survey design and provided overall direction for the project all authors read and approved the final manuscript funding funding was provided by the university of arizona college of public health availability of data and material the datasets during andor analysed during the current study available from the corresponding author on reasonable request abbreviations sd standard deviation or odds ratio ci confidence interval llin longlasting insecticidal nets pmi presidents malaria initiative ksh kumasi south hospital who world health organization auc area under the receiver operating characteristic curve jss junior secondary school jhs junior high school sss senior secondary school shs senior high school additional files additional file 1 main ownership regression model additional file 2 main use regression model additional file 3 sensitivity analysis models author details 1 department of epidemiology and biostatistics mel and enid zuckerman college of public health university of arizona campus po box 245211 1295 n martin avenue tucson az 85724 usa 2 kwame nkrumah university of science and technology kumasi ghana 3 kumasi south hospital kumasi ghana competing interests the authors declare that they have no competing interests ethics statement all protocols were reviewed and approved by the university of arizona and kumasi south hospital informed written consent was given by all participants and participants were only asked to complete portions of the survey with which they felt comfortable the written consent was the only identifier and was removed prior to data entry

background despite progress made in the last decades malaria persists as a pressing health issue in subsaharan africa pregnant women are particularly vulnerable to infection and serious health outcomes for themselves and their unborn child risk can be mitigated through appropriate use of control measures such as insecticidetreated bed nets although social networks can influence uptake of preventive strategies the role of social influence on bed net ownership has not been explored during an evaluation of a bed net distribution programme the influence of nonhealth care advisors on ownership and use of bed nets by pregnant women in kumasi ghana was examined methods data were collected through inperson interviews with 300 pregnant women seeking antenatal care in an urban hospital in kumasi ghana participants were asked about their bed net ownership bed net use and information about three personal contacts that they go to for pregnancy advice information about these advisors was combined into an influence score logistic regression models were used to determine the association between the score and bed net ownership those who owned a bed net were further assessed to determine if interpersonal influence was associated with selfreported sleeping under the bed net the previous nightof the 294 women in the analysis 229 78 reported owning bed nets of these bed net owners 139 61 reported using a bed net the previous night a dose response relationship was observed between the interpersonal influence score and bed net ownership and use compared to the lowest influence score those with the highest influence score 1 sd above the mean were marginally more likely to own a bed net or 237 95 ci 087 639 and much more likely to use their bed net 538 95 ci 189 1525 after adjusting for other factors conclusions interpersonal influence appears to have modest impact on ownership and use of bed nets by pregnant women in an urban area of ghana further investigations would need to be conducted to determine if the relationship is causal or if individuals who associate are simply more likely to have similar practices

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background between 53 and 121 of australian adults are estimated to manifest behaviours associated with problem gambling these proportions are generally consistent with figures reported for other countries such as the united states canada sweden and the united kingdom studies across countries have shown that prevalence estimates for problem gambling among adolescents and young adults are higher than in adult populations among young people aged 1317 years between 60 and 80 gamble at least once per year and around 35 report symptoms of problem gambling or pathological gambling a range of factors have been associated with the risk of problem gambling among adolescents and young adults such as gender age antisocial behaviours academic performance family socioeconomic status parental gambling involvement as well as alcohol consumption it is not only the extent to which alcohol consumption normally coexists with gambling behaviours it may also be an antecedent of problem gambling suggesting considerable implications for intervention strategies the correlation between alcohol consumption or alcohol use disorder and problem gambling among adolescents and young adults has been well documented in crosssectional studies for example a national survey of gambling among 10765 college students in the united states found that students who gambled were less likely to abstain from drinking alcohol and a crosssectional swedish survey of youth aged 1624 years found that among males the higher the alcohol consumption the greater the likelihood of gambling and problem gambling behaviours the few longitudinal studies examining alcohol consumption by adolescents as a risk factor for problem gambling consistently show that higher levels of alcohol consumption or early initiation of alcohol use have been associated with problem gambling we have previously found that those who started their drinking alcohol before age 15 years were more likely to be gamblers than those who did not drink the gambling literature provides crosssectional and longitudinal evidence of the association between adolescents alcohol consumption and problem gambling behaviours however to our knowledge there is no study examining the relation between maternal alcohol consumption and their young adult offspring having problem gambling behaviours comorbidity between problem gambling and other substance use including alcohol consumption or alcohol use disorder has long been recognised these studies suggest that those who consume or binge on alcohol are more likely to gamble and to have problem gambling behaviours further previous research has provided evidence showing the association between parental alcohol consumption and offsprings outcomes such as alcohol use and other substance use or child antisocial behaviours researchers argued that if parents drink at heavy level they are less supportive and more aggressive toward their children they also pay less attention to their child and are less inclined or less able to monitor their childs behaviour in this study we expected that there will be an association between maternal alcohol consumption and young adults problem gambling behaviour a longitudinal association of maternal alcohol consumption predicting offspring gambling behaviour has not previously been reported such research would provide a basis for determining whether a mothers alcohol consumption trajectory is associated with her adolescents problem gambling behaviours this may help in the development of prevention programs for both alcohol consumption and problem gambling there are numerous studies investigating socioeconomic status and other factors such as paternal alcohol consumption as these are related to offsprings alcohol consumption and gambling problem for example male adolescents are more likely to be involved in problem gambling than female adolescents maternal alcohol consumption has a greater affect on male drinking than female drinking lowest social economic status women might be heaviest drinkers and have children who are more likely to have a drinking problem or parental substance use problems have an adverse impact on offsprings alcohol consumption these factors possibly confound and mediate the association between maternal alcohol consumption and offsprings outcomes we included mother and childs socioeconomic status as confounders while paternal alcohol consumption was treated as a mediating variable for the purpose of this study the present study uses prospective data from the materuniversity of queensland study of pregnancy comprising a linked prebirth cohort of mothers and children spanning over 30 years to investigate the association between maternal alcohol consumption trajectories and offsprings problem gambling controlling for other possible factors we hypothesise that higher levels of maternal alcohol consumption are associated with young adults problem gambling and mothers pattern of alcohol consumption has a greater impact on male than female young adult gambling behaviours methods participants and procedures data were taken from the materuniversity of queensland study of pregnancy and its outcomes a prospective prebirth cohort study of women enrolled at a public obstetric hospital in brisbane australia between 1981 and 1984 details of the study have been described elsewhere women were recruited at their first clinic visit at approximately 18 weeks of gestation and 6753 women were asked about their alcohol consumption social demographic characteristics life style behaviours and health information before pregnancy these women were reinterviewed when their child was 6 months 5 14 and 21 years of age their offspring were also interviewed for the 14 21 and 30 year followup surveys the present study is based on the subsample of 1691 mothers and their children remaining in the study at 30 years the subsample includes mothers who provided details of their alcohol consumption for up to five phases of the study and their children who provided data on gambling behaviours at 30 years written informed consent was obtained from mothers at all data collection phases and from the young adults at the 30 year followup of the study ethics committees from the mater hospital and from the university of queensland approved each phase of study measures measure of outcome variable young adults risk of problem gambling behaviours at 30 year followup young adults were asked the question do you spend money on gambling with possible responses yesno respondents had not gambled were not asked the nine cpgi question whereas those responding yes were asked to complete a short version of the canadian problem gambling index to determine their levels of problem gambling behaviours over the last 12 months the cpgi has been tested and retested for its validity and reliability in both general population and clinical sample surveys with cronbachs alpha 084 higher than the one tested for other measures such as diagnostic and statistical manual of mental disorder fourth edition and south oaks gambling screen the tool has been widely used in previous studies in queensland in the 2001 20032004 20062007 and 20112012 in other states in australia and other countries the short version of cpgi comprises nine questions as follow bet more than afford to lose gamble with larger amounts tried to win back losses borrowed or sold to get money felt have a problem with gambling caused health problems told had gambling problem caused financial problems and felt guilty about gambling the response options for the cpgi are never which scored 0 sometimes scored 1 most of the time scored 2 and almost always scored 3 in the present study together with the responses from spending money on gambling individual scores on the nine questions were added to generate an overall score ranging from 0 to 27 where respondents were classified into one of four gambling behaviour categories 0 non problem gamblers 12 low risk 37 a moderate risk and 8 a problem gambler consistent with other studies the proportions of moderate risk and problem gamblers in our study were low 32 and 11 respectively in order to increase the statistical power we collapsed the four problem gambling behaviours into two groups as follows non problem gambler or no risk behavioursome risk behaviours of problem gambling the distribution of no risk and some risk behaviours of problem gambling is also the cutoff point of 10 of the population sample measure of main predictor the main exposure in this study is the maternal alcohol consumption trajectory over 21 years these trajectories were based upon selfreported information from mothers at time 1 time 2 time 3 time 4 and time 5 21 years after the birth of their child maternal alcohol consumption at each phase of study at each survey mothers were asked how often they drank alcohol and how much alcohol they consumed on each occasion respectively six prespecified response options ranging from never to daily alcohol consumption and from none to seven or more standard drinks were provided guidelines from the australia national health and medical research council suggest that womens alcohol consumption should be calculated on the basis of weekly alcohol consumption standard drink scores in our study alcohol consumption scores were estimated by a method described by dawson whereby the midpoint estimate of frequency was multiplied by the midpoint of quantity consumed 1 for consistency with other studies respondents levels of alcohol consumption were categorised as nondrinkers occasional drinkers moderate drinkers and heavy drinkers long term trajectories of maternal alcohol consumption long term trajectories of alcohol consumption by women were examined by using groupbased trajectory modelling we used a censored normal model suggested by jones and nagin to examine the changes of alcohol consumption consistent with other studies square root transformation was applied to alcohol data to reduce the effects of the skewed distribution first we used an unconditional model to identify the number of trajectory groups then because the patterns of maternal alcohol consumption over the mothers life course may depend on the number of children women may have we fitted a conditional model by adding parity variable as a function of time varying covariate in the model while simultaneously estimating the parameters that defined the trajectory group the estimation of the unconditional trajectory group model showed that we could identify between two to four drinking trajectory groups in our sample group membership and the posterior probabilities for all four trajectory models the threegroup model had the largest bic with mean posterior probability ranging from 086 to 093 suggesting that it represented a better fit than did the other models the fitted model provided distinct drinking trajectories that were much bigger than the minimum average posterior probability of 70 for all groups in the conditional trajectory model adding the number of offspring over five time period slightly improved the model fit on the basis of bic criteria we selected a conditional model with three drinking trajectory groups as our final model for examining the association between maternal alcohol consumption trajectories and their young adults risk of problem gambling behaviours figure 1 displays the shape of three drinking trajectories and the mean alcohol consumption level of each trajectory over five time points • the largest group was labelled as the lowstable drinkers group women in this trajectory group consumed an average of 15 standard drinks per week at time 1 they reduced their consumption by half when they found out they were pregnant then slowly increased their consumption but their level of alcohol consumption was still low at time 3 and time 4 14 years after the birth of their baby after 21 years their weekly average alcohol consumption was the equivalent to two glasses a week • the next largest group consisted of moderateescalating drinkers members of this group were those who consumed alcohol at a moderate level at time 1 prepregnancy they slightly reduced their consumption at time 2 but returned to their prepregnancy drinking level at time 3 a 5 year followup then gradually continued to increase their level of alcohol use at the 21 year followup the weekly average alcohol consumption for these women was 101 standard glasses per week covariates to examine the independent association between maternal alcohol consumption trajectories over 21 years and their young adults risk of problem gambling behaviours we included a number of potential confounding variables in different models these covariates included mothers age and educational level at time 1 mothers income and marital status at time 4 paternal alcohol use problems at time 4 the young adults socioeconomic status at time 5 a 21 year followup in addition we controlled for offsprings alcohol consumption which was measured at time 6 the same time as gambling behaviour is assessed offsprings alcohol consumption was measured using the similar tool assessed mothers alcohol consumption at each phase of study due to the low proportion of heavy alcohol consumption of offspring of mothers who are members of the moderateescalating drinking trajectory and their risk behaviours of problem gambling we treated young adults alcohol consumption as a covariate to test the possibility that maternal alcohol consumption patterns could be related to offsprings alcohol consumption which in turn may be associated with offsprings problem gambling behaviours analyses of data the data analyses were performed in four stages first we assessed collinearity to examine the correlations among the predictor variable and covariates the variance inflation factor ranging from 102 to 148 indicated that no collinearity was involved all predicting variables were included in further analyses second we examined the association between maternal patterns of alcohol consumption and their young adult offsprings risk of problem gambling behaviours using logistic regression models initially we examined the crude association between the outcome variable and the main predictor we subsequently adjusted the association using a range of covariates in different models to examine whether or not each predicting variable group confounded the association as suggested by previous research we adjusted for mothers age and educational level at baseline mothers income and marital status at the 14 year followup then included paternal alcohol related problems at 14 year followups young adults socioeconomic characteristics at the 21 year followup and young adults alcohol consumption at 30 year followup next to examine whether the effect of maternal trajectories of alcohol consumption over 21 years on young adult offsprings risk of problem gambling behaviours varies by the sex of a child we performed all the analyses separately for male and female young adults of the cohort of 3416 motherchild pairs at time 6 about 1691 children were retained and provided information on problem gambling behaviours we assessed how attrition may have affected our results using a multivariable logistic regression model of lossto followup with young adults demographic characteristics at 21 year followup starting from a missing at random assumption we used stata to multiply impute missing data from the main predictor covariates and outcome initially we used 20 cycles of imputation for the analyses of imputed data subsequently sensitivity analysis was employed by repeating the whole process using 50 cycles of imputation all analyses were undertaken using stata version 130 where a p value of 005 was adopted as a threshold for significant results the no risk gambling behaviour group was selected as the reference category in all our analyses data are presented in the results section based on the analyses of 1691 motherchildren pairs results overall 106 of participants at age 30 reported having some risk behaviours of problem gambling of which males accounted for 583 the prevalence of any risk behaviour of problem gambling among male young adult offspring in our sample is consistent with previous studies among those who were determined as having some risk of problem gambling behaviours more than 80 had a high income and were single and nearly twothirds finished their secondary schooling the univariate analysis between maternal alcohol consumption trajectories and their young adults risk of problem gambling behaviours shows that young adult offspring who have mothers in the moderateescalating group tend to have greater risk of problem gambling behaviours than those with mothers in the lowstable and abstainers groups table 1 presents bivariate and multivariate associations between young adults risk of problem gambling behaviours and maternal alcohol consumption trajectories bivariate results from logistic regression analysis show that the maternal moderateescalating group is associated with their young adults risk of problem gambling behaviours while the lowstable group is not related to any risk of problem gambling behaviours the results remained statistically significant for the moderateescalating group when 10 12 table 1 maternal alcohol consumption trajectories and young adults risk of problem gambling behaviours at 30 year followup italic p 0 12 11 11 09 moderateescalating drinkers 308 10 21 20 21 21 16 adjusted for mother and young adults socioeconomic status and paternal alcohol problems the model was not statistically significant after adjustment for offsprings alcohol consumption suggesting that the association between mothers moderateescalating drinking trajectory and young adults risk of problem gambling behaviours was partially mediated by alcohol use by offspring tables 2 and3 show the results for male and female young adult offspring separately maternal alcohol consumption trajectories did not significantly predict risk of problem 36 37 46 46 30 gambling behaviours for young adult females however the analyses among male offspring indicate a strong association between the maternal moderateescalating group and male adolescents risk of problem gambling behaviours with ors ranging from 36 for unadjusted to 46 for adjusted analyses adjustment for offsprings alcohol consumption at 30 year appeared to reduce the strength of the association between maternal moderateescalating drinking trajectory and young adult males risk of problem gambling behaviours ors reducing from 46 in model 330 in model 4 maternal alcohol consumption for the moderateescalating group appears to predict problem gambling behaviours for their male rather than female young adult offspring women who exhibit a persistent life course pattern of heavier alcohol consumption have male children who have a high risk of engaging in problem gambling behaviours of the cohort of 3416 motherchild pairs at time 5 a 21 year followup about 1725 were lost to followup and did not provide information on gambling behaviours at time 6 a 30 year followup young adults who dropped out of the study or were excluded from the study due to not providing gambling information were more likely to be male who did not finish their secondary schooling and had higher income levels repeated analyses which used 20 cycle and 50 cycle multiple imputations showed similar results as the ones in the main analyses of the sample of 1691 motherchild pairs suggesting that our findings do not reflect selection bias discussion using the data from a linked prebirth cohort of mothers and children extending over 30 years we examined the association between mothers alcohol consumption trajectories and their offsprings risk of problem gambling behaviour including the extent of gender differences we found that a maternal trajectory of moderateescalating alcohol consumption over 21 years is independently associated with a risk of their young adult offspring having problem gambling behaviours at 30 yearseven after adjustment for a range of potential confounding variables with the exception of alcohol use by offspring mothers who consume alcohol at a moderate to heavier level over an extend period of their childs early life course are more likely to have a child at risk of problem gambling the association between mothers alcohol consumption trajectories and problem gambling behaviour by their adolescent offspring differs by their gender in our study there is crossgender influence observed for the moderateescalating drinkers group mothers moderateescalating drinking trajectory predicts male offspring rather than female counterpart gambling specially problem gambling this finding differs somewhat from previous research which indicates that children tend to model their same sex parents substance use but it is supported by the work of cleveland et al and englund et al showing that maternal alcohol consumption is a good predictor of male alcohol use adjustment for mothers and their young adult offsprings socioeconomic status does not change the magnitude of the association among young adult male group however it is of note that adjustment for paternal alcoholrelated problems increased the magnitude of the association suggesting that paternal alcohol consumption is associated with and contributes to young adults problem gambling behaviour we were unable to test whether the mothers or fathers alcohol consumption pattern had the greater impact on their adolescents problem gambling behaviours as we did not have this information for fathers however our analyses suggest that fathers alcohol use partly predicts child problem gambling outcomes at 30 years in a way that paternal alcohol consumption is likely to influence young adults alcohol use which in turn may impact on gambling behaviour further research should address the patterns of both paternal and maternal alcohol consumption on adolescents problem gambling behaviour our study results show that alcohol consumption by offspring partially mediated the association between mothers moderateescalating drinking trajectory and young adults risk of problem gambling behaviours after adjustment for offsprings alcohol consumption the association of maternal alcohol consumption and offspring gambling was no longer statistically significant the results suggest that together with maternal alcohol consumption trajectories alcohol use by offspring is associated with and contributes to gambling behaviours alternatively the present study implies the cooccurrence of alcohol consumption and gambling problems among offspring suggesting that such behaviours may have a shared antecedent factor our analyses indicated that not only is there a significant cooccurrence between alcohol consumption and problem gambling among the general sample but also that this association is considerably stronger in males rather than females prevention and intervention programs need to target males for this reason there are number of possible mechanisms explaining why maternal alcohol consumption is associated with gambling behaviour generally and problem gambling behaviour particularly in offspring first both alcohol use and gambling behaviour may reflect other influences such as family problems poor parenting possibly associated with being a teenage mother or a history of family poverty in our analyses we controlled for a number of confounders and found that the association between maternal alcohol use and gambling remained largely unaffected to the extent that our measures of family dynamics are associated with family problems and related factors these dynamics are not responsible for the gambling behaviour of offspring secondly alcohol use and gambling behaviour are both forms of sensation seeking andor risk taking and may reflect an underlying pattern of antisocial behaviour it may simply be the case that offspring of mothers who consume alcohol in a persistent manner are more prone to behave in a risky manner of which offspring drinking and gambling are a part alternatively males are more likely to consume alcohol and to gamble at a risky level and females are less likely to behave in delinquent andor antisocial ways consequently males are more likely to reflect such associations than females a third possibility is associated with the disinhibiting effects of alcohol thus it may be that mothers who are more persistent consume of alcohol behave in a more disinhibited manner and themselves are more likely to gamble and take risks the gambling behaviour of offspring in this context is simply learned behaviour another possibility is that mothers who consume more alcohol have offspring who are more likely to consume alcohol the gambling behaviour of offspring may simply reflect their own level of disinhibition which may involve gambling as an outlet it is in this study not possible to determine which of the above possibilities is correct specific studies which test some of the above options are needed however it is appear that we have identified a causal pathway that links maternal alcohol consumption trajectories with levels of alcohol consumption by offspring and offspring problem gambling behaviour the present study had some limitations it is likely that selfreported alcohol consumption typically accounts for up to 60 of total alcohol sales problems with sampling nonresponse bias as well as underreporting bias may all contribute to the underestimates of alcohol consumed a selfreport measurement of alcohol consumption using quantitiesfrequency may not be able to completely capture the heaviest drinking group nevertheless as noted by researchers frequencyquantity questionnaires are a generally reliable and valid way of measuring alcohol consumption among populations future studies should examine group of mothers who involve in long term heavy alcohol consumption in a relation to their offsprings problem gambling behaviour the musp study has not collected information on fathers alcohol consumption at each phase of the study we only asked mothers at the 14 year followup about fathers alcohol use problems therefore we cannot fully account for the influence of paternal alcohol consumption on offspring gambling there is a good reason to expect that young adults alcohol use or substance use may be related to fathers alcohol consumption it is possible that the association between mothers alcohol consumption patterns and their young adults risk of problem gambling behaviour may partly reflect paternal influences this could result in residual confounding involving fathers alcohol use levels more research investigating both the impact of mother and fathers alcohol consumption trajectories on offsprings problem gambling is needed another limitation is that in our study young adults gambling behaviour was assessed at the 30 year followup suggesting that it may reflect the prevalence of the gambling status in the late transition period from adolescence to adulthood previous studies indicated that gambling behaviours among young adults are more stable than among adolescents however in order to have a comprehensive understanding of the association between maternal alcohol consumption and their offsprings patterns of problem gambling behaviours future research should examine the role of maternal alcohol consumption trajectories on their offsprings gambling behaviour development patterns finally loss to followup may have biased some results of the cohort of 3416 mothers and their young adult offspring at 21 year followup some 1691 motherchild pairs remained and were eligible for main analyses the attrition rate was about 505 of the sample our multiple imputation analyses indicated that the results are not likely to have been substantially affected by selection bias conclusion a crossgender difference was observed in the associations between maternal drinking trajectories and adolescent problem gambling behaviours membership of the maternal moderateescalating alcohol consumption trajectory independently predicted a risk of problem gambling for male offspring at 30 yearseven after adjustment for a range of potential confounding variables it appears that patterns of maternal alcohol consumption may have an independent effect on their young adults risk of problem gambling behaviours with male children being more vulnerable to the effects of maternal alcohol use than female children programs intended to address problem gambling behaviours by young adults may need to focus on male group with a cooccurrence of alcohol consumption and problem gambling as well as alcohol consumption patterns by mothers in addition to other family factors the findings also suggest that the problems that respondents have with gambling have their origins in the family life and patterns of behaviour of the family of origin of the gambler this implies that providing services for problem gamblers may be necessary but not sufficient there is a need to focus on family factors which predict the onset of gambling related behaviour at one level this raises the need to educate families about gambling before gambling begins at another level there may be a need to let mothers who consume alcohol be aware of some collateral consequences of such consumption competing interests the authors declare that they have no competing interests in the present study maternal alcohol consumption trajectories were identified by stata plugin software application we identified two to four possible group models of maternal alcohol consumption all models had bic and posterior probabilities that met the standards generally used the three drinking trajectory groups was selected as the best fitting model based upon the largest bic mean posterior probability and the size of membership in each trajectory group appendix

although a large number of studies have examined the association between young adults alcohol consumption and their problem gambling behaviours none of these studies address the prospective association between mothers alcohol consumption and their young adult offsprings problem gambling behaviours using data from a 30 year prospective prebirth cohort study in brisbane australia n 1691 our study examines whether different maternal alcohol consumption trajectories predict offsprings risk of problem gambling behaviours and whether these associations differ by the young adults gender offsprings level of problem gambling behaviours was assessed by the short version of the canadian problem gambling index with about 106 of young adults having some risk of problem gambling behaviours trajectories of maternal alcohol consumption were determined by groupbased trajectory modelling over five time points our study found that mothers alcohol consumption pattern fits into three drinking trajectory groups namely abstainers 172 a lowstable drinkers group 646 and a moderateescalating drinkers group 182 multivariate logistic regression analyses showed that the moderateescalating alcohol trajectory group is independently associated with a risk of their male young adult offspring having problem gambling behaviours at 30 yearseven after adjustment for a range of potential confounding variables mothers who exhibit a persistent life course pattern of moderateescalating drinking have male children who have a high risk of engaging in problem gambling behaviours offsprings alcohol consumption partially mediated the association between maternal drinking trajectories and young adults risk of problem behaviours high levels of maternal alcohol consumption may lead to male offspring antisocial behaviours programs intended to address problem gambling behaviours by young adults may need to focus on male group with a focus which specifically addresses family influences as these contribute to gambling behaviour

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introduction the loss of a child is an extremely painful experience which exposes human beings to their own impotence 1 this matter becomes even clearer when such a loss occurs in the neonatal period since it implies a very specific type of grief one that is slow and painful involving individual aspects of the parents and their relationship dynamics to face this situation 2 parents who go through this experience live a moment of crisis and need to adjust to the new situation 3 and it is essential that they be free to live and express their pain and grief 4 and that they receive support from the health team accompanying them 5 it can be even harder for the mother especially because of the physical and psychological experience of pregnancy and hormonal changes 6 the grieving process involves adjusting to the loss which means suffering as well as the ability to find some hope comfort and alternatives of life 7 people in grief look for meaning in that transition not only in the personal and family scopes but also in the social and cultural spheres so grief has a social role 89 in the case of death of infants the silence which is very common among people who are close to the grieving families may give the feeling that this death is not considered significant after all he or she had not yet been introduced socially 10 in this sense this death is socially invisible and professionals must be careful not to reproduce this idea 11 that is why it is important for health services to provide sensitive care to families who have lost their babies early 11 caring for the communication of death and for the provision of support to the woman and the family this study aimed at analyzing the communication of a childs death and grief support to the women in the puerperal period method this is a qualitative study which is part of a larger project carried out with women living in the city of são luís who have had deliveries in different maternity wards from july 2012 to july 2014 the participants were identified based on the death certificates of their newborn children registered in the mortality information system the inclusion criteria were mother living in the city of são luís gestational age equal to or higher than 32 weeks and weight at birth equal to or higher than 2500 g these criteria aimed at excluding newborns with higher chances of death and gestational age of 32 weeks was conditioned to the classification ranges of duration of pregnancy established in the dc the exclusion criteria were women with mental impairment which could mean cognitive impairment we found 410 dcs of newborns in the study period and based on the inclusion criteria 55 were selected of these nine had no address and were excluded based on the addresses we identified the health sanitary districts of the households and the coverage status by the family health strategy program thus the initial sample contained 31 women we contacted the health community agents to locate the household and to request an authorization for the visit of the 31 women 15 accepted to participate in the study the sociodemographic data were extracted from the dcs and from a structured questionnaire that was previously elaborated contemplating the following variables from the mother age skin color schooling occupation religion marital status and obstetric historyand the newborn weight at birth and birth conditions the diagnosis of preventable death was obtained in the file of investigation of infant and fetal death from the epidemiological surveillance center in the municipal secretary of health based on the list of preventable deaths by interventions from the unified health system 12 there were semistructured interviews conducted by the main researcher in the household on dates and times established by the interviewees recorded and then transcribed using a script with open questions including questions related to the death of the child and the grieving process there were five workshops using the technique of content analysis in the thematic modality according to the steps of the preanalysis categorization and interpretation 13 this study was approved by the research ethics committee of the university hospital at universidade federal do maranhão the identities of the women were kept anonymous their names were replaced by those of women known nationally andor internationally for losing their children or who somehow fought for the rights of women and children results and discussion we interviewed 15 women aged between 20 and 32 years mostly brown skinned as to schooling years 7 had 4 to 6 6 8 to 11 and 2 12 or more six were housewives one was a student and eight had a paid occupation eight were married or were in a stable union six were single and one was divorced only one was in the first pregnancy three had already had stillborn children nine had had a term pregnancy eight had vaginal delivery and two did not undergo prenatal care nine women reported some type of problem in pregnancy but only three were referred to specialized prenatal care four babies had malformation but in only two cases it was identified in prenatal care regarding the deaths seven occurred on the first day of life four between one and seven days and four after the eighth day five occurred due to sepsis three to malformation three due to respiratory causes two because of hypoxemia one due to heart problems and one because of perinatal conditions all deaths occurred in maternity wards or reference hospitals of sus and 13 were considered as preventable the statements of the interviewees about the death and the grieving process express suffering and anguish facing the loss of a child and were organized in two empirical categories receiving the news of death and going back home emptyhanded communication of death based on the statements we observed difficulties from the professionals to communicate not only the death but also the news that something was wrong with the newborn showing flaws in the communication between professionals and patients the women realized something was wrong with their babies mainly after birth and especially because of changes such as crying paleness change in skin color changes in breathing and agitation many reported delay from the health team to pass on information about the clinical status of the baby i looked at her way because every child who is born cries right after and she was quiet and i said she is not fine they took her and ran but didnt tell me anything it is very important that the professionals be available to inform about the procedures by creating conditions so that the users can share doubts and yearnings 514 the news of death was mostly addressed by the health team mainly by nurses and doctors some however could not tell which professional broke the news the attitudes of these professionals point to lack of preparation as well as violence in the communication of death the lack of sensitivity from the health team was identified at the time of hospital admission birth and labor care as well as in the communication of the news the reports refer disregard and abandonment in several situations one of the interviewees for example told that after losing her child she stayed at a nursing room with new mothers feeding their babies without any concern with the singularity of her context another situation that shows institutional violence is the report of telling the news of a childs death on the telephone my cell phone rang in the middle of the night it was them letting me know that she had died ten minutes ago that was all i answered the phone and the woman said is this the mother of the baby of that day i said yes and she answered mom i am sorry to inform you but your baby died montero et al 15 showed that health professionals are still unprepared regarding care in situations of perinatal loss the findings in this study indicate that many end up acting cold especially due to the lack of strategies and ability to handle the demands presented by the parents besides they do not recognize their role in the handling of this traumatic experience the communication of the news of death presents itself as a challenge for health professionals who are often little skilled to handle the pain of another individual 616 when they do they establish a relationship of affection 17 instead of empathy which shows the lack of preparation to communicate difficult news and to provide emotional support for the parents this reinforces the importance of training to give difficult news in a way that the professional is confident enough to fulfill this task 18 19 20 another situation that can be an important marker of the need for institutional changes in the work process was told by zilda the doctors only came in to give the medication and asked where is the child in that case the child was already dead the professional care of searching for information before contacting the mother is very important to prevent the worsening of the pain rev paul pediatr 201836422427 the professional approach and even that of family members despite having been identified as supportive was often inadequate as reported mom it is just like that she said i was young then i answered doctor but you dont know the pain that im feeling i have been waiting for my daughter for five years this is not easy and she said go on my girl you will soon have another baby wait one year after that you can get pregnant again according to iaconelli 21 it is common for mothers to hear sentences like take it easy you are young and can have other children it was better this way… we can infer that one of the reasons for such attitudes is the difficulty that people have in getting in touch with sadness since nowadays we are experiencing a movement of total suppression of feelings facing that loss many are impelled to go back to their routines as fast as possible pretending that nothing has happened 22 the statements reinforce the idea that death is a social taboo and the difficulties to deal with this communication seem to affect everyone the way death is communicated has a longlasting repercussion for the family 23 the content and the form of this communication are equally important considering that the news of death is the beginning of the realization about the loss and the healthy grieving experience for the elaboration of grief people must be encouraged to share the feelings caused by the loss 69 in grief there is no formula to mitigate the pain but it is possible to be present and to show the person in grief that heshe is not alone and that living the loss is necessary 8 in this sense the health professionals need to be much better prepared to provide care and support in these situations 20 they need to have technical experience and to embrace an ethical and cozy posture since this is how the family members will gain trust and safety 324 the effective and affective communication minimizes difficulties and uncertainties besides strengthening the feeling of safety which facilitates good relationships vital for the quality of care and helps in the understanding and acceptance of death 9181925 part of the professionals preparation is the possibility that they have institutional support to deal with limit situations 19 which can generate suffering and increasing levels of sickening however unfortunately institutional policies addressed to the attention and health care of the employees are still insufficient 18 going back home emptyhanded going back home without the child was one of the most difficult moments reported by the interviewees this represented the reality of losing a child followed by the sensation of emptiness and impossibility to begin a new phase for the family which would occur with a baby in the house the worst part is coming home without the baby this is bad its what hurts the most getting home looking at all of the babys things the discharge from the maternity ward can be pictured as a moment of joy and symbolizes an event of social presentation of the baby to the family this baby is about to enter 26 the death of the baby becomes a situation of difficult personal struggle besides social embarrassment 10 the death of a child represents the beginning of a difficult journey for the elaboration of this loss the parents need to build a new reality considering the investment and the expectations as to the future of a child that is no longer there 27 most of the interviewees did not have a chance to participate in the wake of their children some justified they were still hospitalized however others who could have lived this experience of the perception of losing a child as support to elaborate the grief mentioned they were encouraged not to do it i regret it and i wish i could go back to that moment because i wanted to have had unwrapped my daughter given her a bath and burried her with clothes you know as any other child but i was in great despair and they had already cut her her head was all shaved she was so ugly that i didnt have the courage to look maybe if anita had been encouraged to she would have been able to face her pain and care for her dead daughter so now she would not feel this regret do health professionals recognize this role as inherent to the care of women who have lost their children according to oishi 2 for the experience of grief it is important to encourage the parents to deal with their childrens death by indicating actions like seeing and touching the dead baby choosing a name and place of burial as well as having a wake however the team must be sensitive to respect the singularity of the situations 311 the rites of passage are intermediate and temporary moments of imprecision and crisis enabling the individual to reflect about his or her existence in society among them deathrelated rituals refer to the wake ceremony but also to details like picking rev paul pediatr 201836422427 up the body washing the dead body choosing the clothes and the place for the wake and burial their role is to symbolize an experience of loss and separation 28 and my mother didnt want to give the news to the whole family to the brothers because the body didnt come you know so i thought that but then after a while i was like mom i needed everyone around me i had to be with my sisters in this first moment after his death grief is mostly experienced in the family environment and mutual support helps in the process of adjusting to the loss 129 even though the family participates in this suffering the members need to understand that the parents especially the mother need unconditional emotional support 23 religion was referred to as an important factor for the acceptance of death in some reports death was seen as a gods will but we have to understand right its gods will not ours god is not obliged to justify anything to us right we have to accept it higher levels of religious involvement are positively associated with indicators of psychological wellbeing as well as better physical and mental health religious beliefs and practices can reduce the feeling of abandonment and loss of control that accompanies the sickening processes providing support and relieving the pain 12630 the support of family members and religious belief work as protective factors to deal with the pain caused by death 923 these women have told us about their grieving stories and for many of them this was the only chance to narrate the loss of their children which can contribute with the elaboration or the resignification of the experience on the other hand this scenario led to one of the study limitations considering that some did not accept to participate justifying they did not want to revisit this painful experience other limitations refer to the difficulty to ensure privacy in the household so some interviews were interrupted continuing later and to the difficulty to locate the women who had changed address conclusion the conclusion is that many teams are not prepared to communicate difficult news nor give the support to women who have lost their newborn children indicating the need for professional training and institutional policies that support and provide care to the workers for the interviewed women two things have helped in the grieving process the support received from the family and religion it is important to mention that it is essential that such support be offered also by the health team especially in the maternity ward and in the first moments after returning home finally the responsibility of the team does not end after communicating the death it is necessary to let the mother the father and the family aware that they can return to the hospital in case they wish to to talk about the death and clarify any doubts this return must be with the same neonatology team especially with a professional who has a closer relationship with the family besides it is essential to articulate with the primary care team so that care can be continued financing fundação de amparo à pesquisa e ao desenvolvimento científico e tecnológico do maranhão brazil conflict of interests the authors declare no conflict of interests

to analyze the communication of a childs death and the grief support provided to the women during puerperium methods this is a qualitative study performed at a capital of the northeast region of brazil semistructured interviews were carried out with 15 women whose children died from july 2012 to july 2014 the interviews contained questions about the childs death and the grieving process the content analysis was performed with a thematic approach results the women expressed the suffering and the anguish of the loss of a child sometimes aggravated by the way in which the news of death was delivered and by the lack of support offered in the coping process two empirical categories were found receiving the news of death and going back home emptyhanded the health care teams are not prepared to deliver bad news nor to give support to women who lose a newborn child according to the women the support received from the family and religion helped them in the grieving processthe results indicate the need for professional qualification for the delivery of bad news and for grief support they also showed the need for institutional policies that offer support to the professionals besides the articulation with the primary health care team is imperative for the continuity of care

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background loading mathjax jaxoutputcommonhtmlfontstexfontdatajs nepal is a tiny landlocked country that lies in the laps of the himalayas with an area of 147516 km 2 with a population of 26494504 and a population growth rate of 135 per annum women comprise more than half of the population ie 13645463 among the female population nearly half of the women are in the reproductive age group 1 the total fertility rate of the country is nearly stagnated at 23 in the 2016 nepal demographic health survey from 26 in the 2011 ndhs which is still high ndhs 2016 shows that approximately 53 of currently married women use a method of family planning and 24 have an unmet need for family planning services in nepal 323100 women had undergone abortion in 2014 and the abortion rate was 42 per 1000 women of reproductive age overall half of all pregnancies were unintended 2 the infant mortality rate was 32 in ndhs 2016 and maternal mortality was 229 per 100000 live births in 2011 which is still high 3 pregnancy intentions refer to the thinking of women at the time when she became aware that she was pregnant 4 pregnancy intention status can be categorized as intended and unintended 5 it can be measured by asking the pregnancy intentions of women at the time when she became pregnant 6 unintended pregnancy is a pregnancy that occurs either earlier than desired or when no more children desire at any time 7 unplanned birth is the birth resulting from unintended pregnancy 8 unintended births in contrast to intended births are less likely to recognize early in pregnancy and receive adequate prenatal care likewise unintended births are less likely to be on breastfeeding of any duration including exclusive births and they have to face outcomes such as preterm birth and low birth weight than intended births 5 the number of pregnancies worldwide is estimated to have been 213 million in the year 2012 and among them 190 million occurred in the developing world similarly more than half of all pregnancies occurred in asia worldwide 40 of pregnancies or 85 million pregnancies were unintended pregnancies in 2012 9 in the developing world the pregnancy rate was 143 pregnancies per 1000 women whereas in the developed world it was 90 pregnancies the rate of unintended pregnancy in the developing world was 57 per 1000 women and in the developed world it was 42 per 1000 women the unintended pregnancy rate was 36 higher in the developing world than in the developed world according to data from 2008 out of a total 1188 million pregnancies 38 were unintended in asia in 2008 10 in nepal the rate of unintended pregnancy was 68 per 1000 women of reproductive age and overall 50 of pregnancies were unintended in 2014 2 unintended pregnancy is a worldwide problem that causes serious health economic and social consequences for women their family society and nation 10 abortion is the frequent consequence of unintended pregnancy sixtytwo percent of unintended pregnancies ended in abortion in nepal in 2014 2 unintended pregnancy is one of the major reproductive health issues and troubling public health problems creating a socioeconomic burden on individuals and society it also affects a fertility indicator that reduces quality of life and workforce e ciency 11 unintended pregnancy varies by different factors including maternal age ethnicity poverty and education 12 the age of the respondents the total number of births family planning worker visits and knowledge related to family planning are the major contributing factors to unintended pregnancy 13 among multiparous women those who experience adverse outcomes in the previous pregnancy are more likely to report their pregnancy as unintended 14 a study conducted in bangladesh shows that unmet need for contraception is strongly loading mathjax jaxoutputcommonhtmlfontstexfontdatajs associated with unintended pregnancy the programme that addresses the unmet need for family planning could be helpful to reduce the prevalence of unintended pregnancy which consequently reduces the unsafe abortionrelated burden of mortalities and morbidities family planning programs aimed to reduce the unmet need for family planning that bene ts the reduction of the prevalence of unintended pregnancy 15 a study conducted in nepal in 2009 identi ed the age of mother age at early marriage media exposure and knowledge on family planning methods as important contributing factors to unintended pregnancy 16 more than half of the unintended pregnancies ended in abortion in nepal unsafe abortion is still common in nepal despite its legalization in 2002 2 worldwide 40 of pregnancies or 85 million pregnancies were unintended in 2012 9 the rate of unintended pregnancy in the developing world was 57 per 1000 women and in the developed world it was 42 per 1000 women out of a total 1188 million pregnancies 38 were unintended in asia in 2008 10 a crosssectional study of pakistan conducted in 2015 showed that 382 of pregnancies were unintended whereas 618 of pregnancies were intended among 3010 women 17 in 2014 unintended pregnancy was 68 per 1000 women of reproductive age in nepal it was highest in the central region half of the pregnancies were unintended either mistimed or unwanted with abortion as one of the most frequent consequences of unintended pregnancy nationally 31 of all pregnancies ended in abortion this proportion was highest in the central region one strategy to reduce abortion is to reduce the level of unintended pregnancy 2 the study shows that experience of unintended pregnancy is more common among younger women women who did not complete graduation and those who have higher birth order compared to intended pregnancy similarly women with unintended pregnancy had to face negative birth outcomes such as preterm birth and low birth weight which are less likely to breastfeed their child than intended pregnancy 5 an analytical study based on the ndhs 2011 dataset showed that education status occupation parity media exposure and autonomy on decision making were key predictors of unintended pregnancy 6 a study of india based on national family health survey data has shown lower unintended pregnancy among women of higher age having autonomy and access to mass media and higher education status 18 likewise a study of southern ethiopia conducted among married women in 2011 has shown less experience of unintended pregnancy among women who discuss family planning issues with husband and spousal communication was associated with unintended pregnancy with p 005 value 19 similarly another study of ethiopia showed that ever used family planning ve or more children were associated with unintended pregnancy 20 a study conducted in malawi concluded that pregnancy intention is associated with mother and father age education marital status number of live children socioeconomic status birth interval etc 21 identifying pregnancy intentions during prenatal periods helps to employ careful monitoring of pregnancy that is at high risk for mother and childrens health outcomes 22 unplanned birth and abortions are the major outcomes of unintended pregnancy it is considered one of the root causes of women seeking an abortion in 2014 the abortion rate in the central region was 59 per thousand women of reproductive age which was higher than the national average of 42 per thousand women of reproductive age 28 unintended pregnancy is one of the major troubling public health problems of reproductive issues it is loading mathjax jaxoutputcommonhtmlfontstexfontdatajs causing a socioeconomic burden to individuals and society ultimately decreasing the quality of life and workforce e ciency therefore it must be addressed adequately on time 11 unintended pregnancy is a contributing factor for maternal and infant mortality which is still high in nepal to reduce maternal and infant morbidity mortality and the need for abortion different types of programs strategies plans and policies should be planned with a focus on the highrisk group therefore it is crucial to identify and understand the factors in uencing unintended pregnancy which is essential to maintain and improve the overall health and wellbeing of women family society and nation 16 this study validated this information similarly very few studies have been carried out in nepal regarding pregnancy intentions with studies studying factors associated with pregnancy intentions taking primary data almost nonexistent no study has been found on this topic in a similar area of the county considering the high unintended pregnancy rate the proposed study has been forwarded to study the factors associated with it it is expected that the ndings of this study would be useful for academic as well as health management purposes at a different level the main aims of this study were to determine pregnancy intentions and assess associated factors among married women in resunga municipality gulmi nepal we estimated the prevalence of intended and unintended pregnancy analyzed factors associated with unintended pregnancy identi ed spousal communication on contraception between partners for pregnancy planning and identi ed autonomy to choose contraception methods this is a communitybased crosssectional study the study employed a quantitative paradigm with the aim of estimating pregnancy intentions and their association with different factors the sociodemographic and reproductive health variables are shown in fig 1 data collection the study was conducted in resunga municipality gulmi gulmi is a hill district of the western development region of nepal and one among the twelve districts of province ve it has been politically divided into two municipalities and ten rural municipalities the districts cover 1149 square kilometers the census of 2011 identi ed 64921 households with a total population of 280160 and a female population of 159165 in the district the district headquarters of gulmi is tamghas which is located 208 kilometers west of kathmandu a populationbased study using national survey data concluded that women from the hill region were more likely to report mistimed pregnancies than women from other regions and gulmi is also in the hill region the data was collected from ward numbers 1 2 4 6 7 8 9 10 11 12 and 13 wards of resunga municipality we collected data over a period of 15 months to achieve a sample size of 410 using the pretested semistructured interview schedule we prepared a consent form and semistructured interview schedule the questionnaire was pretested in a similar community that was different from the study site taking 10 of the sample size to remove ambiguity in answering with the purpose of easy administration the questionnaire was translated into nepali and then back translated to english to ensure accuracy the english version of the questionnaire is attached as supplementary le the study enquires about sociodemographic characteristics household economic status reproductive health and autonomy of women which was developed based on a standard questionnaire of the nepal demographic health survey 2011 with some modi cation to the local context the schedule was prepared in the nepali language for the actual eld study pregnancy intentions can be measured by using a measure of the national survey of family growth which is also known as a conventional measure of pregnancy intentions and is most used in the united states recognizing the need for a more re ned measure of nsfg has expanded its conventional measure which is known as an alternative measure of pregnancy intentions another measure is the london measure of unplanned pregnancy tool which is validated and used in multiple settings including south india this lmup tool had been modi ed to make it contextual as per study design and was used taking consent from the authority loading mathjax jaxoutputcommonhtmlfontstexfontdatajs data analysis the collected data were edited organized recorded and inserted into the latest data entry program prepared by the researcher in epidata following coding the compiled data were exported and analyzed using the latest statistical package for social science software version 25 ibm chicago united states then the data were analyzed using both descriptive and inferential statistics data analysis was performed in three stages in the rst stage descriptive analysis was carried out and frequency and percentage were presented and the mean median and standard deviation were calculated for continuous variables as per the need principal component analysis was used to generate the wealth index of families using household assets the socioeconomic status of the surveyed families was measured using the wealth index in determining the wealth index of the families covered in the study the presence or absence of a list of principle elements were taken into consideration and were determined by the method commonly known as principal component analysis and divided into ve quintiles of wealth the rst quintile represented the poorest segment of the population and the fth quintile represented the least poor segment the second stage of analysis involved testing the association between various independent variables and pregnancy intentions chisquare statistics and pvalues at the 95 level of con dence was conducted to maintain the minimum sample size in every cell for bivariate analysis necessary consideration was made while categorizing the response of the participants crosstabulation was performed for each variable of interest with pregnancy intentions the third stage involved logistic regression analysis between dependent and independent variables both bivariate and multivariate analyses were performed to determine the existence of statistically signi cant associations and strength of association between the dependent and independent variables of the study first bivariate logistic regression was performed followed by multivariate logistic regression based on a binary logistic regression model to adjust for the effects of other variables within the model control for possible confounders and test the strength of any association noticed in the bivariate analysis those independent variables that were found to be signi cant in the bivariate analysis and those variables that were important but not found to be associated in this study were also included in the multivariate analysis based on previous studies for this study a pvalue of 005 was considered signi cant hosmer and lemeshows goodness of t test was carried out to ensure that the model was t the model was t for our data as shown by the hosmer and lemeshow test and the test statistic was 0929 pregnancy intentions was the main outcome variable which was measured using the london measure of unplanned pregnancy lmup is a psychometrically validated measure of the degree of intentions of current and recent pregnancy that is designed to measure both pregnancy planning and intentions it is validated in a diverse setting and is in increasing use as a research tool lmup includes six questions each scored 0 1 or 2 then the score is summed to create an ordinal variable on a scale of 012 the loading mathjax jaxoutputcommonhtmlfontstexfontdatajs score can be interpreted as 03 unplanned 49 ambivalent 1012 planned re ecting increasing pregnancy intention with increasing each score 25 independent variables were compiled in the heading of sociodemographic characteristics and reproductive healthrelated variables sociodemographic variables included maternal age age at marriage ethnicity household size education occupation and socioeconomic status reproductive healthrelated variables include gravida parity history of abortion age of youngest child age at rst child ideal number of children use of contraception spousal communication and autonomy of woman ethical considerations this research was approved by the institutional review committee of institute of medicine tribhuvan university 075076 formal permission was taken from the concerned authority of gulmi district the interview was conducted only after obtaining informed verbal and written consent from the participants after explaining the studys aim objectives bene ts and con dentiality in cases of illiterate participants consent was obtained by a thumbprint on the consent form study participants had the right to withdraw from the study at any time they were told that they could decline the questions if they thought were sensitive and distressing to them con dentiality of each of the participants was maintained and no personal identi er was included in the analysis coding and aggregate reporting were used to eliminate participants identi cation and ensure anonymity respondents willing to know more about family planning were provided with some information at the end of the interview results a total of 410 married women who became pregnant within the last year including current pregnancy were enrolled in this study the descriptions of sociodemographic and reproductive healthrelated variables are presented in table 1 the study revealed that the majority of the women had two and fewer children as an ideal number of children and the remaining expressed more than two children as the preferred number of children it was interesting to see that approximately 320 percent of the womens husbands oppose family planning use according to this study 122 percent of the women never discussed family planning with their husbands before using contraception approximately 310 percent of the respondents reported that they were using any kind of contraceptive method to prevent pregnancy with the majority of modern methods users one in four women adopted natural methods for the prevention of pregnancy before the current pregnancy in addition 710 of women reported having no autonomy followed by some autonomy and full autonomy the data showed that out of 410 pregnancies 248 pregnancies were unintended of which 78 were unplanned and 170 were ambivalent the remaining 162 pregnancies were considered intended loading mathjax jaxoutputcommonhtmlfontstexfontdatajs bivariate analysis the bivariate analysis is shown in table 4 the chisquare analysis showed that female age socioeconomic status husband opposition methods used before pregnancy and intention to use contraception in the future were signi cantly associated with pregnancy intentions the analysis showed that marriage age ethnicity family size womens education spousal education womens occupation spousal occupation and other reproductive healthrelated characteristics and level of autonomy were not signi cantly associated with the pregnancy intention of women of reproductive age group despite the fact that their signi cance has been reported in other studies loading the proportion of unintended pregnancies was highest among women younger than 20 years compared to women aged 20 and older however intended pregnancy was highest among women aged 20 years and older these differences in pregnancy intentions by age group were statistically signi cant with a pvalue of 0008 in the chisquare analysis however the association became statistically nonsigni cant when adjusted for other variables in multivariate analysis the proportion of unintended pregnancies was highest among the women who were married before 20 years of age compared to women who were married after 20 years in contrast the proportion of intended pregnancies was highest among women who were married after 20 years of age most of the unintended pregnancies were from a relatively disadvantaged ethnic group followed by a disadvantaged and relatively advantageous ethnic group most of the unintended pregnancies were among women who belonged to the rst wealth quintile and intended pregnancies were more common among women who belonged to the third wealth quintile it is also statistically signi cant in chisquare analysis with pvalue 0001 unintended pregnancies were high among women who were primi had more than two para had done abortion and had done an abortion at least one time nonspontaneously more than 60 percent of unintended pregnancies were among women whose youngest child was more than one year and who delivered her rst child before or at 20 years of age most of the unintended pregnancies were among women who preferred less than or equal to 2 children as an ideal number of the child approximately 580 percent of unintended pregnancies were among women who did not discuss with her husband before using contraception there were 695 percent of unintended pregnancies among women whose husbands opposed using contraception other factors signi cantly associated with pregnancy intentions as shown by bivariate analysis were husband opposition in using contraception method of family planning used before pregnancy and womens intention to use contraception in the future multivariate binary logistic regression loading mathjax jaxoutputcommonhtmlfontstexfontdatajs the multivariate binary logistic regression is shown in table 5 in the multivariate logistic regression model after possible effects of confounders were adjusted the method of family planning used before pregnancy and wealth quintiles as the independent variable were signi cantly associated with pregnancy intentions at 95 ci women from the second and third wealth quintiles had a lower chance of having an unintended pregnancy in comparison to women from the fth wealth quintile women who used the natural family planning method before pregnancy had a lower chance of having an unintended pregnancy than women who used the modern family planning method before pregnancy however husband opposition to use contraception parity the ideal number of children spousal communication level of autonomy and future intention of using contraception were not depicted to be associated with pregnancy intentions as per this study loading mathjax jaxoutputcommonhtmlfontstexfontdatajs pregnancy in this study is higher than that of the studies from ethiopia 13 pakistan 17 bangladesh 27 and brazil 14 in our study age was signi cantly associated with unintended pregnancy young women below the age of 20 years were more likely to report unintended pregnancy in comparison to women from the above age group with a similar pattern from other studies of nepal 6 ethiopia 28 pakistan 17 malawi 21 nairobi kenya 29 and congo 27 these effects of age on unintended pregnancy can be explained by the fact that young women may have sexual relations for reasons other than childbearing and they may have inadequate knowledge and skills regarding birth control therefore increasing the likelihood of pregnancies being unintended 30 likewise the number of family members was not found to be associated with unintended pregnancy in this study which is consistent with the ndings of ethiopia 28 this study revealed a higher percentage of unintended pregnancies among women with less than or equal to six family members than among women with more than six family members the reason might be that women with a small number of family members may perceive their pregnancy as unintended due to the lack of care takers in house and being unable to allocate time for rearing and caring of children regarding the educational status of respondents husbands it has been found that couples with higher education have better knowledge of the uses and bene ts of family planning making every pregnancy planned in contrast it was found not to be associated with pregnancy intentions this is consistent with the ndings made from another study conducted in nepal 6 but contrasts with the ndings of a study by malawi 21 and congo 27 where there was an association between partners education and pregnancy intention this study has shown a higher percentage of unintended pregnancies among women whose husbands had taken formal education the reason might be simply because they might have more con dence regarding the ability to control the timing of their pregnancies 6 and could also be because of negligence in the current study the occupation of women was not found to be associated with unintended pregnancy which is similar to the nding of a study in egypt 31 however this nding is contrasting with the ndings of a study of nepal 6 iran 32 and brazil 14 which could be because of differences in circumstances and varying natures in the measurement of study variables this study has resulted higher percentage of unintended pregnancies among women who were engaged in nonagricultural paid work this could be due to being more career oriented and due to lack of leave as per their requirements making them perceive their pregnancy unintended a signi cant association was seen between pregnancy intentions and socioeconomic status after adjusting for other factors which is similar to the ndings of ethiopia 28 and nigeria 33 this nding contradicts the ndings made in nepal 6 and pakistan 17 women from the lower wealth quintile that means the lowincome group and third wealth quintiles had a lower chance of having an unintended pregnancy in comparison to the women of a uent ones this could be because this study has not included loading mathjax jaxoutputcommonhtmlfontstexfontdatajs educational status in the construction of the wealth index 28 therefore education may play a vital role in decision making gravidity was not found to be associated with pregnancy intention in this study which is similar to the nding of a study by ethiopia 34 but it contradicts the nding of a study by tanzania 30 and canada 35 where there was a signi cant association between the number of pregnancies and unintended pregnancies in this study there was a higher percentage of unintended pregnancies among women who had been pregnant for the rst time the reason behind this nding might be that rst pregnancy might not necessarily be planned making that unintended the frequency of abortion was not found to be associated with unintended pregnancy in this study which is consistent with the ndings of a study in egypt 31 this study revealed a higher percentage of unintended pregnancies among women who had terminated their pregnancies at least once compared to those who had terminated their pregnancies more than or equal to twice this result might be because women who had terminated their pregnancy more than once may become more cautious toward pregnancy planning due to the experience of complications and consequences of abortion the age of the youngest child was not found to be statistically signi cant with pregnancy intentions in this study which contradicts the ndings of a study of malawi in which time since last birth was associated with pregnancy intentions 21 there was a lower percentage of unintended pregnancies among women whose young child was less than and equal to twelve months of age this could be because couples might feel comfortable raising both children with a short gap between them so that they grow together communication between husbands and wives regarding contraception might help to involve husbands in contraception decisions leading to increased acceptance of contraception utilization and decreased failures in contrast to this concept it was not found to be associated with pregnancy intentions in this study which is similar to the ndings of congo 27 and ethiopia 34 this nding is inconsistent with the ndings of tanzania 30 ethiopia 19 and egypt 31 in this study there was a 28 percent higher prevalence of unintended pregnancy among women who had communication with their husband the reason might be that although they have communication between partners women might not have autonomy to decide on fertility 34 husbands play a major role in family planning utilization husband opposition in using contraception was found to be signi cantly associated with pregnancy intention in the bivariate analysis of this study this nding is inconsistent with the results of the study of ethiopia 36 there were 695 percent of unintended pregnancies among women whose husband opposed using contraception which is higher than that of ethiopia where there was 185 percent unintended pregnancy due to husband refusal to use contraception 37 the reason might be due to the lack of autonomy regarding household decision making and deciding their health needs including lack of knowledge regarding consequences of unintended pregnancy 36 loading mathjax jaxoutputcommonhtmlfontstexfontdatajs a signi cant association was seen between pregnancy intentions and method of family planning used before pregnancy to control pregnancy in bivariate and multivariate analyses in this study this nding is similar to the outcome of a study by congo 27 and bangladesh 38 similarly behind the higher probability of unintended pregnancy among women who had used modern contraception before pregnancy there might be a possibility of problems with contraceptive use effectiveness including contraceptive discontinuation and failure 38 another view might be that the users of modern methods might have high expectations towards limiting and spacing their pregnancies and misconceptions regarding lower fertility while using contraception therefore they may consider their pregnancy as unintended 39 the intention of women to use contraception in the future was found to be signi cantly associated with pregnancy intentions in the bivariate analysis in this study there was a lower risk of having unintended pregnancy among women who had not intended to use contraception in the future in comparison to those who intended to use contraception in the future this nding is inconsistent with the outcome of the study of nepal 6 where there were lower odds of unwanted pregnancy among women who were intended to use contraception in the future the reason behind this nding might be that this study assessed intention to use contraception in the future as a proxy measure of behavior the possible gap between intention and actual practice of women could be the presence of some factors that were considered to be constraints to their intentions to use contraception in the future such as husbands opposition and fear side effects making differences between intentions and actual behavior 31 empowered women with strong decisionmaking power in major household decision making are more likely to plan their pregnancy however in contrast to previous literature the level of autonomy was not found to be associated with pregnancy intentions in this study which is similar to the nding of a study of nepal that was conducted in 2009 16 and contradicts the nding made from a study based on the ndhs dataset of 2011 in nepal 6 ethiopia 19 india 18 and bangladesh the study of bangladesh has shown that a oneunit increase in the autonomy scale decreases the odds of unintended pregnancy by 16 40 in this study most unintended pregnancies were among women with some autonomy the mechanism behind this might be due to taking previous or current pregnancy unintended because of lower fertility aspiration by empowered women or limited decisionmaking opportunities to women being in the patriarchal society 616 although this study was strengthened by being communitybased research and having used the validated pregnancy intentions scale to measure the pregnancy intentions of women it had some notable limitations this was a crosssectional study so it does not allow causal inference for pregnancy intentions and other independent variables such as sociodemographic and reproductive healthrelated variables this study included only married women whereas the majority of unintended pregnancies resulted from illegitimate sexual intercourse which is more common among sexually active teenagers and unmarried women in addition another limitation might be social desirability bias leading to reporting intended pregnancy although it was not this might lead to underestimating the burden of loading mathjax jaxoutputcommonhtmlfontstexfontdatajs unintended pregnancies similarly this study does not determine the intentions and associated factors of women who terminate their pregnancy by abortion and miscarriage lastly the results may not be generalized to the whole country as the study was conducted in one municipality of a district conclusion this study estimated the prevalence of unintended and intended pregnancy among married women of reproductive age and identi ed the factors associated with it the study showed that unintended pregnancy is still high and more than fty percent of pregnancies are unintended the factors that were found to be associated with an unintended pregnancy were socioeconomic status and method of family planning used before pregnancy women who were from the second and third wealth quintiles were less likely to have an unintended pregnancy than those from the fth wealth quintile likewise women who used the natural family planning method before the most recent pregnancy were less likely to experience an unintended pregnancy than those who used a modern method of contraception before pregnancy therefore the relationship between the use of modern methods and increased risk of unintended pregnancy suggests an urgent need for further research however other study factors such as marriage age of women ethnicity family members womens education husbands education womens occupation husbands occupation gravidity parity history frequency reason of abortion age of youngest child age of women at her rst child ideal number of children and contraception use before pregnancy were not found to be associated with pregnancy intentions spousal communication and autonomy of women were also not associated with pregnancy intentions unintended pregnancy was high in this study so awareness programs should be raised at the community level women using natural family planning methods before pregnancy are less likely to have an unintended pregnancy the use of natural family planning methods is not always accurate therefore both types of methods need to be equally valued and promoted efforts to increase the knowledge and availability of family planning especially the different methods should be strengthened the use of modern methods and increased risk of unintended pregnancy suggests an urgent need for further research a qualitative study is recommended to explore the relationship between unintended pregnancy and the method of contraception used before pregnancy and socioeconomic status of the family at the same time it is a crosssectional study that might not have shown a causal relation between various independent variables and pregnancy intentions therefore further studies are required to evaluate the causal relationship between independent variables and pregnancy intentions anc descriptive analysis the mean age of the respondents was 2432 years and the mean age of marriage was 1894 the descriptive analysis is shown in table 3 the highest proportion of women were from the age group 2034 years of age the youngest respondents accounted for 105 percent of the total respondents more than 77 percent of the women were married before and at the age of 20 years furthermore most of the respondents were multigravida and para 2 aborted pregnancy at least once the mean age of the women at her rst child was 2074 the majority of the womens rst childbearing age was 20 years and less followed by 20 years above loading mathjax jaxoutputcommonhtmlfontstexfontdatajs variable crude odds ratio 95 ci adjusted odds ratio 95 ci pvalue full autonomy ref the analysis was t in a logistic regression model where y is the log odds of the dependent variable β 0 is a constant β i is the regression coe cient and xi is an independent variable the logistic regression revealed the following equation for pregnancy intentions pregnancy intentions 6485 3029 discussion the ndings of the study showed that 248 pregnancies were unintended pregnancies of which 78 were unplanned and 170 were ambivalent in total the remaining 162 pregnancies were considered intended this nding is consistent with the estimated national prevalence of unintended pregnancy by ndhs 2016 24 a hospitalbased crosssectional survey conducted in pakistan in 2015 adopting the lmup tool revealed 383 unintended pregnancies of which 139 percent were ambivalent and 243 percent were unplanned 26 similarly a study carried out on the basis of the ndhs 2011 dataset in 2015 showed that the unintended pregnancy rate was 2459 6 in 2012 40 percent of pregnancies were unintended globally 9 a communitybased crosssectional study carried out in ethiopia in 2013 showed 365 percent unintended pregnancy 13 the estimate of this study is higher than that of previously reported data which might be because previous studies used a dichotomous scale whereas this study employed sixitem lmup the prevalence of unintended js has contributed in data collection all authors read and approved the nal manuscript figure 2 sampling procedure supplementary files this is a list of supplementary les associated with this preprint click to download questionnairedocx loading mathjax jaxoutputcommonhtmlfontstexfontdatajs

pregnancy intention refers to a womens thinking at the time she became aware that she was pregnant pregnancy intentions can be categorized as intended and unintended it is an important public health concern in every corner of the world especially in developing countries the study was carried out with an objective of determining the pregnancy intentions among married women in resunga municipality gulmi nepal and test the association of pregnancy intentions with various sociodemographic and reproductive healthrelated variablesthe community based crosssectional study design was used to achieve the objective of the study married women of reproductive age of the resunga municipality gulmi were selected and a multistage random sampling technique was adopted total 406 participants were involved in this study pretested semistructured interview schedule adapted from demographic and health survey of nepal was used for data collection all the statistical tests were performed in spss version 250 the p value was set at 5 level of signi cance descriptive and data exploratory analysis were performed bivariate and multivariate logistic regression analysis technique were conducted to explore the association between pregnancy intentions and predictor variablesthe study showed that out of total 410 pregnancies 248 605 pregnancies were unintended of which 78 1905 were unplanned and 170 415 were ambivalent the remaining 162 395 pregnancies were considered intended the chisquare analysis and bivariate analysis showed that women age socioeconomic status husband opposition methods used before pregnancy and intention of using contraception in the future were signi cantly associated with pregnancy intentions when these variables were subjected for multivariate analysis only socioeconomic status and method of family planning used before pregnancy were found to be signi cantly associated with pregnancy intentionsthe study showed that unintended pregnancy is very high the factors that were found to be associated with an unintended pregnancy were socioeconomic status and method of family planning used before pregnancy the ndings of this research work could be useful while providing different reproductive and family planning related services to women by considering predictors of unintended pregnancy that might increase planned pregnancy ultimately

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background breast cancer accounts for 30 of new cancer diagnoses and is one of the most common types of cancers 12 according to the world health organization bc is the second leading cause of death from cancer in women 1 the prevalence of bc has been estimated to increase from two million patients in 2018 to more than three million patients in 2046 representing 46 increase 1 bc also accounts for 76 of cancer cases among iranian women and the total number of bc diagnosis is 42 000 annually more than 7 000 new cases of bc are diagnosed 3 it has been estimated that the incidence of bc in iranian women will be tripled annually until 2030 4 more than 40 of iranian women with bc diagnosis are in the age range of 4050 years indicating a lower age at bc diagnosis compared to women in other countries 5 the relative 5year survival rate of these women has improved over the past 3 decades due to advances in early detection through increased awareness and the widespread use of mammography 6 according to global statistics the relative 5years survival rate of bc has reached 90 1 studies show that the fiveyear survival rate in iranian women with bc varies from 51 to 765 7 8 9 10 open access correspondence the recent high survival rate of bc has attracted the attention of health researchers to the quality of life and sexual life of these women and their families 1112 sexual problems can be the result of any type of cancer but it is more common in women with bc because the breast is the symbol of femininity and plays an important role in sexual pleasure and arousal 13 bc treatment has a wide range of physical and psychosocial consequences and leads to dysfunction and unpleasant changes in womens sexual function 1415 for example mastectomy can change the individuals perceptions of body image and reduce sexual attractiveness and femininity 16 chemotherapy causes hair and weight loss and induces premature menopause moreover radiotherapy causes pain and dermatitis which decrease womens libido 17 it is believed that deficiencies in sex hormones and changes in the body image alter the sexual function and cause arousal disorders painful intercourse and sexual dissatisfaction 18 bc is a complex health problem and is difficult to cope with 19 bc diagnosis in women can cause different health consequences for the whole family especially for their spouses 20 bc can directly influence the quality of marital relationships and sexual function 1821 therefore bc is considered a disease of couples or relational cancer it causes challenges including anxiety depression and sexual dysfunction in the marital relationship that are experienced not only by women but by also by their husbands 2223 sexual relationship is an important part of marital relationships 24 and reduces emotional stress during bc treatment it can improve psychosocial reactions to bc cancer diagnosis 25 it is believed that couples experience more issues in their sexual relationships after bc diagnosis compared to before it 21 a study on 1011 patients showed that 70 of women with bc suffered from sexual dysfunction during the treatment process 26 bc survivors often avoid having sexual relationships with their partners but some others prefer having a close and intimate sexual relationship without vaginal intercourse 19 moreover bcrelated changes can increase the emotional distance between couples related psychological stress reduces marital satisfaction 27 the husbands of women with bc also experience many problems in their sexual life 20 that can have negative consequences for their emotional psychological and physical wellbeing 28 they have to deal with and adapt to life changes and provide support to their wives and children 20 issues in their sexual intimacy and inclination to talk about their feelings and concerns can ignite frustration anxiety and communication problems 20 29 therefore their marital relationship should be strengthened to prevent more damages to their sexual relationships 29 background in iran cultural and religious factors can influence the psychosexuality of women and their husbands 17 in the iranian culture the desire for having sexual relationships by women through requesting or showing interest is considered inappropriate also the husbands preferences and satisfaction with sexual relationships are considered more important than the wifes satisfaction 21 since couples usually do not talk to each other about sexual issues they do not reach an agreement on how sexual issues should be resolved 30 couples also are ashamed of talking about sexual issues with their healthcare providers it causes that sexual problems to remain unrecognized and unresolved 31 therefore couples should be assessed by healthcare professionals with regard to their sexual problems and receive recommendations to meet their needs 32 nevertheless the iranian healthcare system has not reached the optimal performance to proactively assess sexual problems among bc patients and their husbands 33 the role of the husbands of women with bc to cope with bc has been emphasized 34 given that they are in the best position to identify challenges in their sexual life accordingly healthcare providers can devise strategies to improve the couples adaptation to sexual problems during the treatment process 31 therefore this study aimed to explore changes and challenges in sexual life experienced by the husbands of women diagnosed with bc methods design and participants a qualitative research using conventional content analysis was used qualitative content analysis helps describe and interpret textual data based on the systematic process of data coding indepth descriptive and wellorganized summary of research findings requires conducting qualitative research instead of quantitative research 35 the article was reported using the standards for reporting qualitative research guideline 36 the participants were selected using purposive sampling from june 2019 to february 2020 in an urban area of iran based on the following eligibility criteria men living with their wives diagnosed with bc being at stages 13 of bc and undergoing bc treatment for the past 15 years the presence of mental and other chronic diseases in men and their wives led to their exclusion ethics considerations the ethical approval was obtained from the ethics committee affiliated with shahroud university of medical sciences also authorities granted permissions to enter the hospital before getting access to the patients medical files sufficient explanations were given to the participants about the research purpose voluntary nature of participation in this study anonymity and right to withdraw from the study at any time and confidentiality of collected data written informed consent and permission to audiorecord the interviews were obtained from the participants before data collection data collection two researchers decently reviewed all medical files of the women diagnosed with bc who completed their treatments in the past five years in a referral hospital among 156 reviewed medical files 52 of them had initial eligibility criteria next the husbands of these women were contacted via phone call to review their additional eligible criteria those participants who met the full inclusion criteria were invited to be interviewed the recruitment process was continued until data saturation was reached when data analysis did not lead to the exploration of new findings which happened after 18 interview sessions indepth semistructured interviews using openended questions were carried out by the male researcher in farsi he scheduled appropriate time and place convenient to the participants to ensure of not interfering in their daily life routines the interview guide consisted of questions that helped with collecting indepth data about the research phenomenon the main focus of the questions was changes happened in the life and sexual relationships after bc diagnosis these questions were compiled by the research team after conducting a literature review on sexual life and its related issues among bc survivors the depth of interviews was improving through asking probing questions to follow up the participants perspectives the interviews lasted 4575 min and 14 participants were interviewed once four other participants were interviewed twice to remove ambiguities in the data collection process therefore 22 interviews were performed with 18 participants all interviews were recorded using a digital audio recorder questions about the participants sociodemographic characteristics including the participants age education level duration of the marriage number of children place of residence employment status economic status the participants wifes age time passed from bc diagnosis and cancer treatment modalities were asked before the interviews the researchers were faculty members of nursing and midwifery schools at the time of the study they were experts in qualitative research and had previous experiences with conducting qualitative research in cancer care two researchers have clinical work experiences with cancer patients but they had no relationship with the study participants before the research they wrote reflective notes to bracket their own assumptions regarding the study phenomenon data analysis verbatim transcribing of the interviews was performed immediately by the responsible researcher and simultaneously was entered into data analysis by the research team applying conventional qualitative content analysis 3738 to immerse in the data and gain an indepth understanding of the interviews content the transcripts were read linebyline several times the meaning units were derived from the transcriptions and were labeled through open coding codes were assigned into categories based on their similarities the codes and categories were compared together and concerning the whole data using the constant comparison method to develop the main theme and related subthemes 3538 trustworthiness of data the four components of trustworthiness for qualitative research suggested by lincoln and guba including credibility transferability dependability and confirmability were applied strategies used to strengthen the credibility of this study were prolonged engagement with the research settings and participants reflexivity peer debriefing and member checking also the interviewer wrote reflective notes to bracket his own assumptions about the study phenomenon and ensure that the research findings reflected the participants perspectives for peer debriefing a third researcher reviewed and assessed the data analysis process also a summary report of research results was provided to two participants who confirmed that our findings demonstrated their perspectives transferability was ensured through the provision of a thick description of the research findings for dependability and confirmability audit trial was used an impartial person who was expert in qualitative research was asked to review and assess the transcripts data analyses and findings 39 results the participants were married and had the age range of 4257 years the mean duration of their marriage was 2116 years most of them had one child or 2 children resided in the city and had an underdiploma education degree their wives had an age range of 3350 years bc diagnosis happened in 566 and 444 of the participants wives more than 3 years ago and in the last 13 years respectively the majority of the participants wives had undergone mastectomy the participants experienced substantial changes in their sexual life due to the diagnosis and treatment of bc in their wives our research findings consisted of the main theme of sexual life suspension and three subthemes of unfulfilled sexual expectations perceived barriers to satisfy sexual expectations and efforts to adapt to sexual problems sexual life suspension bc severely affected the sexual life of the men following the occurrence of changes in the wellbeing and sexual health of their wives after the diagnosis of bc major changes occurred in the couples marital life leading to various challenges there were barriers to meet their sexual needs but each person responded differently to them therefore the sexual life of the men was suspended unfulfilled sexual expectations the participants mostly reported a normal sexual life before the onset of bc some other men complained about sexual coldness in their wives even before bc before this disease my wife and i had sexual relationships almost every 10 or 15 days and we experienced no problem in our married life 6 48 years old we did not have an understanding about sexual issues at the beginning of bc my wife was sexually very cold and she did not like to have any sexual relationship we had a sexual relationship once or twice a month it reduced greatly after bc diagnosis negative changes in their sexual relationships following bc diagnosis were characterized as a reduction in sexual desire frequency of sexual relationships and sexual dissatisfaction a sharp reduction in the frequency of sexual relationships was reported indicating having no sexual relationships during a year it was attributed to the consequences of bc treatment including decreased physical charm and libido vaginal dryness and painful intercourse before my wifes disease we had sex every 710 days but my wife felt often bored was not interested in having sex was harassed during intercourse then the frequency of our sexual relationship decreased a lot and this is now once or twice a year the frequency and duration of our sexual inter bc had negative consequences for their wives sexual desire the men wanted to have sex and satisfy their own sexual needs but their sexual desire for their partner had been diminished though their instinctive sexual desire was high before the disease we had sex twice a week even three times a week but at this moment we do not have sex my sexual desire is fine no but i do not want to have sex with my wife anymore the occurrence of bc was a great shock to the participants life and affected all aspects of their life so that their sexual desire toward their wives decreased therefore their wives more often asked for having sexual relationships given the reduction in the participants sexual desire for their wives and the frequency of sexual relationships their sexual needs were not met leading to sexual dissatisfaction my sexual expectations in the marital relationship have not been really met after bc diagnosis breast removal and many other things related to my wifes illness suppressed my sexual desire naturally i withdrew myself so i have no longer sexual satisfaction perceived barriers to satisfy sexual expectations barriers to meet the participants sexual needs were the sense of human aestheticism culture and insufficient sexual health support and education by healthcare providers changes in their wives appearance were the basis of a series of new changes in their sexual life their wives had no longer those previous beauties and charm on the other hand the participants innate sense of aestheticism like any human being who was attracted to beautiful phenomena inevitably reduced the sexual attraction of men to their wives the presence of this innate sense was an important obstacle to have sexual relationships appearance changes such as hair loss affected my sexual relationships suppose you had a beautiful woman now she has no hair her breasts are removed well you do not like to touch her if i go to my wife she will be aroused but i do not go i no longer have that state of lust i love beauty and my wife has no longer that beauty … a woman who until 6 months ago for example combed her hair arranged her eyebrows did makeup … but now my wife has no beauty to persuade me to go to her culture as an integral part of human life influenced sexual life concubine as to have extramarital sexual relationships was culturally unacceptable in the iranian society therefore it hindered finding a sexual partner at a time when the men were unable to meet their sexual needs with their wives the participants needed to receive support training and information on sexual issues from healthcare providers they acknowledged that they had not received any support or training about it having sex with another woman is culturally unacceptable here others may say look at this man his wife is still alive but she is just sick and he has sexual relationships with another woman in my opin healthcare staff was supposed to talk to us in the hospital about sexual problems but later they said no consultation about it could be provided no one talked to us about it anymore i did not know where to go and what to do they healthcare providers did not inform us about the sexual relationship the doctor only said you should not have children and getting pregnant means death some participants turned to unofficial information sources after that they did not find answers to their inquiries about sexual problems when i found out that my wife and i had no problem in sexual intercourse but my wife vagina was dry i searched on the internet and found out a series of gels that could alleviate vaginal dryness efforts to adapt to sexual problems the participants experienced sexual crisis and used a variety of adaptation measures to overcome it for instance they imagined their wives condition and made empathy i thought to myself what my wife would have done if this had happened to me i expected that my wife should deal with it and should not leave me alone therefore i decided to cope with it loyalty to and affection for their wives facilitated coping with sexual problems i have a belief that if someone gets married to someone he must remain faithful to her and stay by her side if my wife does not even have two hands i deal with it it is so unscrupulous and cowardly that i leave my wife because my sexual needs are not met i do allow myself to look at her breasts so that she does not feel embarrassed i act as if nothing has happened at all and it does not matter to me i am ready to sell my eye cornea for her to get recovered i love her so much that i have dedicated my life to her to deal with the sexual crisis the participants reduced their sexual expectations from their wives they dreamed a day when everything would return to normal after my wifes illness our marital and sexual life was completely destroyed the situation became very difficult for me and i hoped that the situation would change over time i am just waiting for that our sexual relationship gets improved i should reduce my sexual expectations there is no other way and i think this is the best strategy although the participants were committed to have sexual relationships only with their wives some of them had sexual relationships with another sexual partner in the face of sexual crisis and to meet their sexual needs during my wifes treatment when we could not have sex for a long time i went looking for another partner this was only to meet my own sexual needs one of the most difficult adapting behaviors was the suppression of sexual desire the participants experienced sexual helplessness as they had no choice but to suppress their sexual desire i have suppressed my sexual desire for a long time because of my wifes illness and i try not to think about it anymore my sexual need is not met i cannot do anything special but to suppress it discussion a few qualitative studies so far have addressed sexuality and sexual health among men after the diagnosis of bc in their wives this qualitative research explored changes and challenges in sexual life experienced by this vulnerable group we found that men experienced unfulfilled sexual expectations given the occurrence of significant changes in their sexual relationships barriers to meet their sexual needs and efforts made by them to adapt to sexual changes were explored unfulfilled sexual expectations consisted of a reduction in the frequency of sexual relationships diminished sexual desire and sexual dissatisfaction similarly a quantitative descriptive study on sexual adjustment among israeli men after bc diagnosis showed that over 70 of them had difficulties in their sexual activities 40 a qualitative study in the usa reported that mens sexual desire for their wives diminished after bc diagnosis 41 furthermore in another qualitative study in the iranian context mens sexual desire decreased mostly due to mastectomy and treatment complications such as alopecia 31 a cohort study revealed that the partners of young bc survivors had more sexual difficulties and less sexual enjoyment compared to the partners of healthy controls 42 undesirable sexual functions have been reported in studies on the sexual issues of women with bc the majority of chinese women with bc suffered from a significant reduction of sexual desire and frequency of sexual activities 43 changes in sexual life including reduced sexual relationships and sexual desire in bc survivors have been reported by many studies 44 45 46 47 barriers to meet sexual needs were described by our research participants the participants innate sense of aestheticism reduced their sexual attraction to their wives given the occurrence of changes in the womens physical attractiveness according to nasiri et al s study unpleasant senses experienced by men because of physical changes in their wives led to avoid close contact with their wives and having sexual relationships 31 men often get separated from their wives because of the diseases impact on their sexual relationships 1420 indian women with bc undergoing mastectomy also stated that their husbands had arousal difficulties 48 bc treatments usually cause most women to feel sexually inadequate and incomplete which is likely associated with marital separation and breakdown of sexual relationships 49 physical and appearance problems in women following the treatment of bc are the common sources of sexual problems in men 181947 sexual attractiveness and body beauty for women are emphasized in some cultures brazilian men consider the body beauty of women as an ideal not only for marriage but also for sexual relationships 50 therefore breastconserving surgery has become a routine approach to bc treatment in recent years however some patients still require mastectomy to decrease the risk of bc relapse 5152 a prospective controlled study suggested that those women who underwent a mastectomy were probably more at the risk of postoperative sexual dysfunctions 53 zehra et al in a systematic review and metaanalysis reported that patients with breastconserving surgery exhibited a better body image and physical and sexual health than those with mastectomy 54 therefore it is important to pay attention to the quality of the surgery type because poor surgeryrelated cosmetic outcomes can impair sexual health 55 in some cultures such as brazil having extramarital sexual relationships in situations that wives are unable to meet their sexual needs has been suggested 4450 however having an extramarital sexual relationship is unacceptable in islam and the iranian culture 19 the tradition of temporary marriage in islam supports mens decision to marry more than one woman on the other hand remarriage for men when their wives become ill is unacceptable in the iranian culture and is dependent on fulfilling legal requirements 56 iranian women also forcefully disagree with their husbands remarriage lack of support education and training about sexual issues by healthcare providers was another perceived barrier in our study provision of adequate support and information concerning intimacy and sexuality can decrease distress in women with bc and their husbands 57 this is a common finding in other studies that healthcare providers typically do not provide support and education about sexuality to patients with bc and their partners 49 58 59 60 there is a need to create an open truthful accepting communication environment with bc women and their husbands within the healthcare system and help them meet their sexual health needs 6162 education programs for healthcare providers can improve their knowledge of sexual issues related to bc and how to communicate them to patients and their husbands 61 when sexual issues are discussed with healthcare providers husbands may not always be present to hear written information regarding sexual issues can improve their knowledge of how to resolve sexual issues during bc treatment 59 the participants experienced sexual crisis after the diagnosis of bc in their wives some of them used the strategies of empathy loyalty patience and hope to normal conditions in the future some others went looking for sexual relationships with another sexual partner or suppressed their sexual desire in dealing with this crisis the adopted strategies can be various based on religious beliefs and relationship contexts 47 muslims believe that illness is a kind of test of god and god wants to see if they can endure difficulties or deviate a qualitative study on iranian men after bc diagnosis in their wives reported that the suppression of sexual desire toleration of sexual frustration and loyalty to their wives helped overcome unmet sexual needs 31 however in the taiwan context women with bc reported that their husbands had illegal sexual affairs with another partner 45 in addition malay women with bc proposed their husbands to marry another woman in order to meet their sexual needs 47 jones et al s study on canadian women with bc showed the necessity of having appropriate empathy and a greater understanding and awareness of their husbands throughout cancer trajectory 63 limitations the present study is the pioneer of exploring mens sexual changes and challenges after bc diagnosis in their wives some limitations might have affected our data collection and analysis our participants experiences might not be the representative of men with wives diagnosed with bc that would be outside of the reproductive age the researchers bracketed their presumptions and ideas using reflexivity but the researchers subjectivity inevitably might have affected the interview process this condition is especially relevant in the current study since the interviewer has been a qualified nurse and had a specific interest in this topic the participants were recruited from a hospital in an urban area of iran which could impact on the transferability of our findings to other contexts taboo attached to sexual and marital issues in the iranian culture might have caused the concern of disconnection of the alliance between the researcher and the participants and could hinder collecting indepth data about the research phenomenon conclusion this study improves our knowledge of sexual changes and challenges experienced by the husbands of women diagnosed with bc following the diagnosis of bc major changes and challenges occur in the marital life of women with bc and their husbands which suspend mens sexual life our findings inform healthcare providers about the significance of paying attention to sexual health problems experienced by men during bc treatment they should provide opportunities for the husbands of women with bc to express their concerns about their sexual health issues this will promote helpseeking behaviors in this vulnerable group it is also recommended that topics concerning the sexual life of women with bc and their husbands are incorporated into healthcare programs aiming at the improvement of qol in couples education and counseling about sexual relationships during the treatment of bc should be one part of the holistic program aiming at the improvement of couples sexual life and should be easily accessed by them in community settings supportive interventions by healthcare professionals for the husbands of woman with bc hinder further damages to marital relationships between couples future research is needed to design strategies for the provision of appropriate support to women with bc and their husbands and examine their effects on couples sexual life in addition future research should be conducted in other contexts they can consider the development of appropriate practical instruments for the investigation of sexual life among the husbands of women with bc abbreviations additional file 1 interview guide competing interests the authors declare no conflict 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 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background breast cancer bc in women can bring various problems to their marital and family life sexual life based on the experiences of the husbands of women diagnosed with bc has not been fully understood therefore this research aimed to explore changes and challenges in sexual life experienced by the husbands of women diagnosed with bc methods a qualitative research was carried out on 18 men whose wives had been diagnosed with bc at reproductive age they were selected using purposeful sampling and were interviewed using indepth semistructured interviews collected data were analyzed using the conventional content analysis method results sexual life suspension was the main theme of this research also unfulfilled sexual expectations perceived barriers to satisfy sexual expectations and efforts to adapt to sexual problems were subthemesthe husbands of women with bc need support to improve their sexual and marital relationships education and counseling about sexual life during the treatment of bc should be incorporated into the healthcare program

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introduction the criminal career perspective incorporates an approach to studying offending which examines criminal activity over time acknowledging the connection between offending and the life course however the ways in which the concept of a criminal career has been adopted within the discipline of criminology differ significantly broadly one approach lies within the positivist paradigm concerned with predicting criminal careers using a list of risk factors an alternative approach privileges the individuals subjective experiences and acknowledges the potential for change during the life course this latter approach conceptualising offending as a process of change connected to life events requires an understanding that not only incorporates criminological theory but additionally considers the social cultural and political processes that impact on individuals lives some recent examinations of youth offending therefore have drawn on youth sociology presenting offending in the wider context of young peoples biographies and their transition into adulthood thus taking account of larger social contexts and processes of change drawing on selected findings from an indepth biographical study of a group of young peoples offending careers in ireland this article provides an analysis of those processes associated with the onset of offending specifically it examines one dimension of this process by considering the context of young peoples leisure careers as part of their broader transition through youth conceptualising criminal careers prospective longitudinal studies based on large scale quantitative surveys located within a positivist approach to the study of criminal careers aim to identify ways in which certain risk factors such as offender characteristics social environmental factors and criminal justice interventions can predict the onset frequency persistence and exit from criminal activity over time the replication of a number of findings across these studies has led to a consensus on the precipitative factors of offending such as low iq family breakdown low family income deviant peers criminal parents impulsivity substance use and low parental supervisioncontrol while f or some people risk factor research represents the most important and significant breakthrough in understanding and explaining juvenile delinquency at the same time the approach has been heavily critiqued for its limitations a consistent critique is the ability of such studies to identify causes of offending or desistance and arguments that risk factors are merely correlates of relatively vague proxies for criminality abound the risk factor approach also fails to fully unravel the complexity of individual pathways andor to provide insight into the meaning of life events therefore shedding little light on the ways in which individuals make choices about their lives put differently prediction studies ignore the effects of unpredictable critical moments and life events which have been found by others to turn individuals biographies either away from or towards offending linked to this prediction studies have been criticized for their individualisation of the phenomenon of offending and for ignoring the wider socioeconomic effects and questions about immediate social contexts such an emphasis on individual risk factors to the exclusion of the biographical and social structural contexts also has the potential to lead to a policy focus which blames individuals alone for their propensity to offend making them responsible for their offending and often doing so through punitive means an alternative approach to studying criminal careers evolved within the symbolic interactionist paradigm concerned with presenting a view of the world which emphasizes the flexibility of individual approaches to social situations an interactionist approach to criminal career research which informed the current study conceptualizes the criminal career as a process that is indeterminate unpredictable and susceptible to change over the life course and privileges the perspectives of research participants and the meanings and understandings they attach to their lives and experiences central to the process are notions of constraints and contingencies whereby individuals face structurally constrained opportunities at key moments in their lives in the face of these constraints individuals make choices that may take them in different offending pathways additionally contingencies or factors on which mobility from one position to another depends including both objective facts of social structure and changes in the perspectives motivations and desires of the individual affect the constraints and opportunities available to an individual contingencies heighten an individuals consciousness of what has happened in the past and what might happen in the future and can encourage a period of reflection which may contribute to variation in the career such a perspective on offending careers allows for the same events or contingencies to result in variable outcomes since each person has the potential to react differently in comparison to risk analysis studies therefore the subjectivity of the interactionist approach allows for certain events or contingencies to turn the course of an offending career one way or another the emphasis within interactionist accounts on the structurally constrained nature of contingencies and the situational nature of choices made removes the focus of policy intervention from the microlevel of individuals lives and alternatively p olicies…would be directed at the social structures institutional structures communities peer groups and families that present the situational constraints and opportunities within which developmental processes take place biographies unfold and within which people make choices between conventional and criminal activity early offending the process of onset of offending careers both qualitative and quantitative research on the patterning of criminal careers identify important characteristics of crime and criminals that have served as the backbone of many criminological and developmentallifecourse theories across these studies broad consensus on certain patterns has emerged including the age of onset of offending occurring between 8 and 14 years the prevalence of offending peaking in late teenage years and that most people will desist from crime at some point few having a career extending beyond the age of thirty although criminology has witnessed a growth of interest in the later stages of criminal careers and in particular the stages associated with desistance from crime onset of offending remains a key issue in criminal career research it is considered by some a significant predictor of future offending with early onset suggesting longterm offending high frequency of criminal activity and more serious offending however while the age of onset may be a useful marker and provides potentially important knowledge about agerelated risk factors for offending it is nonetheless only one dimension of initiation to offending and tells little about the context or experience of the first offence alternatively initiation to offending is more usefully conceptualized as a process linked to other transitions and careers that emerges over time in this way youth offending can be located in the wider context of young peoples biographies taking account of the number of life course events related to offending careers the limitations of criminological theory alone in explaining young peoples offending are noted and it is argued that sociological theories of delinquency are unable to account for the relationship between age and crime indeed as macdonald and marsh assert i t would be difficult to comprehend an individual criminal career without also considering concurrent wider experiences of transition not normally surveyed in criminology thus recent research has drawn on the contribution of youth studies and a youth transitions framework in particular in order to more fully understand young peoples engagement in offending through youth and into adulthood traditionally research considering the transition to adulthood focused on the schooltowork transition but more recent attention has been given to wider aspects of transition reflecting recognition that there is more to becoming adult and to understanding youth than movement into the labour market this broader conceptualisation of transition has thus incorporated an examination of housing and family careers exploring young peoples move into independent living and to becoming a parent macdonald and marsh additionally argue that a more holistic study of transitions should push the boundaries further to include an investigation of young peoples leisure social networks and in particular their affective engagement with the informal youth cultures of the street thus they stress the importance of criminal and drugusing careers in understanding some youth transitions and the interconnection of these with young peoples leisure careers leisure careers are defined as the dominant modes of freetime leisure activity and socialising engaged in by a person and how they change or persist over time exploring young peoples leisure involves accounting for their changing freetime associations peer networks and leisure activities and their significance in explaining their current life situations opportunities to occupy oneself during leisure time differ between young people and according to what is available to them a young persons socioeconomic position at an individual and community level can thus shape the development of their leisure careers for example parker identified parents in the neighbourhood not in a position because of structural constraints to offer a viable alternative to street leisure consequently conditions in the family home encouraged a young person out to the streets constrained leisure opportunities led murray to consider the concepts of outdoor child and indoor child whilst it can be argued that young people are spending increasing amounts of time indoors with the advent of technologies murray argues that this is not the case for all young people the outdoor child who spends much of their leisure time on the streets has limited or no space at home and faces financial constraints to accessing formal leisure activities loader similarly identifies young people for whom the use of public space looms large at the same time the choice to occupy public spaces is one which is constrained by young peoples exclusion from both autonomous private spaces and cultural resources resulting in a lack of choice having nowhere to go nothing to do and no money to spend it is the arrival of the young person in the neighbourhood which is significant in the emergence and development of young peoples offending careers i t is to the streetcorner worlds in which many…youngsters become immersed that we must look to understand the creation of delinquent action there are a number of elements to this street corner world that are connected to the initiation of offending at an individual and familial level an inability to finance an increasingly costly life can lead to for example theft as a response to the disjunction between the desire to participate in social activities with peers and the absence of legitimate sources of funds to finance this participation at the neighbourhood level young people in areas suffering from a lack of accessible leisure amenities typically refer to boredom with nothing to do being a constant complaint consequently alternative sources of entertainment may be sought or engaged in and for some may lead to illegal activity or acts of transgression crucially according to parker the context of the street corners introduce young people to the cultural traditions and skills to be learnt through interaction with social networks in other words street life both transmits delinquent traditions and provides an atmosphere for innovation and creation thus whilst focussing on one particular dimension of the onset of offending the development of young peoples leisure careers in interaction with their broader transition through youth and their lived experience of the local neighbourhood offers a contextualized understanding of the emergence of young peoples offending the study the research aimed to provide a detailed analysis of the offending careers of a group of young people in contact with criminal justice agencies in dublin ireland the study was initiated against a backdrop of changing discourse around youth justice in ireland the reform of the youth justice system in ireland had been underway since the children act was passed in 2001 and its legislative provisions introduced a number of key areas of change perhaps most notably in a shift towards a focus on the prevention of offending and the diversion of young people from the criminal justice system more recently the national youth justice strategy 20082010 set out a holistic response to youth offending on the one hand including universal aims to promote child wellbeing yet the individualisation of the social problem continued with a commitment in the same document to deliver programmes and services targeted at at risk individuals and families considered readily identifiable through a process of risk assessment and the requirement for young people to be held accountable for offending and to develop socially responsible behaviour although some developments in irish youth justice policy have been welcomed these have occurred against a backdrop of a dearth of empirical research on youth crime and justice in ireland this study thus aimed to go some way in addressing these gaps in knowledge the research aimed to identify and understand the processes related to young peoples offending transitions including their initiation to offending and the subsequent course of their offending careers broad criteria were used to identify young people who were eligible to participate in the study in order to facilitate a sample that was diverse in age gender and offending history thirtyseven young people twentysix males and eleven females participated in the study between december 2007 and august 2009 aged between fourteen and twentythree and the vast majority reported as white and irish they were recruited from probation projects individual probation officers and a garda youth diversion project participants had lived most of their lives in irelands most prosperous times growing up in a time of unprecedented economic growth with 1987 marking the start of a sustained and wellbalanced economic boom in ireland before entering recession in mid2008 after twenty years of economic growth fahey et al assessed that subjective wellbeing and national morale are among the highest in europe living standards have risen and have done so more or less for everyone however the rising economic tide did not lift all boats ireland always had a high degree of income inequality which persisted during the boom years and the income gap between those at the top and those at the bottom of the income distribution widened furthermore many local communities within dublin city did not benefit from the economic boom and continued to experience high levels of deprivation nearly all the young people in this study were residing in one of the rapid areas the most disadvantaged communities in irish cities and towns and in areas where levels of disadvantage had increased between the years 1991 and 2006 or had remained very or extremely disadvantaged an interactionist conceptualisation of criminal careers necessitated a method which would prioritize young peoples interpretations of events and the sense that they make of their social world thus the biographical mode of interviewing was employed focussing on the understandings and significance that people give to their lives with human conduct studied and understood from the perspective of the persons involved the life history method facilitated an understanding of offending as it interacted with multiple dimensions of young peoples lives portraying a somewhat more complex picture than a list of risk factors at the outset of the interview young people were requested to tell their life story and subsequently guided through this story prompted to share memories and offer reflections interpretations and insights while not a prescriptive adherence to the steps set out by glaser and strauss the analysis was influenced by a grounded theory approach adopting some of its defining components simultaneous data collection and analysis identifying analytic codes and categories from the data theoretical sampling where later interviews aimed to extend refine and check categories which had emerged from the initial coding of data and memowriting in addition to a crosssectional thematic approach to analysing participants narratives the life history approach necessitated the production of methodologically and theoretically grounded individual accounts thus a case summary for each individual was prepared including insights and observations on a young persons offending career and significant turning point moments that is interactional moments and experiences which leave marks on peoples lives biographical backdrop there is a danger with studies on youth offending that young people will be presented solely in terms of their offending histories thus neglecting their complex biographies a life history approach permits an unravelling of biography thereby providing a critical contextual backdrop to offending careers thus instead of portraying young people in contact with criminal justice agencies primarily as offenders the biographical data revealed multiple experiences that surrounded offending behaviour thereby locating rather than isolating offending from broader aspects of life experience young people typically highlighted the disrupted nature of their lives in their opening life story whilst not a homogenous group in terms of their experiences or responses to life events nevertheless accounts of particular difficulties and challenges featured noticeably in their narratives family and home life were often discussed with reference to negative andor traumatic events parental separation illnessdeath and domestic violence while family poverty was set in the wider context of living in poor neighbourhoods attempts to move from the family context often in search of independence were also characterized by disruption as respondents struggled with housing instability and continued to face difficulties previously characteristic of their earlier home life negative experiences of school andor training were most typically followed by fractured or extended transitions into the labour market as young people at best took up sporadic casual parttime employment or entered training schemes those still attending school cited suspension expulsion and discouragement which also formed much of the educational narratives offered by the samples early school leavers friends were referred to as an important source of support and reference point in the gradual move away from the family context outdoor spaces occupied by friends and acquaintances began to take on great significance in the daily routines of participants within the peer group young people reported exposure to and engagement with new activities which began to characterize their leisure time these particular experiences in participants lives are not presented as predictive of future offending given that they are shared by nonoffending young people nonetheless young people faced particular constraints in light of which they made choices about their lives indeed many life events or critical moments were identified as implicated in the process of beginning to offend while not causal factors such moments did become a significant marker of change for some taking the individual along a different path it is against these strained contexts that criminal careers were understood as young people respond to and manage these experiences with varied offending histories the following analysis draws on those biographical experiences that were bound up in young peoples accounts of initiating offending and focuses specifically on one dimension their strained leisure careers initiation of offending age of onset and first offence young people were asked to identify the point or age at which they started to offend for the total sample the onset of offending ranged from 8 to 18 years with an average age of 127 years the types of first offences reported extended to nine in total most reporting having committed only one offence at this point a smaller number reported multiple offences yet were unable to identify a specific sequence since they had occurred simultaneously or in close succession young women predominantly initiated their offending careers with shoplifting others reporting selling stolen goods and drug dealing among their first offences accounts of shoplifting also dominated young mens accounts of their first offence although joyriding and other types of theft featured strongly criminal damage selling goods without a trading licence arson begging and selling stolen goods completed the first offences of young men with all but the latter being reported by males exclusively this does not deviate to any great extent from the broader picture of onset of youth offending in the literature however to understand how young peoples offending emerged requires these data to be considered in conjunction with the situational context of young peoples biographical accounts context of social environment the importance of locality was strongly implicated in participants narratives as they described strong bonding networks located in the immediate neighbourhood they described close knit communities within which they knew everyone and were known and thus the neighbourhood held particular relevance all me family and friends and everyone i know is here and everything i do is in neighbourhood really such networks could provide important support in young peoples lives who highlighted the benefits of close relationships with friends and family as well as the notion of familiarity for wanting to remain within their communities however narratives also depicted the lack of mobility in young peoples lives with the majority unable to envisage a future outside of their community reflective of their inability to get out their narratives thus alternated between wanting something different in the future and not wanting to move too far from the castle this lack of mobility was perceived by some to have further implications as residing in a particular neighbourhood young peoples options were depicted as bounded rather than characterized by choice they know what kids are growing up intotheyre not going to have jobs and big houses…if youre raised here youre staying here id never move out of neighbourhood i wouldnt be able to…do i want to stay here id love to get out of it but i cant in this way young peoples narratives reflected strong bonding social capital a sense of connectedness which enabled them to get by but relatively little bridging social capital which may aid a young person to get ahead through access to wider social resources outside the local community growing up in a particular neighbourhood was raised by some as impacting on the likelihood of their becoming involved in criminal activity youre bollixed if you grow up here put it that way a sense of futility permeated the accounts of young people who conveyed a strong awareness of the constraints associated with living in certain communities or neighbourhoods for them offending behaviour was considered inevitable some participants clearly recognized that their situations differed quite dramatically from young people growing up in other parts of the city especially compared to those who grew up in nearby posher areas it was this sense of relative deprivation linked to the area where one is born and brought up which was depicted by eamon as a determining factor in his criminal justice involvement at the same time living intensely localized lives and growing up in high crime areas meant that young peoples main relationship with crime was as witnesses alana for example described leisure spaces in her neighbourhood as potentially unsafe because of the presence or threat of crime all the little kids do is stand around at the corners all day… and then all the robbed cars come along and all the little kids have to go in junkies thats all the kids ever see around here alanas representation presents public spaces as places where young people meet and socialize and simultaneously as potentially dangerous places where they come into contact with crime both as victims and witnesses young peoples accounts of their neighbourhoods repeatedly incorporated images of criminal activity including burning stolen vehicles and vandalism you have to walk the long way everywhere you cant take the shortcuts through the fields… there used to be robbed cars in them every night accounts also made reference to the sound of joyriding which was perceptible from inside their homes and some reported the impact of murders in their locality the cumulative effect of these experiences can be that young people come to accept crime as an inevitable everyday part of their existence and as a result tolerate its presence and downplay its importance contributing to a feeling that crime is everywhere it was in this highly localized context of the neighbourhood that young peoples leisure careers evolved leisure careers and leisure poverty young people identified transitions in their leisure careers marked by spending less free time in their homes or the street on which they lived accessing instead larger public spaces in the community thus public spaces took on greater significance in their daily lives and peer activities arguably normative behaviour for those in their teenage years some however like the outdoor child depicted a sense of being driven on to the streets given the spatial constraints encountered in their homes we had nowhere else to go so we were hanging around the roads housing estates… if someone had a free house all of us couldnt go into the free house cos we wouldnt fit in of course the street has positive attractions given the freedom and autonomy experienced by young people in these settings and it is the place where something might just happen nonetheless the leisure activities of young people in this study suffered from the confines of local possibilities given the particular nature of the public spaces accessible to young people in these areas of deprivation the lack of amenities and the consequent engagement in unrestrained activities the neighbourhood was the setting for the onset of young peoples offending careers eamon for example identified the lack of recreational facilities for young people in his community and described a sense of exclusion in this regard we had nothing to do and all day to do it we just had fields we never had a community centre until the new estate got built we had fuck all they never done anything for us society kicked us in the bollix caoimhe growing up in a community adjacent to eamons identified no significant change in more recent years and claimed that young people continued to have few options in terms of where and how to spend their time theres nothing around here for us that was our excuse saying what else do you want us to do youre wondering why were doing this but you arent doing anything about it all we have is fields and theyre waiting for us to go out drinking and do stuff and wreck things almost without exception the complaint of having nothing to do and nowhere to go echoed throughout the narratives and was a reality used to explain behaviours such as substance use and offending initial use of public spaces for leisure usually coincided with processes or events particularly truancy or school exclusion resulting in much more free time at young peoples disposal while the choice to access public spaces for leisure was to an extent structurally bounded by the lack of alternative opportunities so too were the choices of activities in which they were engaged additionally constrained by their personal financial resources their narratives almost always suggested levels of leisure poverty for some attempts to circumvent these challenges of filling time and accessing finances resulted in the emergence of offending as they engaged in criminal activity either as a source of entertainment or as a way to fund leisure activities thus resonating with classic strain theory with the goal of enjoyment or entertainment perceived as unattainable through legitimate means crime and leisure whilst this section depicts the onset of offending as emerging alongside strained leisure careers it is important to emphasize that similar to previous studies identifying the majority of time in young offenders life as crimefree during the early stages of their offending careers crime formed only a minor part of participants lives and leisure time both in terms of the importance they attributed to crime and the amount of time spent involved in offending indeed young people reported that most of their time could be accounted for by participation in legitimate activities as they described rewarding and lawful ways to be entertained we try and think of new things every week say one week wed all go gokarting… something to keep us amused and look forward to at the weekend i think this week its paintballing the fridays and saturdays do be grand but the sundays you do be too bored and you have to go out and do something jack 19 periods of boredom or nothing to do were therefore often interspersed with engagement in legitimate activities nevertheless participants described large sections of free time in which there was nothing to do it was in these periods of doing nothing that they attempted to account for their free time and to create excitement in this context much of young peoples early offending emerged that crime can be fun or alternatively that crime becomes a way to fund leisure was therefore relevant to understanding the onset of offending accounts of high levels of boredom were attached to explanations of engagement in criminal activity just for the fun and getting in trouble was directly linked by some with unoccupied time joyriding theft and criminal damage were presented as activities that created an adrenalin buzz or thrill the attraction of the emotionality of the criminal act most evident among male participants similar to the weird ideas of young men in corrigans study seán depicted how opportunities to do something would present themselves such as in the form of an abandoned car just for the sake of it nothing to do…and when something good like that arson opportunity comes round you cant miss the opportunity of doing something fucked you have to do something otherwise youre just going to regret it… thinking i should have lit that poxy car on fire participants accounts thus suggested that the onset of criminal activity occurred in the context of leisure time but some also dismissed the notion of choice in this regard suggesting instead that they were driven to doing things in reference to criminal activity such offending was not necessarily planned activity and instead arose in the context of hanging around and coming across opportunities for example marks first offence at the age of 15 occurred incidentally when in the company of a friend while they were hanging around he stumbled on an unattended pushbike and simply seized the opportunity to steal it it was a nice push bike…just wanted iti went over and grabbed it and was buzzing around with them he later explained that although he felt nervous at the time with butterflies in his stomach he simultaneously felt happy having derived positive emotions and experienced an adrenalin rush the potential benefits of offending however were not perceived in isolation rather it was in interaction with social networks at a neighbourhood level typically older peers that young people began to appreciate crucial elements of offending and in this sense echoed some key assertions of differential association theory for example eamon explained a desire to start joyriding having witnessed others in his estate engaged in similar behaviour it was at a young age…youd see all the joyridingyou got a buzz off seeing everyone doing that…you see a robbed car you want to rob a car i done what the generation ahead of me doneits like monkey see monkey do while the enjoyment of the offending act was more evident in young mens accounts of early offending both males and females had developed an awareness of the potential of attaining money or goods and the positive implications for leisure through their observations of older peers the illegal acquisition of money or goods was motivated for some by a desire to enhance leisure time or to fund a lifestyle which almost always incorporated alcohol and drug use for example louise described wanting a load of money for drink at the time she initiated offending by shoplifting and selling stolen goods adam likewise explained that he and his friends wanted to make money to buy cannabis i started robbing things to make money building sites and things tools and stuff…wed only sell them on for hash small little things while adam was motivated by the prospect of making money importantly he and his friends had come to appreciate the potential benefits of these activities by witnessing older acquaintances in the community who were engaged in similar types of offending all of the older lads would have been doing it and making money off it and wed think theyre making money lets do that dearbhla located the onset of her offending as coinciding with her immersion in a new peer group and also at the time she began to drink alcohol peer group activity and the behaviour she observed in this context encouraged her to steal and sell stolen goods we started hanging around with different groups young fellas they were all doing it so we just done it…cos they were getting away with it and we were still paying for everything and they had their money for drink and we wouldnt while dearbhlas assessment of peer activity and the perception that others were getting away with it without detection was an important dimension of her account for others cooffenders provided the expertise or tutelage required to carry out the offence successfully for example ronan explained that he was introduced to joyriding by other young men in the locality who taught him how to hotwire a car someone that knew how to do it someone would be there with you and youd just fiddle around with providing a crucial element to his success at the task critical moments while respondents narratives of the onset of offending depicted its processual nature nevertheless turning points or critical moments were identified in young peoples stories of transition and offending as young people respond in diverse ways to significant life events or experiences these moments are not presented as causal in the onset of offending but are considered as potential markers of change which may take an individual along a different path absence from school either through truancy exclusion or early school leaving meant that young people had increasing amounts of spare time which often compounded feelings of boredom for some offending became a way to account for this time however the significance of school absence was often amplified with the occurrence of other processes for example while conor noted i done me secondary school and left after just got into trouble ever since this development also coincided with the removal of his source of leisure from his home neighbourhood in a similar vein the impact of school leaving for peter was compounded by the fact that it was not replaced by another activity i was doing nothing when i left school carly too identified multiple events that coincided with her early school leaving including her fathers death and the emergence of new peer relationships she identified that she subsequently went a bit wild and started to offend finally young people who moved to new neighbourhoods with their families often reported immersion in new peer groups as well as exposure to new behaviours in the following account jack explained that he started getting in trouble during the period subsequent to moving to a different area of the city i just got into a bit of trouble when i moved up to the other place i started mixing with the wrong crowd started getting in trouble going around doing stupid things going around in cars while such events parental separation death leaving school moving neighbourhoodemerged as critical moments in the lives of young people and were implicated in their offending careers these moments interacted with other developments or experiences for example in seans account the connection between the removal of a father figure and the onset of his offending was mediated by the availability of an alternative role model and then when you dont have an auld fella and you need someone to look up to who are you going to look up at youre going to look up to the lads standing at the corners so thats it youre bollixed then in this way as thomson et al suggest critical moments must be understood as related to their social and geographical location clearly many young people experience the events detailed above yet only in a minority of cases does this lead to the initiation of offending careers the ability to respond to these circumstances is subsequently shaped by available social and cultural resources the response of the young person rather than the event itself constitutes if a moment is critical discussion participants experiences of onset broadly reflected those documented in the literature with most commencing offending in early teenage years and engaging in acquisitive and expressive crime as typical first offences these facts of onset were set against young peoples biographical backdrops characterized by disruption and disadvantage and punctuated by critical moments which they often located at the same time as their initiation to offending concurrently young people depicted a period of transition where they moved along those lines traditionally associated with approaching adulthood schooltowork housing and domestic and those more recently incorporated into such an understanding drug criminal and leisure leisure careers were central to understanding the earliest phases of young peoples offending careers they evolved in interaction with other processes as young people bought into agerelated scripts aspiring to the culturally expected goals of exciting leisure pursuits and quality time spent with friends in their teenage years this coincided for most with the replacement of the family home as a site of leisure as young peoples lives were largely played out in the neighbourhood milieu the significance of leisure or at least of accounting for time was most heightened for those who had left school or who sought to escape adverse home circumstances growing up in some of the most disadvantaged areas of the city where they also experienced strong exposure to crime their experiences of leisure poverty were not only linked to structural disadvantage at an individual and familial level but were also connected to the limited leisure amenities available in the neighbourhood leading to prolonged periods of nothing to do spent unsupervised in public spaces whilst an almost homogenous group in terms of class and ethnicity the analysis does point towards certain nuances illustrative of gendered experiences at the early stages of offending most notably while the interaction of community leisure and peers holds relevance for both males and females young women were less likely to perceive enjoyment in the act of offending per se and rather viewed criminal activity as a way to fund an enhanced leisure experience the focus in this article on young peoples leisure careers and the depiction of crime emerging as a solution to the strain experienced in this regard indicates common ground with previous research highlighting emotional motives and benefits of early offending particularly in the context of seeking fun excitement and relieving boredom respondents accounts suggesting that crime was primarily a creative leisure pursuit resonated with cultural criminological explanations which emphasize the foreground experiences of offending and depict crime as fun the act of transgression itself having attractions this focus on foreground factors however must be balanced by an appreciation of the background structural factors and particularly with recognition of the restrictions to participants leisure careers and the ways in which opportunities for leisure were structurally bounded through the lack of access to legitimate funds at an individual level and suitable amenities at a community level furthermore the interaction of partipants social networks with their ability to perceive and enjoy the benefits of offending as well as to carry out offences successfully suggest that these relationships help foster criminal activity where illegitimate opportunities exist and are condoned in a social milieu where little else is available thus the way that youth cultures emerge as localized classbased solutions to material inequalities resonating with early theories of subculture point towards implications of this explanation at a neighbourhood level most specifically the interaction of street corner leisure with the early stages of young peoples offending suggests prevention strategies which include the provision of leisure amenities which are accessible both financially and by virtue of location such leisure services must allow for meaningful interaction between young people fostering positive relations through prosocial activities of course street corner leisure is not without its attractions given its unsupervised nature and potential for excitement thus calling for creative thinking on leisure amenities for young people to rival and replace the pleasure derived in the early stages of offending while not all young people living in disadvantaged areas offend and not all offenders come from a disadvantaged background the biographies of participants in this study nonetheless suggested their offending and lives more generally was embedded within social and economic environments characterized by high deprivation thus since the process of offending among young people originated and was located in experiences of social disadvantage addressing social inequalities and relative deprivation is a necessary prerequisite to effectively tackle the origins of youth offending in poor communities this suggests that attempts to prevent or respond to youth crime need to shift in focus from strategies that centre on criminal justice to those that strive to attain social justice defined as largely redistributive justice concerned with limiting reducing or redressing the inevitable disparities that arise in modern societies and which provides fair and decent treatment for all citizens a focus on social justice therefore would be most concerned to create social structures that limit inequalities and genuinely open up opportunities for personal advancement to all citizens thus the lens through which we focus on youth offending must be widened from the individual to incorporate the broader socioeconomic and cultural contexts in a holistic response to youth crime moving towards a model of social justice will serve to tackle the issues that a focus on criminal justice through neglecting the needs of economically deprived communities thus far has served to perpetuate this study aimed to provide an understanding of young peoples offending careers and this article has provided a contextualised analysis of the process of onset of offending while the focus in recent criminal career research has been on the latter stages of the criminal career and processes of desistance in particular close examination of the earliest stages of offending is of equal importance particularly when we consider the potential for such research to provide policyrelevant information on ways to prevent youth crime the neighbourhood milieu emerged as crucial to understanding the development of young peoples leisure careers and initiation of offending this points towards the potential benefit of conducting research in alternative locations such as smaller cities towns and rural areas to examine whether this theoretical stance can be applied more generally to others types of locale while the framework of strained leisure careers was able to account for the early offending by both male and female respondents the gendered experiences in terms of the benefits derived from offending would support a call for more dedicated research focussed on young female offending finally offending careers were set within the wider context of making the transition to adulthood as barry has argued the concurrent examination of youth transitions allows for the conceptualisation of offending in youth as a temporary or transient occupation and incorporates an understanding of crime as dependant on external structural factors and individual selfdetermination setting offending experiences within the broader life histories of young people highlights the relevance of the transitions they make across multiple areas of life consequently literature relating to the sociology of youth and more specifically youth transitions help to frame an understanding of the experiences of young people who become involved in criminal activity this approach would be further strengthened by a longitudinal design which would follow participants stories and the ways in which young peoples lives will change perhaps in significant ways as they approach and enter adulthood both in relation to their offending careers and in wider but connected contexts i just left school hanging around the wrong crowd drinking getting arrested and downhill from that…i was never in trouble before with the police… it was just when i hit like secondary school and then me dad died and just everything fucked me up while there appeared to be a cumulative effect in carlys story she put forward her fathers death as the critical moment if me da hadnt died i wouldnt have bleedin went astray the way i did other young people faced difficulties associated with parental marital breakdown or a parents substance use their responses to these events involved criminal activity among other developments such as the initiation or increase in substance use such accounts perhaps suggest the relevance of agnews revised strain theory since young people often sought to escape the adverse conditions and experiences at home for example joe enjoyed the adrenalin buzz he experienced when joyriding with his friends this activity providing a distraction from homebased difficulties which included his mothers heavy drinking and inability to care for her children marital breakdown was presented in participants accounts as an event to which they reacted with negative consequences as a result of parental separation dara identified less supervision at home feeling that at the age of 14 his parents viewed him as an adult and he began to spend increasing amounts of time socialising in the neighbourhood at which point he went bad similarly cathal located his first experience of joyriding during the period his parents separated me ma and da separated then as well and then i started getting robbed cars and doing drugs and drinking and staying out all night and getting in trouble with the garda he continued to explain that this problematic behaviour emanated from the anger felt due to the minimal postseparation contact with his father

she has worked on a number of research studies focussing on the lives of marginalised youth including a biographical analysis of young peoples offending careers a longitudinal biographical study of youth homelessness and a mixed methods study on young people and domestic violence

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introduction bodyweights have risen substantially in affluent countries during the last three decades in the united states by 2000 nearly twothirds of the population were overweight and almost onethird were obese similar increases happened quite rapidly at different levels and rates in most affluent countries obesity is harmful to health it is seen as unattractive and is known to be stigmatising the literature on obesity is large and covers many disciplines but there is little agreement about causes recently there were seven different models of population obesity a british government consultation has produced causal diagrams of staggering complexity country rankings of obesity indicate that a cluster of wealthy englishspeaking countries have a higher prevalence of obesity than other affluent countries with similar levels of income we seek to confirm this observation to provide an explanation and to support it with data the data we use consist of ninetysix bodyweight surveys undertaken in eleven countries between 1994 and 2004 it is an ecological regression metastudy which pools many surveys over a short period of time these confirm that englishspeaking countries form a cluster of their own with regard to obesity there is separate evidence that overeating may be a personal response to chronic life stress englishspeaking countries have gone further in the direction of unregulated market liberalism than other affluent societies our hypothesis is that marketliberal countries have an environment of greater economic insecurity and that this is the source of the stress that drives higher levels of obesity the institutional structures that neoliberal societies put in place promote insecurity and inequality while workrelated insecurity including low income poor job mobility and absence of union protection elevates the likelihood of stress and illhealth responses to stress in turn include overeating and preferences for high energydensity foods both of which are implicated in the causation of obesity in this study insecurity is a predictor for obesity but the opposite may also be the case obesity can be measured objectively and is difficult to hide disorders like stress and anxiety are not easy to identify diagnose and observe they are not often recognised as attributable to market liberalism richard sennett has written of the hidden injuries of class if the link with stress and insecurity is established then the epidemiology of obesity might be used as a diagnostic for these less visible disorders that is one of the promises of this line of investigation the concept of welfare regimes comes from espingandersen who made a distinction between the nordic social democratic model of welfare the continental european familyoriented model and the englishspeaking liberal model since the 1980s there has been a movement away from social democratic policy norms towards more marketfriendly policies this matches the timing of the emergence of obesity as a mass social phenomenon hall and soskice distinguished two varieties of capitalism on the one side six englishspeaking liberal market economies on the other ten coordinated market economies germany japan switzerland the netherlands belgium sweden norway denmark finland and austria our findings do not confirm espingandersens threefold classification we have not found that the nordic countries form a statistically distinctive group our results are more consistent with the hall and soskice approach which highlights the distinctiveness of the liberal market economies from everyone else it is this distinctiveness that we investigate in its basic form our hypothesis is that economic uncertainty and unequal market and household experiences have increased stress and that stress is conducive to weight gain that market liberal reforms have stimulated competition in both labour and consumption markets and that this has undermined personal stability and security it has affected people more strongly lower down the social scale hence the more intensive the competitive and market orientation of welfare regimes the higher the level of body weight at both aggregate and personal levels support for this view also comes from marketliberal economists who regard shifts in relative prices within markets as a plausible explanation of weight increase due to their commitment to the optimality of market outcomes they are relatively untroubled about the rise in body weight although its choice as a subject suggests an acknowledgement of concern obesity in their view is merely an unintended symptom of otherwise benign personal preferences and policy norms some stylized facts that support the hypothesis are that overweight is more common among the poor that weight has risen overall over time and that there is a gradient in body weight with the highest levels to be found under liberal welfare regimes in the englishspeaking countries these observations are consistent with two interpretations we try to discriminate between them and to estimate their impact the first is the food shock hypothesis a supply shock was driven by the shift in provision of processed food from the home and into the market where it has become much more accessible the relative price of food fell and high energydensity food which is a staple of fastfood supply is highly palatable one individuallevel study of obesity in the usa has found that the strongest explanatory factor is the geographical concentration of fastfood outlets 1 same time the occupational transition from manufacturing to services and increased motorization have both reduced the opportunities for physical exercise a second hypothesis arises from a physiological association that has been observed between stress and overeating at the socioeconomic level two stressinducing mechanisms have been invoked one comes out of the psychosocial hypothesis of socially differential morbidity and mortality in affluent societies the source of stress is the experience of subordination and a proxy indicator is income inequality these authors report that higher income inequality at the national level is associated in the aggregate with higher bodyweight smith and smith et al have proposed that the source of stress might be economic insecurity their point of departure is in the study of animal behaviour animals in the wild and in captivity respond to food uncertainty by putting on weight uncertainty gives rise to anxiety which prompts selfmedication by means of food the notion of comfort food is likewise familiar in a similar way feelings of uncertainty and anxiety encourage overeating smith speculates about the evolutionary basis and biochemical pathways of this mechanism several writers have associated myopia with the rise in body weight people whose longterm objective is a steady body weight nevertheless find it difficult to resist the temptations of weightincreasing foods myopic bias is a form of impatience and hence implicated in anxiety myopia is exacerbated by the pace of market innovation in food provision the pursuit of materialism more broadly is associated with lower subjective wellbeing oswald and powdthavee have shown increasing levels of distress in the uk between 1991 and 2004 twenge has found more than onestandarddeviation rises in anxiety levels in the usa since the 1950s and an even larger increase in general psychopathology since the late 1930s a large international survey of mental disorder in 20013 has shown prevalence in the usa at 263 percent with the average for six continental european countries at 119 percent a mentalhealth gap even larger than the obesity gap 2 2 including anxiety disorders mood disorders disorders that share a feature of problems with impulse control and substance disorders a study of the relation between obesity and emotional disorder suggests modest relationship between obesity and emotional disorders among women in the general population process food technologies have been available equally across the developed world their pace of deployment and their relative penetration provide a means of comparing and testing the supplyshock and welfareregime approaches obesity levels differ among welfare regimes it could be argued that some countries merely lag behind in exposure to the food shock however if the rates of growth in obesity differ between countries with different regimes then that points towards a welfareregime interpretation if the rates of obesity growth are similar then the supply shock interpretation will appear more compelling materials and methods data the surveys were identified through online databases and other relevant webbased searches it was judged that for aggregated data of this type a pooled ordinary least squares regression was the most reliable approach this made it desirable to restrict the selection to a relatively short time frame namely 19942004 this is preparatory to a panel study which will use individuallevel data in fewer countries many suitable surveys were conducted during 19942004 covering a range of countries the social investment in these surveys arose from a rising awareness of obesity as a social problem although measured obesity levels are preferable to selfreported weights and heights the majority of the studies found relied on selfreport in order to create a sufficiently large dataset for analysis both measured and selfreported data were included surveys were included if they reported at least one obesity prevalence level most surveys gave obesity prevalence estimates for males females and in total but 8 surveys only reported percentage obese for males and females combined and a further 8 only reported for males and females separately they had a sufficiently large sample of the 96 surveys included 27 had samples sizes up to 5000 22 had sample sizes of 500010000 36 between 10000100000 and 11 between 100000200000 they included participants with a range of ages minimum age generally varied from 15 to 25 although two 2001 surveys had a minimum age of 30 and one study in italy in 1998 had a minimum of 35 the maximum age ranged from 64 to no limit they were conducted over a period extending at most over two calendar years if surveys were conducted over a period that did not tie in with one calendar year they were categorised for analysis as being in the later year while the majority of surveys were nationally representative sufficiently large surveys were included even if they were only conducted in one or two townscities or regions of a country the percentages reported as obese by these surveys are summarised by country in the table below the usa had the highest levels of obesity whereas italy with the lowest prevalence had almost half the levels model the basic model is totalobese it α β 1 measured it β 2 marketlib it β 3 time it β 4 econsecurity it β 5 econequality it ε it           the number of observations varies between countries but each country is given the same weight the dependent variable is percentage prevalence of obesity for survey i at time t obesity is defined as bmi equal to or greater than 30 genderspecific obesity is estimated as well thirtytwo of the surveys used objective weight measurements while sixtyfour relied on selfreporting of body weights measured is a dummy for measured weights marketlib is another dummy that specifies marketliberal countries in the sample the time variable is incremented one unit per year starting at 1 in 1994 econsecurity and econequality are continuous variables for economic security and equality respectively taken from lars osbergs index of economic wellbeing the iewb is a multidimensional index addressing the consumption wealth economic equality and economic security of selected oecd countries currently available for the years 19802007 wherever possible observed annual data are provided and missing years are filled in by imputation there is no reason to think that this biases the results since change is slow designed to allow comparison across countries of a range of household socioeconomic indicators each of the four major indices of the iewb is in turn comprised of subcomponents two of these composite indices are of interest in the current study economic equality and security the index of economic equality derived from the luxembourg income study is comprised of the intensity of poverty ie the poverty rate times the poverty gap and the inequality of income measured using gini coefficients these subcomponents are inversed added and weighted to form the economic equality index this index is used as our variable econequality which is scaled up from 01 to 0100 one component of the economic equality index is also later investigated as an alternative specification of economic equality namely the inversed gini coefficient the index of economic security is a weighted composite of four subindices security from unemployment illness singleparent poverty and poverty in old age security from unemployment and from illness are derived from oecd statistics and security from singleparent poverty and from poverty in old age from the luxembourg income study security from unemployment is constructed from the unemployment rate and the proportion of earnings that are replaced by unemployment benefits and singleparent and old age poverty from the prevalence of these conditions and poverty intensity security from ill health is represented by the share of private expenditure on healthcare in personal disposable income these four components are weighted by the relative sizes of the populations subject to each risk and together are aggregated to obtain the economic security index for this study this index is also scaled up to 0100 forming our variable econsecurity the economic security components are also investigated separately in a later analysis both variables derived from the iewb are of comparable magnitudes the observations are pooled and the regression method used is ols osberg indicates which data points are observed and which are derived by imputation results the main findings are reported in table 2 the relative strength of each variable is indicated by the standardized beta coefficients and that is the variable of interest the regression coefficients are however intuitively meaningful although not quite comparable to each other totalobese ie obesity prevalence ranges from 5 to 32 percent of the adult population measured raises obesity prevalence by about a third over this range marketlib raises obesity prevalence by four percentage points the passage of time raises obesity prevalence by about four percentage points from start to finish of all the variables econsecurity has the strongest effect as measured by its beta a rise in economic security from the bottom to the top of its range would account for about 14 percentage points ie more than half the obesity prevalence amplitude the result for economic equality is unexpected wilkinson and pickett using bivariate analysis found a strong relation between inequality and obesity prevalence but in a multivariate analysis the effects observed here for inequality have the opposite sign the beta is low and in the case of gendered observations it is not significant similar results are obtained using the inversegini variable instead although econequality and inversegini are quite different the first mostly measures poverty intensity ie the ratio between income in poverty and the poverty line while the other measures inequality overall among the households sampled this finding does not completely invalidate inequality as a cause as we shall discuss below finally gender does not seem to have a large effect it is worth investigating further but not in this paper discussion three putative determinants of obesity are discussed in turn fast food shock security and equality time and the food shock that obesity is a response to the shock of ever cheaper and more accessible food is the most prevalent socioeconomic interpretation if countries differ merely in the levels of obesity prevalence it can be argued that latecomers to obesity merely lag behind in the diffusion of the food shock and will eventually catch up with the leaders thus the pace of growth of obesity prevalence offers a test of the food shock interpretation this hypothesis implies that nonmarketliberal countries should have similar rates of obesity growth to those of market liberal ones despite having lower levels of obesity prevalence the period we survey is a short one but it coincides with strong obesity growth in table 2 above the time variable captures the pace of growth over time and is both strong and significant the food shock hypothesis would predict no difference in the rate of growth between market liberal and other countries this is investigated in table 3 in column the coefficient for time is high and significant in the other countries this variable is neither this argues against a fastfood shock lag interpretation of obesity levels using this indicator food shock is not a distinctive factor outside market liberal countries but quite a strong one within them the usonly coefficient is even higher there is something about market liberal countries that causes obesity to increase faster than elsewhere a reasonable interpretation of the time variable is that it captures some of the effect of the food shock this possibility can be evaluated further with a variable for fastfood prices this is provided here by the big mac index published for every year in the economist and used by generous permission of the publishers the index compares prices of the macdonalds big mac hamburger in different countries using local currency and us dollars at the official exchange rate two versions of the variable were tried one using absolute prices the other using relative ones ie taking price as a fraction of income per head the relative price version has more statistical power and is the one we use in column of table 3 the bigmac variable pushes the time variable out of significance with a high beta as well but less clearly in marketliberal countries this suggests that a substantial part of what the time variable captures is the food shock of declining real fast food prices but not all of it figure 1 shows that bigmac prices were declining over time the price of bigmac was lowest in the highestobesity countries namely the usa canada and australia figure 1 big mac relative price over time but food shock was not a matter of price alone it also exposed people to intensive marketing and saved them cooking and shopping time once econsecurity is reinstated bigmac is again dominated by time comparing betas however this food shock variable has just over a third of the power of economic security insecurity the welfare regime hypothesis is that stress induces insecurity and that insecurity induces overeating trenton smith has shown that animals in the wild respond to stress by putting on weight there is also evidence that people put on weight in response to stress whether associated with subordinate status inequality work insecurity or financial insecurity in a recent study smith and his collaborators have used the american national longitudinal study of youth to show that insecurity measured in several different ways predicted a rise in body weight in the united states high levels of obesity are associated locally with high levels of food insecurity the united states department of agriculture has stopped using the term hunger in its reports and uses food insecurity instead as we have seen osbergs econsecurity variable is the strongest predictor of obesity prevalence the united states was an outlier with high levels of both economic insecurity and of obesity nevertheless the effect of insecurity remains when the united states is taken out figure 2 shows the relation between econsecurity and obesity prevalence it indicates that the united states was in a class of its own economic security was low and obesity was high the difference is particularly marked in the measured surveys and is smaller in the selfreported ones figure 2 obesity and economic security osbergs econsecurity variable is made up of four components namely security in old age security from unemployment security in singleparenthood and security from illhealth the first three are indices which combine the chance of being in the affected category multiplied by an index of the strength of social protection the fourth security from illhealth is an index of private medical expenses expressed as a percentage of disposable income in table 4 col 3 this latter variable which proxies private medical cost risk has the strongest effect on obesity this is plausible the risk of high medical spending is lumpy and volatile it gives rise to financial employment and psychological stress and in some instances to sustained physical pain and discomfort in the united states medical costs are the most frequent causes of bankruptcy and this is more common than heart disease or divorce unemployment protection is also a significant variable but has the wrong sign this is reversed if marketlib is taken out the osberg security index focuses on conditions of dependence and expectations of social support it is a powerful variable but almost all the work is done by a single component namely the uncertainty arising from having to pay for health care out of personal income a different index approaches the role of security in predicting obesity from a different angle not of dependency but of work it confirms the connection between security and obesity by achieving similar results with different data and a different approach this is the ilo index of economic security it is derived from various surveys between 1991 and 2003 ie the period covered by our sample but is not available year by year and only provides one data point for each country hence it only measures differences in levels not in trends it is not entirely dissimilar in this respect to the osberg econsecurity variable where temporal variation is controlled for by the time variable the effect of the ilo security variable are estimated in table 5 column 1 3 the index is composed of seven components labourmarket security employment security work security job security skill security representation security and income security column 4 estimates the relative power of each of these components only three of them are significant representation and income security have the expected sign obesity decreases as they increase representation is a particularly strong determinant these two variables are partially offset by skill security which is also strong but has a positive sign one way is of interpreting this finding is that representative security stands for the ability of workers to bargain collectively and skill security for their ability to bargain individually the skill variable measures the general rise of educational and training levels one of us has argued elsewhere that accumulation of human capital has inclined workers towards more individualistic forms of bargaining but this security may be delusive and provides little respite from the rising anxieties of market competition if this is correct then as workplace security declined through our period then paradoxically the general rise in educational levels which has taken place in the most advanced societies was accompanied by insecurity and its corollary obesity alternatively and perhaps more plausibly the rise of obesity in higherhumancapital countries does not indicate that it is higherskilled persons who are becoming more obese the shift to individual bargaining will have benefited those who have bargaining power while worsening the position of the rest hence it may not be the brain workers who suffer from obesity in these countries but disproportionately the manual workers who have been left behind and who have lost their bargaining power equality the prevalence of obesity is inversely related to socioeconomic status an additional or perhaps alternative source of stress for inducing obesity is inequality as we have seen in multivariate analysis insecurity dominates inequality but this finding may not be decisive insecurity may be an aspect of inequality the unobservable epidemiological insult in question may be captured better by insecurity than inequality insecurity is a personal attribute inequality a social one or we may not be using the right measure of inequality the variable used measures household income controlled for household size derived from surveys this is likely to truncate both the bottom and the top of the distributions it says nothing about other forms of inequality especially inequality of wealth which is much stronger than inequality of income in the work of marmot and of wilkinson and pickett the stress mechanism is assumed to be the burden of subordination this mechanism is not captured by our statistical analysis atkinson and brandolini stress how difficult it is to identify the appropriate inequality measure the osberg inequality measures are particularly turbulent and unstable for these years some countries were already reversing the steep rise of inequality of early marketliberalism during these years while others were beginning their descent others were stable or moved both ways this makes it difficult to generalise about the role of inequality with a multicountry study for these years one way in which the inequality hypothesis is manifest is in twoway correlations figure 3 shows the relation between obesity prevalence and economic equality the trend is weaker than for economic security but does replicate the findings of wilkinson and pickett the trend derived from the multivariate model diverges strongly from the twoway plot conclusion this study is a snapshot of obesity in advanced countries at the end of the 20th century and allows some preliminary conclusions marketliberal countries stand out as having high levels of obesity and higher rates of obesity growth the time variable is more powerful in marketliberal countries the united states in particular is an outlier ranking first on both levels and rates of growth of obesity but marketliberal distinctiveness remains when the united states is left out one reason is market freedoms fast food prices as proxied by the bigmac variable are considerably lower in marketliberal countries due to lower levels of taxation and wages which prevail in marketliberal countries in other words the fast food shock which is invoked in explanation of obesity has acted more powerfully in marketliberal countries the most powerful influence we have uncovered on levels of obesity is insecurity this relation remains even after controlling for marketlib which has a strong significant and positive effect in most regressions we have measured insecurity in two ways using an index of dependency and another one of insecurity at work each of these independently has considerable explanatory power but the former dominates the latter in regressions 3inequality is another contender in multivariate analysis equality is dominated by security but that does not settle the matter insecurity may be a consequence of inequality and the measure of inequality used may not be the best one in bivariate analysis higher equality is inversely related to obesity prevalence and that is also the case for unemployment protection which likewise has the wrong sign in the multivariate model the study is essentially crosssectional but it raises an historical question if welfare regimes are such a critical determinant of obesity where do such regimes themselves come from figure 2 shows the united states clustered at the high end and the scandinavian countries clustered at the low end the marketliberal countries in our sample all share english as a common language norway and sweden at the low end of obesity and high end of security both use variants of the same language and share a common culture and religion in addition to having similar welfare regimes this suggests that welfare regimes have historical and cultural roots and that the search for causes needs to venture into the past that a disposition for excess or moderation for risktaking or security may be rooted in the respective cultures on the other hand culture may not be destiny social pathology can respond to experience and learning and can moderate seemingly of its own accord out of several examples that could be chosen smoking the most salient rose to majority use in the first half of the 20th century and has declined ever since the trajectory of obesity in the united states and the uk also appears to have flattened in the last few years our conclusions are derived from aggregates the actual mechanisms require investigation at the level of individuals we have already begun to do so and hope to replicate this study with a smaller number of countries using such datasets the study is still in early days the implications however are large the association of insecurity and obesity has a bearing on larger policy norms it suggests that the economic benefits of flexible and open markets such as they are may be offset by costs to personal and public health which are rarely taken into account the controlled market economies all support successful and affluent societies they also appear to perform better on this important dimension of personal and public health acknowledgments papers may be downloaded from

among affluent countries those with marketliberal welfare regimes which are also englishspeaking tend to have the highest prevalence of obesity the impact of cheap accessible highenergy food is often invoked in explanation an alternative approach is that overeating is a response to stress and that competition uncertainty and inequality make marketliberal societies more stressful this ecological regression metastudy pools 96 bodyweight surveys from 11 countries c 19942004 the fastfood shock impact is found to work most strongly in market liberal countries economic insecurity measured in several different ways was almost twice as powerful while the impact of inequality was weak and went in the opposite direction we are grateful for good comments to the economics and human biology journal referees to michael lipton and to participants at the obesity and welfare regimes conference at oxford in november 2009 as well as at several other seminars and conferences financial support was provided by the bupa foundation and by a british academy conference grant the economist generously provided big mac index data