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introduction korea has achieved impressive economic development referred to as the miracle of the han river over the past halfcentury korea overcame absolute poverty by generating strong income growth but the fruits of this economic growth were not equally distributed koreas old age relative poverty rate is the highest among organization for economic cooperation and development countries many experts have suggested that the overwhelming elderly poverty rate proves that income has not been redistributed well between generations and classes 1 2 3 4 in addition korea is expected to enter a superaged society having more than 20 of aged people among the total population by 2025 5 which increases the risk of elderly poverty the theme of this study the problem of poverty among the elderly arises at the interface of two key issues in korean society polarization and aging the current poverty and income inequality among the elderly are attributed to the fact that inequality in the labor market is reflected in the social security system at a time when private support for the elderly is weak a socioecological system perspective that focuses on the interaction between an individual and the environments surrounding that individual indicates diverse poverty factors first on an individual level there is not enough preparation for retirement although awareness of preparation for retirement has increased senior citizens fail to prepare for their retirement due to higher spending this spending often comprises debt repayment and education expenses for children that are more than these citizens can afford second an increase in womens social participation and nuclear families at the interpersonal level weakens the familys private support of aged parents third the legal retirement age in korea is 65 but the average retirement age is much lower due to corporate labor cost avoidance fourth at a community level koreas labor market is divided between a primary labor market composed of large companies and regular workers and a secondary labor market consisting of smalland mediumsized companies and irregular workers this division results in high income inequality workers in the secondary sector often find preparing for retirement difficult by means other than public pensions which are not sufficient enough moreover retirement pension one of the representative public pensions is often not subscribed to since only workplaces with more than 300 employees have been obligated to introduce retirement pensions since 2019 so most smalland mediumsized workplaces have offered it voluntarily finally in terms of the legal system koreas public pension has a lowlevel income replacement rate that refers to the pension as a proportion of income received by the worker and a wide gap that does not include the elderly who worked in the secondary job market or who were unemployed poverty among the elderly is always mentioned as one of the most urgent social problems when discussing the issues facing korean society the seriousness of elderly poverty is also evident in the fact that korea maintains one of the worlds top 10 gdp levels while showing the highest elderly poverty rate among oecd countries on average oecd countries do not have much difference in poverty risk by age but in korea poverty risk increases rapidly in old age the poverty rate of senior citizens in korea which saw a median income of 50 in 2016 stood at 438 more than three times that of the oecd national average of 135 age is much lower due to corporate labor cost avoidance fourth at a community level koreas labor market is divided between a primary labor market composed of large companies and regular workers and a secondary labor market consisting of smalland mediumsized companies and irregular workers this division results in high income inequality workers in the secondary sector often find preparing for retirement difficult by means other than public pensions which are not sufficient enough moreover retirement pension one of the representative public pensions is often not subscribed to since only workplaces with more than 300 employees have been obligated to introduce retirement pensions since 2019 so most smalland mediumsized workplaces have offered it voluntarily finally in terms of the legal system koreas public pension has a lowlevel income replacement rate that refers to the pension as a proportion of income received by the worker and a wide gap that does not include the elderly who worked in the secondary job market or who were unemployed poverty among the elderly is always mentioned as one of the most urgent social problems when discussing the issues facing korean society the seriousness of elderly poverty is also evident in the fact that korea maintains one of the worlds top 10 gdp levels while showing the highest elderly poverty rate among oecd countries on average oecd countries do not have much difference in poverty risk by age but in korea poverty risk increases rapidly in old age the poverty rate of senior citizens in korea which saw a median income of 50 in 2016 stood at 438 more than three times that of the oecd national average of 135 figure 1 poverty rates among older age groups and the total population source oecd 6 along with this prevalent risk of aging poverty the worlds fast pace of population aging is rapidly increasing the number of elderly people in poverty if the current poverty rate is maintained the number of people aged 65 or older is expected to rise by 319 in 2025 from 35 million to 46 million entering a superaged society means more that 20 of the population are elderly 7 approximately one out of every two impoverished people will be elderly in the future social and economic problems caused by elderly poverty are not just income issues but can affect various aspects of korean society korea has the highest suicide rate among oecd countries 8 and suicide rates increase with age the 2017 elderly survey conducted by the ministry of health and welfare indicated that their major suicide motivations were financial difficulties and health problems a needy life may lead an individual to commit suicide if the government does not actively respond to the economic insecurity of the aged generation social problems caused by the income gap and economic inequality of the elderly are expected to intensify therefore to increase opportunities to age with equity and dignity this study aims to analyze the current status and causes of elderly poverty in korean society and to explore future policy responses along with this prevalent risk of aging poverty the worlds fast pace of population aging is rapidly increasing the number of elderly people in poverty if the current poverty rate is maintained the number of people aged 65 or older is expected to rise by 319 in 2025 from 35 million to 46 million entering a superaged society means more that 20 of the population are elderly 7 approximately one out of every two impoverished people will be elderly in the future the study is divided into three domains first section 2 examines the current status and trends of elderly poverty in korea and analyzes the characteristics of this status and these trends section 3 systematically identifies various factors affecting the entry into poverty in the elderly section 4 proposes a policy alternative that can protect the elderly from poverty in a longlived era based on the factors of influence previously analyzed dynamics of elderly poverty in korea definition of poverty the dictionary meaning of poverty is a state in which the minimum basic needs required for survival are not met ie a state in which basic material needs cannot be met due to a lack of resources 3 here are various definitions of poverty but there are two main approaches to defining poverty these are absolute poverty and relative poverty absolute poverty is the condition in which household income is insufficient to afford the basic necessities of life this definition of absolute poverty stems from rowntree 9 who described primary poverty as households whose total earnings would be insufficient to note number of people aged 65 for every 1000 of the workingage population source oecd 6 social and economic problems caused by elderly poverty are not just income issues but can affect various aspects of korean society korea has the highest suicide rate among oecd countries 8 and suicide rates increase with age the 2017 elderly survey conducted by the ministry of health and welfare indicated that their major suicide motivations were financial difficulties and health problems a needy life may lead an individual to commit suicide if the government does not actively respond to the economic insecurity of the aged generation social problems caused by the income gap and economic inequality of the elderly are expected to intensify therefore to increase opportunities to age with equity and dignity this study aims to analyze the current status and causes of elderly poverty in korean society and to explore future policy responses the study is divided into three domains first section 2 examines the current status and trends of elderly poverty in korea and analyzes the characteristics of this status and these trends section 3 systematically identifies various factors affecting the entry into poverty in the elderly section 4 proposes a policy alternative that can protect the elderly from poverty in a longlived era based on the factors of influence previously analyzed dynamics of elderly poverty in korea definition of poverty the dictionary meaning of poverty is a state in which the minimum basic needs required for survival are not met ie a state in which basic material needs cannot be met due to a lack of resources 3 here are various definitions of poverty but there are two main approaches to defining poverty these are absolute poverty and relative poverty absolute poverty is the condition in which household income is insufficient to afford the basic necessities of life this definition of absolute poverty stems from rowntree 9 who described primary poverty as households whose total earnings would be insufficient to the study is divided into three domains first section 2 examines the current status and trends of elderly poverty in korea and analyzes the characteristics of this status and these trends section 3 systematically identifies various factors affecting the entry into poverty in the elderly section 4 proposes a policy alternative that can protect the elderly from poverty in a longlived era based on the factors of influence previously analyzed dynamics of elderly poverty in korea definition of poverty the dictionary meaning of poverty is a state in which the minimum basic needs required for survival are not met ie a state in which basic material needs cannot be met due to a lack of resources 3 here are various definitions of poverty but there are two main approaches to defining poverty these are absolute poverty and relative poverty absolute poverty is the condition in which household income is insufficient to afford the basic necessities of life this definition of absolute poverty stems from rowntree 9 who described primary poverty as households whose total earnings would be insufficient to achieve the lowest level of total income required to maintain physical efficiency discussion of relative poverty began when townsend 10 criticized this definition because of the lack of consensus on basic needs for survival explaining poverty in terms of income in relation to the income level of the entire population relative poverty refers to a lack of basic ability to achieve minimum living standards the areas of assessment include proper nutrition participation in activities and availability of resources for widely accepted minimum living conditions 11 or for living conditions to reach a minimum acceptable level 12 the poverty line or poverty thresholds are the minimum income levels needed to achieve a proper standard of living in a given country the poverty line can be divided into the absolute poverty line belonging to the objective poverty line and the relative poverty line according to the measurement method the absolute poverty line is determined by estimating the cost of purchasing essential goods in a society and considers the condition that does not reach the objectively prescribed minimum standard of living as poverty the absolute poverty rate measures the proportion of households below the poverty line to all households after establishing a certain standard of poverty the world banks global poverty line of one dollar ninety cents per day is widely used however relative poverty lines are determined in a comparative manner such as a specific ratio based on average or median income townsend 13 defined the relative poverty line as 80 of the average household income and 50 or less of the average household income for the poorest for international comparison this study defines poor households as less than 50 of the disposable median income based on modified household income weighted by the oecd 14 the household equivalence scale is an indicator of the additional rate of income growth required to maintain the same level of welfare as the number of household members increases the expression of household income denoted by the equation √ n adjusted by the equivalence scale is i k √ n where n is the number of household members in 2020 koreas poverty line was krw 1499000 per year 15 poverty status by assets and income there is a possibility that the status of poverty is statistically overstated or underestimated due to the measure of relative poverty based on disposable income for example people having large assets should be excluded from poor households even if their income falls short of the poverty line however distinguishing the difference with available data is difficult 16 if the impact of asset retention and income are considered in the calculation of poverty rates at the same time the relative poverty rate could fall by 17 1 however even if poverty rates do fall the seriousness of the fall and relative position of elderly poverty in the world are not likely to change a high proportion of individuals in most countries except for the united states have real estate 17 so their poverty rates would decrease too when all assets are considered in addition property income is reflected in the total disposable income since a household gross income consists of employee income selfemployment income property income and transfer income concerning property that does not generate income there are no data that accurately reflect the diversity and complexity of assets 18 therefore the identification and comparison of its impact is difficult regarding concerns related to identifying wrong policy targets when implementing policy alternatives the possibility of confusion in policy targets is low this is due to the fact that the korean government operates the allowance and benefits calculation schemes for social security to reflect specific nonfinancial assets including land buildings cars and golf course memberships poverty by age and gender as shown in figure 4 poverty among the oldest those aged 75 and over is more frequent than among the younger old those aged 6575 6 the poverty rate in the latter group is 355 but the poverty rate in the oldest aged 75 and older is substantially higher 559 most oecd countries have similar trends where age is proportional to poverty rates the oecd average poverty rate is 116 for the younger old and 162 for the oldest although korea also has this tendency the difference between the two groups is particularly high showing a 204 gap 6 the main drivers of higher poverty incidence among the oldest are less or no contribution in the national pension system 1 which was introduced in 1988 and a lower ability to work 19 the older aged group is less likely to participate in the labor market and expend more existing savings or assets this increases the risk of poverty and reduces the likelihood of escaping poverty 20 although korea also has this tendency the difference between the two groups is particularly high showing a 204 gap 6 the main drivers of higher poverty incidence among the oldest are less or no contribution in the national pension system 1 which was introduced in 1988 and a lower ability to work 19 the older aged group is less likely to participate in the labor market and expend more existing savings or assets this increases the risk of poverty and reduces the likelihood of escaping poverty 20 the poverty rate of korean male seniors was 371 but that of female seniors was 49 119 higher considering that the oecd average poverty rate for male senior citizens is 103 and the poverty rate for female senior citizens is 157 the korean poverty rate for female senior citizens is particularly serious higher poverty risk among women than men is attributed to longer life expectancy and lower earningsrelated pensions 6 this also reflects differences in the past labor market such as male and female work experiences and the gender wage gap 2122 int poverty by household type one of the changes that should be of interest in the issue of elderly poverty is the change in the family structure in old age korea was a familycareoriented society that supported aged parents 23 this used to offset the weak national care system however the poverty rate of korean male seniors was 371 but that of female seniors was 49 119 higher considering that the oecd average poverty rate for male senior citizens is 103 and the poverty rate for female senior citizens is 157 the korean poverty rate for female senior citizens is particularly serious higher poverty risk among women than men is attributed to longer life expectancy and lower earningsrelated pensions 6 this also reflects differences in the past labor market such as male and female work experiences and the gender wage gap 2122 group is 355 but the poverty rate in the oldest aged 75 and older is substantially higher 559 most oecd countries have similar trends where age is proportional to poverty rates the oecd average poverty rate is 116 for the younger old and 162 for the oldest although korea also has this tendency the difference between the two groups is particularly high showing a 204 gap 6 the main drivers of higher poverty incidence among the oldest are less or no contribution in the national pension system 1 which was introduced in 1988 and a lower ability to work 19 the older aged group is less likely to participate in the labor market and expend more existing savings or assets this increases the risk of poverty and reduces the likelihood of escaping poverty 20 the poverty rate of korean male seniors was 371 but that of female seniors was 49 119 higher considering that the oecd average poverty rate for male senior citizens is 103 and the poverty rate for female senior citizens is 157 the korean poverty rate for female senior citizens is particularly serious higher poverty risk among women than men is attributed to longer life expectancy and lower earningsrelated pensions 6 this also reflects differences in the past labor market such as male and female work experiences and the gender wage gap 2122 poverty by household type one of the changes that should be of interest in the issue of elderly poverty is the change in the family structure in old age korea was a familycareoriented society that supported aged parents 23 this used to offset the weak national care system however poverty by household type one of the changes that should be of interest in the issue of elderly poverty is the change in the family structure in old age korea was a familycareoriented society that supported aged parents 23 this used to offset the weak national care system however as the family culture becomes westernized married children do not live together with their parents the proportion of the elderly living with their children decreased from 547 in 1994 to 237 in 2017 accordingly the proportion of households composed of only the elderly such as one elderly person or elderly couple is increasing the proportion of only the elderly households surged from 404 in 1994 to 550 in 2004 reaching 72 as of 2017 2425 looking at the household types of all the elderly aged 65 or older specifically the distribution was 236 living alone 484 living with an elderly partner 237 living with their children and 44 other 26 according to the relative poverty rate by types of households single elderly households had the highest poverty rate 715 this was followed by elderly couples other elderly households and nonaged households 514 287 143 and 102 respectively the proportion of single elderly households is expected to continue to increase in the future due to the differentiation of households between parents and children establishment of a public support system for senior citizens who have difficulty feeding themselves or do not have anyone to care for them is necessary to ensure a minimum standard of living in response to the decrease in private care by their children as the family culture becomes westernized married children do not live together with their parents the proportion of the elderly living with their children decreased from 547 in 1994 to 237 in 2017 accordingly the proportion of households composed of only the elderly such as one elderly person or elderly couple is increasing the proportion of only the elderly households surged from 404 in 1994 to 550 in 2004 reaching 72 as of 2017 2425 looking at the household types of all the elderly aged 65 or older specifically the distribution was 236 living alone 484 living with an elderly partner 237 living with their children and 44 other 26 according to the relative poverty rate by types of households single elderly households had the highest poverty rate 715 this was followed by elderly couples other elderly households and nonaged households 514 287 143 and 102 respectively the proportion of single elderly households is expected to continue to increase in the future due to the differentiation of households between parents and children establishment of a public support system for senior citizens who have difficulty feeding themselves or do not have anyone to care for them is necessary to ensure a minimum standard of living in response to the decrease in private care by their children drivers of senior poverty in korea framework socioeconomic model there are various competing theories about the causes of poverty the debates include advocates who support culturalbehavioral arguments or structuraleconomic arguments 27 however poverty among the elderly in korea cannot be explained by just one point of view and various factors have affected the poverty level over the long term this study seeks to analyze the causes of poverty by applying socioecological models a theoretical framework useful for understanding multidisciplinary levels of factors affecting individual behavior socioecological models built from bronfenbrenner 28 have been used primarily in the field of public health the key principle of this model is that various dimensions including individuals between individuals organizations communities laws and policies mutually influence behavioral status 28 29 30 31 considering the fact that there are various factors to explain poverty approaching poverty systematically is feasible this includes the consideration of all diverse levels of external environments in which individuals belong rather than only focusing on a personal level of responsibility 30 such as an insufficient preparation for retirement in addition socioecological models can effectively shed light on developing policy improvement measures including not only policy targets but also social practices and cultural and legal environments 31 the socioecological model application on drivers of senior poverty is shown in figure 7 drivers of senior poverty in korea framework socioeconomic model there are various competing theories about the causes of poverty the debates include advocates who support culturalbehavioral arguments or structuraleconomic arguments 27 however poverty among the elderly in korea cannot be explained by just one point of view and various factors have affected the poverty level over the long term this study seeks to analyze the causes of poverty by applying socioecological models a theoretical framework useful for understanding multidisciplinary levels of factors affecting individual behavior socioecological models built from bronfenbrenner 28 have been used primarily in the field of public health the key principle of this model is that various dimensions including individuals between individuals organizations communities laws and policies mutually influence behavioral status 28 29 30 31 considering the fact that there are various factors to explain poverty approaching poverty systematically is feasible this includes the consideration of all diverse levels of external environments in which individuals belong rather than only focusing on a personal level of responsibility 30 such as an insufficient preparation for retirement in addition socioecological models can effectively shed light on developing policy improvement measures including not only policy targets but also social practices and cultural and legal environments 31 the socioecological model application on drivers of senior poverty is shown in figure 7 key factors what explains poverty among the elderly 321 individual level retirement preparation each persons economic preparation for retirement affects their retirement poverty generally retirement is a predictable event but economic retirement preparation behavior is different from person to person according to the social security public perception survey conducted by the ministry of health and welfare in 2020 32 57 of the respondents said they were preparing for retirement the remaining 43 said that they were not preparing for retirement preparing for retirement differed greatly depending on the type of housing occupancy the more unstable the housing occupancy contract type was the lower the percentage of respondents who said yes about the question of whether they were preparing for retirement the response that they were preparing for retirement was 647 for selfownership 472 for lease on a lump sum deposit basis and 218 for monthly rent the higher or more stable the salary level the more people were prepared for retirement for example 389 of temporary and daily wage workers and 304 of unemployed workers said that they were preparing for retirement while 569 of regular wage workers and 668 of employersselfemployed and unpaid family workers said that they were preparing for retirement the reason the cause of poverty in old age cannot be attributed simply to individual lack of preparation is that even if selfresponsibility is high implementation of economic retirement preparation is difficult if the employment status is low or the housing type is unstable due to a lack of economic resources specifically current seniors in their 70s and 80s were born in the japanese colonial era these individuals lost their families fled during the korean war and worked hard to overcome absolute poverty after the war then most of them lost their jobs during the 1997 financial crisis considering korean development history and their contribution blaming them for the present poverty of the elderly is unfair key factors what explains poverty among the elderly individual level retirement preparation each persons economic preparation for retirement affects their retirement poverty generally retirement is a predictable event but economic retirement preparation behavior is different from person to person according to the social security public perception survey conducted by the ministry of health and welfare in 2020 32 57 of the respondents said they were preparing for retirement the remaining 43 said that they were not preparing for retirement preparing for retirement differed greatly depending on the type of housing occupancy the more unstable the housing occupancy contract type was the lower the percentage of respondents who said yes about the question of whether they were preparing for retirement the response that they were preparing for retirement was 647 for selfownership 472 for lease on a lump sum deposit basis and 218 for monthly rent the higher or more stable the salary level the more people were prepared for retirement for example 389 of temporary and daily wage workers and 304 of unemployed workers said that they were preparing for retirement while 569 of regular wage workers and 668 of employersselfemployed and unpaid family workers said that they were preparing for retirement the reason the cause of poverty in old age cannot be attributed simply to individual lack of preparation is that even if selfresponsibility is high implementation of economic retirement preparation is difficult if the employment status is low or the housing type is unstable due to a lack of economic resources specifically current seniors in their 70s and 80s were born in the japanese colonial era these individuals lost their families fled during the korean war and worked hard to overcome absolute poverty after the war then most of them lost their jobs during the 1997 financial crisis considering korean development history and their contribution blaming them for interpersonal level changes in filial obligation norms of family caregiving changes in family structure can also be linked to poverty 33 the weakening of family support is an interpersonal factor affecting poverty in the elderly as mentioned earlier briefly changes in the structure of the private support system can be seen through changes in the form of households as the number of elderly parents and adult children living together has decreased the number of elderly couples and elderly households living alone has increased this means that the elderly population is being separated due to the aging population of the nuclear family as the result of industrialization in particular the child support responsibility for bereaved parents in korea especially that of the daughterinlaw was strong however the increasing number of working couples due to womens social participation also contributed to the collapse of the private support system in addition the attitude of the elderly toward supporting their old age is rapidly changing this change in the value of parental support of children can be explained as a change in values and attitudes toward parental support familism centered on filial piety has weakened and social norms and systems have changed according to the statistics korea survey 707 of the respondents answered that they were family members in 2002 but only 22 responded that way in 2020 and 616 said the government and society should be responsible for parental support together changing this change in the value of parental support of children can be explained as a change in values and attitudes toward parental support familism centered on filial piety has weakened and social norms and systems have changed according to the statistics korea survey 707 of the respondents answered that they were family members in 2002 but only 22 responded that way in 2020 and 616 said the government and society should be responsible for parental support together organizational level early retirement and senioritybased wage system early retirement from jobs reduces lifetime income adding to the risk of poverty in old age according to the senior employment promotion act early retirement of middleaged and older workers in their late 40s and early 50s has been considered honorary retirement according to the 2019 economically active people survey conducted by statistics korea 36 the age at which the elderly in korea quit their longestserving jobs continues to fall from 503 in 2006 to 494 in 2019 the main driver for early retirement is the salary pay system the seniority wage system is a structure in which the basic salary continues to rise depending on the number of years of service the rigidity of the corporate wage system centered on the salary system is the main reason for the avoidance of employment of middleaged and older people early retirement pressure and the spread of irregular workers 37 recently performancebased wage systems such as the annual salary system have been spreading but the salarybased wage system is still dominant 38 in the salarybased wage system wages rise in proportion to the number of years of service resulting in a wage gap according to the number of years of service as employees work productivity is not simply a result of their long service years the aging and longterm service of employees who receive higher wages but fall short of productivity lead to an increase in cumulative labor costs that companies have to pay companies have a strong incentive to address such problems through a personnel management strategy that includes early retirement which can slow this increase in costs in the face of an aging society there is a need to reorganize the wage system in a way that helps stabilize employment for the elderly organizational level early retirement and senioritybased wage system early retirement from jobs reduces lifetime income adding to the risk of poverty in old age according to the senior employment promotion act early retirement of middleaged and older workers in their late 40s and early 50s has been considered honorary retirement according to the 2019 economically active people survey conducted by statistics korea 36 the age at which the elderly in korea quit their longestserving jobs continues to fall from 503 in 2006 to 494 in 2019 the main driver for early retirement is the salary pay system the seniority wage system is a structure in which the basic salary continues to rise depending on the number of years of service the rigidity of the corporate wage system centered on the salary system is the main reason for the avoidance of employment of middleaged and older people early retirement pressure and the spread of irregular workers 37 recently performancebased wage systems such as the annual salary system have been spreading but the salarybased wage system is still dominant 38 in the salarybased wage system wages rise in proportion to the number of years of service resulting in a wage gap according to the number of years of service as employees work productivity is not simply a result of their long service years the aging and longterm service of employees who receive higher wages but fall short of productivity lead to an increase in cumulative labor costs that companies have to pay companies have a strong incentive to address such problems through a personnel management strategy that includes early retirement which can slow this increase in costs in the face of an aging society there is a need to reorganize the wage system in a way that helps stabilize employment for the elderly another problem with early retirement from major jobs lies in the growing gap between the age of retirement and the age of receiving benefits from the national pension service a public retirement income security system the pension age varies based on the another problem with early retirement from major jobs lies in the growing gap between the age of retirement and the age of receiving benefits from the national pension service a public retirement income security system the pension age varies based on the year of birth the pension can be received at 60 or younger for those born in 1952 and at 65 for those born in or after 1969 the income vacuum can exist for five to 15 years between retirement from work and the age of receiving the pension in addition senior citizens continue to work even after officially retiring from the labor market because public pensions alone are insufficient for maintaining their lifestyles korea displayed the highest average effective age of labor market exit 723 years for both women and men however labor opportunities are only available for a small number of middleaged and older people and the provision of stable labor opportunities with a decent wage is more limited as experience and proficiency are important factors in professional expertise 39 the shorter the working period in lifelong jobs the more likely the engagement in lowwage work another problem with early retirement from major jobs lies in the growing tween the age of retirement and the age of receiving benefits from the national p service a public retirement income security system the pension age varies based year of birth the pension can be received at 60 or younger for those born in 1952 65 for those born in or after 1969 the income vacuum can exist for five to 1 between retirement from work and the age of receiving the pension in addition citizens continue to work even after officially retiring from the labor market becau lic pensions alone are insufficient for maintaining their lifestyles korea display highest average effective age of labor market exit 723 years for both women an however labor opportunities are only available for a small number of m aged and older people and the provision of stable labor opportunities with a decen is more limited as experience and proficiency are important factors in professio pertise 39 the shorter the working period in lifelong jobs the more likely the e ment in lowwage work community level labor market duality at the community level the gap in workers income in the period of economi ity widens the gap in a life after retirement the total income of households con earned income selfemployment income asset income and privatepublic tran come employment income accounts for 64 of the total income community level labor market duality at the community level the gap in workers income in the period of economic activity widens the gap in a life after retirement the total income of households consists of earned income selfemployment income asset income and privatepublic transfer income employment income accounts for 64 of the total income earned income varies substantially depending on the size of the enterprise and type of employment the labor market in korea is divided according to the size of the workplace and the type of employment 4 fulltime employees of large companies working in the primary market enjoy high wages job security organized labor unions benefits and the protection of labor market regulations however workers in the secondary labor market are mostly nonregular workers in smalland mediumsized enterprises earned income varies substantially depending on the size of the enterprise and type of employment the labor market in korea is divided according to the size of the workplace and the type of employment 4 fulltime employees of large companies working in the primary market enjoy high wages job security organized labor unions benefits and the protection of labor market regulations however workers in the secondary labor market are mostly nonregular workers in smalland mediumsized enterprises these workers suffer from low wages and job insecurity and their jobs are often not protected by labor regulations 41 the monthly wage level of nonregular workers is 45 percent of that of regular workers the hourly wage of nonregular workers was improved to 70 of that of regular workers through the minimum wage hike but the total income gap was not significantly improved 42 the reason for the gap between regular and nonregular workers is the senioritybased wage system 4 regular workers are guaranteed to continue to receive wage raises proportional to their increased work experience while irregular workers are not based on data from 300 employees the wages of smalland mediumsized company workers were 51 of those of large company employees in 2016 this barely increased to 53 in 2019 the dominant conclusion is that the wage gap by firm size stems from the productivity gap between largeand smalltomediumsized companies this productivity gap is often the result of unfair subcontracting practices 43 the wage gap between men and women has improved but womens hourly wages are still under 65 of mens this is mainly because womens careers are shorter than mens due to career breaks such as those associated with marriage and childbirth therefore women are at a disadvantage when considering wage increase opportunities 21 corporate size and employment type duality create income inequality for workers and make retirement planning difficult for example secondary sector workers limited savings insurance and pension subscriptions are frequently insufficient to develop a viable retirement plan systemic level gap in the multipillar income security system koreas multilayered income security system consisting of basic pension national pension and retirement pension appears to be adequate but a wide gap exists in public pension system entitlements a povertyfree life after retirement is not fully guaranteed according to a survey conducted by the national pension service 44 the retirement income required for single households was krw 13 million per month and krw 21 million per month for couples however only 841 percent of single households facing retirement received krw 13 million in income these single households earned a public pension that averaged krw 520000 the national pension service was introduced in 1988 for businesses with up to 10 employees and was expanded to cover all citizens in 1999 the national pension service serves as a major retirement income source in the absence of postretirement earned income korean subscribers between 18 and 60 years of age pay part of their income as insurance premiums to the national pension service however since the national pension service is applying a reserved method that receives as much as individual contributions it cannot receive benefits from the retirement income guarantee if the contribution is low or if it fails to join the national pension only 415 of the population aged 65 and older subscribe to the national pension 19 currently 467 million of the 2184 million subscribers have suspended or longterm arrears due to economic circumstances and 895 million have not joined the national pension because of the lack of participation in economic activities in total 42 of the population aged 1859 does not pay any national pension premium at some point in time the national pension service is the system with the lowest threshold for subscription and the greatest benefit against insurance premiums throughout all pensions and it is practically difficult to use other private systems if they are shunned even from such a public social security system figure 12 shows the income replacement rate of mandatory pensions in oecd countries these figures reflect future reforms set by each country not presently but by 2060 as the national pension system matures the pension amounts that new subscribers receive in the future will rise but the existing gaps will still exist in addition the national pension was designed based on an income replacement rate of 40 based on an average lifetime income however this is the case when the national pension is maintained for 40 years and premiums are paid normally if calculated as the replacement rate of real income guaranteed based on payments of more than 10 years the minimum subscription standard was only 224 in 2020 45 the ilo and oecd recognize an income replacement rate of 50 as an adequate level while a replacement rate of 70 is recommended according to the oecd 46 standard was only 224 in 2020 45 the ilo and oecd recognize an income replacement rate of 50 as an adequate level while a replacement rate of 70 is recommended according to the oecd 46 basic pensions were introduced in 2008 to support stable retirement income security for older people who do not join the national pension scheme or do not receive sufficient pensions since 2014 the basic pension amount and application target have gradually expanded since 2021 the basic pension provides up to krw 300000 per month depending on income to senior citizens aged 65 or older unlike the national pension service which requires insurance payments if their income recognition amount is less than the recipients selection standard they could be a basic pension recipient without contributing to the payment the retirement pension system is a system in which employers accumulate funds during the workers tenure for retirement benefits this guarantees that the worker will receive a retirement income that allows for economic stability retirement pensions reflect gaps in the dual structure of the labor market for example 881 of employees of businesses with 300 or more fulltime workers have retirement pensions and 235 of employees of smalland mediumsized companies with less than 30 employees have retirement pensions 48 regular workers had a 572 retirement pension subscription rate while only 232 of nonregular workers were retirement pension subscribers 42 the retirement pension system which is currently required only in workplaces with more than 10 employees will be mandatory even for workplaces with less than 10 employees in 2022 however since the lump sum receipt rate is very high 979 as of 2018 and the number of early withdrawals has increased there is a limit to the universal retirement income guarantee function 49 int figure 13 future net replacement rates for fullcareer averagewage workers source oecd 6 figure 12 future net replacement rates for fullcareer averagewage workers source oecd 6 standard was only 224 in 2020 45 the ilo and oecd recognize an income replacement rate of 50 as an adequate level while a replacement rate of 70 is recommended according to the oecd 46 basic pensions were introduced in 2008 to support stable retirement income security for older people who do not join the national pension scheme or do not receive sufficient pensions since 2014 the basic pension amount and application target have gradually expanded since 2021 the basic pension provides up to krw 300000 per month depending on income to senior citizens aged 65 or older unlike the national pension service which requires insurance payments if their income recognition amount is less than the recipients selection standard they could be a basic pension recipient without contributing to the payment the retirement pension system is a system in which employers accumulate funds during the workers tenure for retirement benefits this guarantees that the worker will receive a retirement income that allows for economic stability retirement pensions reflect gaps in the dual structure of the labor market for example 881 of employees of businesses with 300 or more fulltime workers have retirement pensions and 235 of employees of smalland mediumsized companies with less than 30 employees have retirement pensions 48 regular workers had a 572 retirement pension subscription rate while only 232 of nonregular workers were retirement pension subscribers 42 the retirement pension system which is currently required only in workplaces with more than 10 employees will be mandatory even for workplaces with less than 10 employees in 2022 however since the lump sum receipt rate is very high 979 as of 2018 and the number of early withdrawals has increased there is a limit to the universal retirement income guarantee function 49 basic pensions were introduced in 2008 to support stable retirement income security for older people who do not join the national pension scheme or do not receive sufficient pensions since 2014 the basic pension amount and application target have gradually expanded since 2021 the basic pension provides up to krw 300000 per month depending on income to senior citizens aged 65 or older unlike the national pension service which requires insurance payments if their income recognition amount is less than the recipients selection standard they could be a basic pension recipient without contributing to the payment the retirement pension system is a system in which employers accumulate funds during the workers tenure for retirement benefits this guarantees that the worker will receive a retirement income that allows for economic stability retirement pensions reflect gaps in the dual structure of the labor market for example 881 of employees of businesses with 300 or more fulltime workers have retirement pensions and 235 of employees of smalland mediumsized companies with less than 30 employees have retirement pensions 48 regular workers had a 572 retirement pension subscription rate while only 232 of nonregular workers were retirement pension subscribers 42 the retirement pension system which is currently required only in workplaces with more than 10 employees will be mandatory even for workplaces with less than 10 employees in 2022 however since the lump sum receipt rate is very high 979 as of 2018 and the number of early withdrawals has increased there is a limit to the universal retirement income guarantee function 49 policy recommendations to tackle the aforementioned social problems the south korean government has pushed to expand the number of people eligible for a basic pension support national pension premiums ease the qualifications of the basic living security system raise the minimum wage and make nonregular workers regular however more effort is still needed to solve the complex problem that has accumulated over a long period of time reinforcing zerofloor of the multipillar pension system as of 2021 koreas elderly population ratio is 166 but the level of public spending on welfare for the elderly is 28 which is very low compared to the oecd average of 74 major oecd countries used 7 of the gdp for senior citizens income security spending senior citizens in these countries averaged around 14 of the total population 50 therefore korea needs to expand the governments financial role to address economic difficulties in old age sion premiums ease the qualifications of the basic living security system raise the minimum wage and make nonregular workers regular however more effort is still needed to solve the complex problem that has accumulated over a long period of time reinforcing zerofloor of the multipillar pension system as of 2021 koreas elderly population ratio is 166 but the level of public spending on welfare for the elderly is 28 which is very low compared to the oecd average of 74 major oecd countries used 7 of the gdp for senior citizens income security spending senior citizens in these countries averaged around 14 of the total population 50 therefore korea needs to expand the governments financial role to address economic difficulties in old age first it is recommended to strengthen the pay adequacy of a multilayered income security system focusing on basic pensions korea operates a national pension basic pension and retirement pension to support postretirement aged workers as the first and foremost solution the basic pension pillar 0 or the pension floor should be raised to guarantee that the poor elderly can have lives that meet minimum quality of life standards this applies to those who are unable to earn an employment income or to expect a privatepublic transfer 52 most of the current generation of senior citizens was unable to join the national pension system when the system was introduced this system is key to guarantee retirement income some senior citizens may have been able to join the system but their contributions were too low to secure benefits however the basic pension is paid to the bottom 70 of the elderly this pension plan has the potential to have a strong antipoverty effect by helping the lower economic class of elderly with fewer national and retirement pensions the basic pension started at krw 80000 in 2008 and now stands at krw 300000 this allowance currently accounts for only 12 of the total income of national pension subscribers in 2020 the average income of these subscribers was krw 2539734 53 first it is recommended to strengthen the pay adequacy of a multilayered income security system focusing on basic pensions korea operates a national pension basic pension and retirement pension to support postretirement aged workers as the first and foremost solution the basic pension pillar 0 or the pension floor should be raised to guarantee that the poor elderly can have lives that meet minimum quality of life standards this applies to those who are unable to earn an employment income or to expect a privatepublic transfer 52 most of the current generation of senior citizens was unable to join the national pension system when the system was introduced this system is key to guarantee retirement income some senior citizens may have been able to join the system but their contributions were too low to secure benefits however the basic pension is paid to the bottom 70 of the elderly this pension plan has the potential to have a strong antipoverty effect by helping the lower economic class of elderly with fewer national and retirement pensions the basic pension started at krw 80000 in 2008 and now stands at krw 300000 this allowance currently accounts for only 12 of the total income of national pension subscribers in 2020 the average income of these subscribers was krw 2539734 53 considering that the labor market history reflects the national pension retirement pension and elderly poverty basic pension redistribution should have a stronger antipoverty role however although basic pensions have practical poverty alleviation effects the cost may be unacceptable to central and local governments raising the basic pension by krw 100000 will cost krw 932 billion in 10 years and will cost an additional krw 4997 billion to cover the elderly aged 75 or older these expenditures are open to the criticism that such huge spending will affect other social welfare programs by pressuring central and local governments finances a public awareness survey conducted by the ministry of health and welfare last summer found that the public agreed to make social security spending for the elderly a top priority 54 regarding the priority support age group for welfare policies 359 of respondents answered that the elderly was the priority for welfare policy followed by middleaged and elderly and young experts also said support for senior citizens was the first priority the public prioritized the elderly with single parents and grandchildren and those with low incomes to receive support at a similar level these findings reflect the possibility of intergenerational solidarity to solve poverty for the elderly there may be those with the counter argument that individuals will avoid paying the national pension in order to be eligible for the basic pension however the prospect of evading the national pension seems excessive because of fears associated with elimination from the basic pension list in addition the current national pension is a mandatory system premiums are automatically deducted from an individuals monthly salary this ensures that those with an income cannot avoid paying the national pension national pension and retirement pension a plan could also be implemented to raise the income replacement rate of the national pension service which is currently 40 percent to increase public pension benefits for senior citizens however while adjusting the income replacement rate of the national pension may be effective in preventing future generations from poverty 55 this adjustment does not solve the poverty problem of the current generation of senior citizens who are already in the national pension gap specifically the adjustment cannot solve the poverty of the current generation of female senior citizens who had no labor participation in the past as for the national pension gap the government is currently providing national pension premiums to lowwage workers working in small businesses with less than 10 employees and farming and fishing villages 56 in addition the government operates a credit system that recognizes the payment period of insurance premiums to those who cannot continue to pay the national pension due to childbirth military service and unemployment for the middle class the government should further strengthen the use of retirement pensions to cover old age income to this end retirees should be induced to receive these in the form of pensions not lump sum payments the retirement pension is a legal obligation system applied to workers employed for at least one year and the user shall bear the full financial resources in the reality of koreas labor market not many people are eligible for retirement pensions retirement pensions are not universal pensions that cover many classes of workers nevertheless most middleand upperclass workers are bound to receive retirement pensions and can therefore play a role in the multilayered pension system by class the key task at this time is to establish retirement pensions as pensions not lump sum payments to this end the collection of lump sum payments may be restricted by designating mandatory receipt of retirement pensions for a certain period of time or by strengthening tax support for the receipt of pensions the reason that retirement pensions are often received as lump sum payments is the resemblance to the severance pay tradition there is a considerable demand for lump sum payments if an individual retires in their 40s and 50s the individual is not old enough to leave the job market yet lump sum payments may be necessary to provide an initial investment for selfemployment according to the 2019 statistics korea survey 49 586 of the respondents were in favor of mandatory retirement payments in the form of pensions and 364 were against the idea in the future when the retirement pension system matures individual reserves will have increased increasing the effectiveness of the pension this in turn could further increase the role of retirement pensions for life after retirement however some maintain that conditions for joining should be eased so that workers under one year can receive retirement pensions in order to resolve the gap in retirement pensions 57 in 2016 a partial amendment to the workers retirement benefit guarantee act which calls for paying retirement pensions to workers for more than a month or less than a year was proposed in the national assembly but abolished in 2020 due to the expiration of the national assembly session without sufficient social discussions 58 given current employment conditions relaxing the conditions for membership may result in reducing existing jobs rather than achieving the purpose of protecting workers despite its potential effect to reduce blind spots in the employment safety net large companies will be less affected but small businesses and the selfemployed could responds to the change by reducing employment rather than paying retirement benefits for onemonth workers according to the 2020 employment insurance statistical yearbook 59 more than 50 of retirees with less than one year of work worked for companies with less than 30 employees in the face of the economic crisis caused by covid19 the burden of severance pay could result in a reduction of lowwage jobs deepening poverty in the elderly population in order to solve lowincome problems caused by the early retirement of elderly workers and the dual structure of the labor market the same wage principle of equal value labor should be realized currently those who do the same job have a large wage gap the wage depends on whether the employee is a regular or nonregular worker and belongs to a large company or to a smalland mediumsized subcontractor therefore realizing equal wages for equal value labor is an important task for korean society once employees enter lowwage jobs they become highly dependent on them elderly workers who have received low wages even in lifelong jobs are likely to suffer from poverty with fewer wages after retirement 60 according to a survey conducted by the seoul metropolitan government in 2020 228 of elderly people living in seoul and reemployed in fulltime jobs after retiring from their main jobs do not receive the legal minimum wage to apply the equal pay for work of equal value principle the wage system should be shifted to be joboriented rather than senioritydriven a jobcentered wage system is a wage system that gives a job rating based on the relative job value and determines the relative level of wages 60 this is effective in preventing unreasonable wage discrimination because wages depend on the importance and difficulty of the job 61 in order for job pay to succeed solidarity and bargaining power of all workers must be supported 62 in europe where job pay is common unions and user organizations set wages for each job or proficiency through collective negotiations by industry as this decision was applied to all workers in the industry equal wages for equal labor could be carried out beyond the corporate fence for example germanys job pay system is negotiated directly by the head of the labor union and the head of the government these negotiations determine the wage structure and wage level according to the industrial group agreement 63 because post adjustment of individual workplaces is not possible the wage gap by institution or employment type is not large however koreas trade union organization rate is only 125 percent and more than 90 percent of workers have no organization to represent their interests 64 in addition the gap between the union organization rate and the number of subscribers depending on the size of the workplace is large the wage rates negotiated by organized labor unions are significantly higher than those that were determined by the employer alone wage gap by institution or employment type is not large however koreas trade union organization rate is only 125 percent and more than 90 percent of workers have no organization to represent their interests 64 in addition the gap between the union organization rate and the number of subscribers depending on the size of the workplace is large the wage rates negotiated by organized labor unions are significantly higher than those that were determined by the employer alone advocates for all employees the chamber of labor therefore consideration for establishing the labor chamber as a way to improve the bargaining power and representation of the entire workforce is necessary all workers with a certain period of employment insurance payments including irregular workers special types of workers and the unemployed are obligated to sign up to the chamber the chamber of labor a labor representative organization corresponding to the korea chamber of commerce and industry can be in charge of joboriented wage negotiations at the national level not at the company level 66 in addition the korea chamber of commerce and industry and the labor chamber may set up the korea labormanagement committee a central governmentlevel labormanagement relations organization to discuss labor and industryrelated policies and to lay the foundation for social dialogue and compromise the austrian chamber of labor could serve as a reference model for the korean chamber of labor the austrian chamber of labor was established in 1920 as a counterpart to the chamber of commerce 67 the most important functions are to participate in the process of revising laborand socialsecurityrelated laws presenting positions on law proposals and improvement measures and to represent labor interests in policy directives the labor chamber is a think tank involving experts from various fields including lawyers and labor as well as workers the labor chamber conducts about 400 collective agreement negotiations every year in addition the company carries out legal advice education and consumer protection unlike labor unions in which membership is autono advocates for all employees the chamber of labor therefore consideration for establishing the labor chamber as a way to improve the bargaining power and representation of the entire workforce is necessary all workers with a certain period of employment insurance payments including irregular workers special types of workers and the unemployed are obligated to sign up to the chamber the chamber of labor a labor representative organization corresponding to the korea chamber of commerce and industry can be in charge of joboriented wage negotiations at the national level not at the company level 66 in addition the korea chamber of commerce and industry and the labor chamber may set up the korea labormanagement committee a central governmentlevel labormanagement relations organization to discuss labor and industryrelated policies and to lay the foundation for social dialogue and compromise the austrian chamber of labor could serve as a reference model for the korean chamber of labor the austrian chamber of labor was established in 1920 as a counterpart to the chamber of commerce 67 the most important functions are to participate in the process of revising laborand socialsecurityrelated laws presenting positions on law proposals and improvement measures and to represent labor interests in policy directives the labor chamber is a think tank involving experts from various fields including lawyers and labor as well as workers the labor chamber conducts about 400 collective agreement negotiations every year in addition the company carries out legal advice education and consumer protection unlike labor unions in which membership is autonomous privatesector workers are obligated to join ensuring excellent worker representation the chamber of labor established in nine metropolitan governments gather to form the federal chamber of labor and the vienna chamber of labor in the capital city is in charge of the chairmans organization the chamber of labor represents a total of 36 million workers excluding civil servants and agricultural workers and the interests of retired workers are represented through the chamber of labor finance is covered by the labor chamber levy an amount equal to 05 percent of the pretax wage there may be resistance from some unions to the introduction of the labor chamber but effective measures are urgently needed considering the fact that there is no organization representing the everexpanding interests of vulnerable workers in response to this a central labormanagement organization called the chamber of labor could be effective in easing the dual structure of the labor market this requires that regular unions of small and large companies overcome the problem by representing the entire labor community and form solidarity with superbusiness agreements to switch to jobbased pay structure developing knowledge and skills for transitions alternatives are needed to minimize unemployment and allow reemployment with decent jobs in response to early retirement one option is to increase productivity by providing vocational training to retirees o1r prospective retirees generally negative stereotypes and prejudices that older people are less productive are common 68 most businesses are not active in vocational training for older workers because the costtoreturn ratio is perceived to be lower and less effective than for younger workers 69 in particular the need to acquire workrelated knowledge or skills is not high because the older workers are usually in charge of laborintensive lowskilled tasks when working in the secondary sector as a result workers career development opportunities are limited and affect early retirement and reemployment the probability of transition from nonregular to fulltime employment is less than 2 in addition most of the reemployment jobs are nonregular to economically inactive or shift to lowskilled simple labor jobs such as security guards and street cleaners 70 promoting vocational learning system by the elderlycustomized program there are employment education centers for senior citizens specialized in vocational training but there are only 15 centers nationwide this is insufficient to meet the needs of workers aged 50 and older and most of the centers programs are focused on simple work such as cleaning and janitorial work 71 to improve middleaged and elderly employment capabilities more professional and effective vocational programs should be developed such as education and training linked to primary lifelong jobs education and training needed for those who want to change careers education that informs the worker on what services the government provides for those middleaged and older and advanced computer literacy education 72 the demand for employment education also varies because of the large differences in physical function educational background experience and available time in order to properly respond to these situations the expansion of various forms of customized vocational training education programs is necessary the most significant factor that causes the current low participation rate in vocational training for senior citizens is that vocational training is not linked to employment 73 developing demandtailored education and training programs by regularly examining companies workforce needs can increase the possibility of employment in a decent job and reduce poverty in the elderly conclusions despite the governments steady efforts the relative poverty of the elderly population remains unresolved according to a systematic analysis of the economic difficulties of the elderly population that applies a socioecological model the cause of elderly poverty is complicated by the specificity of the labor market and the pension system in korean society this is compounded by a lack of a public support system that can overcome insufficient family care and a lack of individual preparation first the national pension which is the core of public pensions has a wide gap and insufficient pension receipts due to the immaturity of the system most retirement pensions are received as lump sum payments and lose their function as pensions second the duality of the labor market creates income inequality by size employment type and gender and has a negative impact on the subscription and maintenance of multilayered pension systems third the seniority wage system leads to early retirement from primary jobs in life which generates an income crevasse until the time of receiving the public pension to alleviate elderly poverty this paper recommends three policy alternatives first a robust multipillar retirement income security system must be established to secure minimal retirement income for the elderly in poverty who have been marginalized from the public pension system design the basic pension should be raised for the bottom 70 of senior citizens even if the national pension system the core of the multilayered income security system matures the existing wide gaps cannot be resolved so strengthening the social safety net will be a feasible alternative to elderly poverty the role of the retirement pension should also be strengthened as an income source by granting tax benefits to the pension recipient to reduce lumpsum payouts second in order to ease the dual structure of the labor market and prevent early retirement from jobs the seniorityoriented wage system should be reorganized into a jobbased wage system in order for wage structure transition reform to succeed a chamber of labor an institution that can represent the interests of all workers is necessary the ultracorporate collective bargaining process centered on the chamber of labor can contribute to reducing unfair wage dispersion third to minimize unemployment and maintain reemployment job quality the government should advance vocational skills development accounts by expanding programs tailored to older people this study contributes to identifying the causes of elderly problems facing our society and suggests ways to solve those problems the study though used the national level data to provide a snapshot of senior poverty in korea future research could consider comparing regional characteristics determinants and trends between rural and urban areas given the fact that in rural areas of korea the proportion of the elderly population is higher than that of urban areas the problem of elderly poverty may appear more dramatic in rural areas this approach could provide more sophisticated targeted policy measures to reduce poverty among the elderly in korea for the elderly to escape poverty on their own is practically challenging if not virtually impossible in order to realize an inclusive society the governments social security policy and labor structure need to be reformed in concert with individual efforts data availability statement the data that support the findings of this study are openly available in oecd and also in author contributions conceptualization jk methodology jk and jp validation jc and jk formal analysis jk and jc investigation jc and jp resources jk and jp data curation jk and jp writingoriginal draft preparation jk writingreview and editing jc visualization jk and jc supervision jc funding acquisition jc all authors have read and agreed to the published version of the manuscript funding this research received no external funding appendix a composition of workers by employment type

poverty for the elderly is one of the most urgent social problems when discussing the social problems facing korean society the purpose of this study is to identify the causes of elderly poverty problems and to seek countermeasures according to a systematic analysis of the economic difficulties of the elderly population that applies a socioecological model the cause of elderly poverty is complicated by the specificity of the labor market and pension system in korean society this is compounded by the lack of a public support system that can overcome insufficient family care and a lack of individual preparation to alleviate elderly poverty this paper recommends three policy alternatives first a robust multipillar retirement income security system must be established to secure a minimal retirement income for the elderly in poverty who have been marginalized from the public pension system design the basic pension should be raised for the bottom 70 of senior citizens second in order to tackle labor market duality and early retirement the seniorityoriented wage system should be reformed into a jobbased wage system third to minimize unemployment and promote quality among reemployment jobs the government should strengthen vocational skills development by expanding programs tailored to older people

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introduction each year 34 million new cases of cancer are diagnosed in europe of which about 16 million are of working age 1 with improvements in diagnosis treatment and survival rates returning to paid work after cancer diagnosis and treatment has become of increased importance to individuals employers and the wider society 2 motivations for return to work are based not only on financial but also on psychological needs as well because work often provides meaning to peoples lives 3 many studies have shown that work plays an important role for cancer survivors identity formation selfesteem financial security and social relationships and represents capabilities skills and health 4 although some people affected by cancer are simply able to continue working in a similar manner as prior to diagnosis 5 a significant proportion of them end up unemployed retire early or change jobs more often than those without cancer 6 7 8 9 while 63 of 64 studies of cancer survivors returned to work 10 one important reason for not returning to work given by patients is a reported lack of understanding and support from their employers 1112 this was also experienced by other stakeholders including insurance institutes doctors and persons in the patients private life 13 some cancer survivors feel vulnerable and insecure in relation to rtw and are in need of acknowledgement of their concerns by their employers 14 from an employer perspective the rtw of knowledgeable and experienced workers enables continuity of skilled manpower and minimizes costs due to lost productivity while reducing payment of disability compensation 15 while there is research on the perspectives of employers with experience with workers with a history of cancer 12 16 17 18 there is a need to determine whether employers experience patterns of useful strategies for rtw across diverse nations evidence suggests that employers have a considerable impact on many aspects of the workers wellbeing 19 and that as expected employers play a central role in the success of rtw employers are in a position to make workplace accommodations provide support and facilitate colleagues or coworkers 1417182021 cancer survivors are more likely to be employed if they perceived their employer as accommodating and received support from colleagues and employers 22 furthermore given the central role of the employer in all matters related to work in a specific organization nine out of ten recommendations in the european declaration call for a guideline on cancer and work involving the employer 23 employers however struggle with this role 1216 and are in need of support to achieve positive outcomes related to work and cancer survivorship 1718 therefore further elaboration of the specific perspectives from various employers in the return to work process of cancer survivors may assist in the process of identifying employer actions that may help improve work outcomes the aim of the present study is to obtain a better understanding of the employers experience with good practices related to employees with a history of cancer and identify specific actions to achieve positive outcomes methods the consolidated criteria for reporting qualitative research checklist was used for reporting of findings 24 sample interviews were performed in belgium croatia israel italy the netherlands norway slovakia romania and the uk all members of the cancer and work network 25 and representing eastern western northern and southern europeanstyle welfare state models or a mix of these using purposive sampling targeting three employers per country were approached that together represented the following characteristics at least two organisations each with small medium and large workforce three different sectors and both profit and nonprofit organizations employers were approached via professional networks and publically available contact information inclusion criteria for interviewees were employer with experience and close involvement in supporting one or more worker diagnosed with cancer in the last 5 years at least two employers per country with employees with some experience with a coworker with cancer who recently returned to work an organisation that complies with national legislation and an employer fluent in the countrys language data collection employer representatives were contacted either by email telephone or facetoface and informed about the aim of the study and asked to provide written or oral informed consent prior to the interview the interview guide was adapted from tiedtke et al 12 with the authors representing the countries interviews provided a consistent set of questions across countries the nine interviewers were researchers or practitioners who were employed in work or health areas and had experienced conducting interviews the majority of the interviewers and interviewees had no established contact prior to the interview and interviews were preferably completed by one interviewee interviews were conducted between may 2016 and march 2017 the interviews lasted 3060 min were held in the interviewers and interviewees native language and were held facetoface at the workplace or by telephoneskype when necessary for logistical reasons all interviews were audiorecorded and transcribed verbatim if the interviewee agreed in two cases a written account of the interview was produced directly after the interview interviews were not returned to interviewees for comments interviews were translated into english by the interviewer or a coauthor from the same country data collected and analysed during the study are available from the corresponding author upon request sample characteristics in total 59 employers were approached and 25 interviews were conducted including 27 employer representatives average age of the interviewees was 48 years 1027 were female 13 were directors or line managers and 14 hr or health and safety professionals the sizes of the organisations varied between small medium and large diverse sectors with 6 companies from the industry sector were represented fourteen organisations were forprofit organisations while the others were nonprofit and mostly public organisations data analysis a mix of grounded theory 26 and thematic analysis 27 was adopted emphasizing collaborative analysis from different country perspectives all themes were derived from the data and none were identified in advance all interviews were coded and a preliminary overall schematic representation of the interviews was provided 28 by the first author next all authors read the interviews completed in their own country in addition to at least two from another country produced narrative reviews in english of these interviews and went through a process of rough coding a meeting with most authors in milan october 2016 was used to collaboratively define preliminary themes for a more refined coding then more specific coding on the basis of themes and data was performed and a first version of results was produced the findings were discussed at a second meeting with authors in loughborough january 2017 and a refined overall schematic representation of the interviews was produced a second version of the results was produced based on this meeting ethical issues and confidential treatment of data all procedures performed involving human participants were in accordance with the ethical standards of the institutional andor national research committee and the 1964 helsinki declaration and its later amendments or comparable ethical standards ethical approval was assured and in line with national standards in each country all interviewers informed the participating employers and asked for their written or oral informed consent and all transcripts were anonymous the researchers who read during the process of data analysis the anonymous interviews from another country all signed a statement that they will treat the transcripts confidentially each interviewer who collected the data was held responsible for treating these data according to national standards results overall employers viewed the experience of assisting a worker with a history of cancer in relation to rtw as a dynamic process six support phases were identified as good practice for addressing rtw of a worker with a history of cancer the support differed in level of comprehensiveness by country organisation employer and worker however the dynamic process implicated by the expressions of employers across these nations is summarized in fig 1 dynamic process rather than a procedure that can be simply managed employers referred to supporting workers as a process depending on the specific context but what i always find important it that it is a process between line manager and worker as indicated in fig 1 this process typically involves six different phases reacting to disclosure by the worker line manager obtains more information related to the situation decisionmaking related to initial actions remaining in touch during the treatment andor the sick leave period decisionmaking on rtw and followup this dynamic process does not always follow a stepwise method where phases are not always addressed in the order described and can be brief or comprehensive employers tend to tailor the process to the situation and person the needs of a specific worker are considered and flexibility is a major priority a good employer should pay particular attention to a serious illnesses like cancer in order to manage working time and required tasks in relation to the worker heres what i think the organisation absolutely has to consider every local situation and people working in the enterprise phase 1 reacting to disclosure by the worker of a cancer diagnosis involvement of the employer is only possible if the cancer diagnosis is disclosed which is not mandatory according to privacy legislation across all nations most workers do explain their situation to their employer alternatively the hr department the occupational physician or the family might discuss the situation with the line manager emphasizing confidentiality of the information the human resources department will normally contact the head of department to let them know within that theres advice about not sharing this information the employers consider a workers cancer diagnosis to have a special status compared to other health conditions for three reasons firstly the diagnosis is not questioned secondly with cancer one thinks immediately of the risk of death and that is what makes it special and thirdly cancer is regarded as psychologically demanding for the worker as a consequence employers often mention that the diagnosis of cancer facilitates workplace support i believe that cancer is creating something extra among all the persons around this person compared to musculoskeletal disorders it cancer creates a greater will to contribute and patience in relation to the unpredictability phase 2 line manager obtains more information related to the situation after the cancer diagnosis is disclosed the employermostly the line managerbegins to obtain relevant information needed for early decisionmaking either in the same meeting during which the disclosure took place or in additional meetings in some countries an occupational physician meets the worker and delivers the information needed the aim of this phase is to gain knowledge on the functional consequences of medical situation the treatment and the psychosocial situation also contraindications for work at the specific workplace is often employers wait with decisionmaking until the medical assessment has been completed and the course of treatment becomes clear if access to health care becomes a problem employers might help the worker to obtain medical care sooner phase 3 decisionmaking related to initial actions after a first impression is made of a workers situation employers decide whether or not the worker will continue to work during treatment and if so under what conditions four types of this initial decisionmaking process were reported firstly the worker might continue working in the same job under the same conditions this might involve redistribution of specific tasks within the team eg strenuous work tasks are replaced by more simple tasks when the workers energy level is low because of chemotherapy furthermore some flexibility from the line manager regarding working times can be required but this might not be possible when the affected worker is the manager himself secondly the worker might continue working in adapted work for example shift work may be suspended thirdly the worker might continue working in a different job with a different contract continuing to work can be regarded as beneficial for the worker yet it is more of an exception than a rule fourthly the worker may be given sick leave by the occupational or treating physician then an important employer issue is the decision to replace the worker or not some employers suggest that not replacing the worker represents good practice according to them replacement might be perceived by the worker as a sign that the job is no longer available for them and that the employer might possibly not want him or her back because of impending mortality however most employers indicate that they prefer to avoid such expectations i would like to add he the worker simply must have the feeling that he has a place to return to and not the feeling that he is not valued within the company and that his position will be occupied by someone else this phase of initial decisionmaking causes employers to struggle with diverse dilemmas regarding informing and guiding the workers colleagues firstly they feel responsible for safeguarding the privacy of the worker secondly there is the emotional reaction of the team and this also requires the employer to take time for communication there is an important impact on the person and on the team one has to be on stand by for ones workers thirdly lack of replacement for the affected worker might be a burden to coworkers in such cases employers report using their managementleadership skills to create goodwill in the team at least for some time phase 4 remaining in touch during the treatment andor sick leave period all employers try to keep in touch with their affected workers in different ways and with different frequencies there might be meetings at home or in the organisation or telephone calls the line manager hr professionals or occupational physicians might be involved the goals of this problem solving includes staying in touch with the worker in order to ensure that a workers needs are clear and to collect necessary information on the course of the illness and the treatment via the worker in some countries a formal plan that for example specifies proposed work adaptations counselling meetings with the line manager and occupational physician and the organization of phased rtw is required this plan is written up by the employer at an early stage and adjusted as needed and requires regular meetings hr is really strict on providing a plan there are routines on that etc they send out questions that are supposed to be responded to and there must be a written followup plan every fourth week for example if it is due on 26 th they follow up soon after phase 5 decisionmaking on rtw when the effects of treatment on the workers work ability become clear a more lasting decision for the near future needs to be made at this stage it is not only the employer who decides but depending on which stakeholders are available in a country occupational physicians a psychologist in the organisation or community social workers social insurance and trade unions can also be involved essentially five possibilities were described by employers 1 the workers workability is too low and the worker applies for financial compensation if available 2 the worker is on a temporary contract that expires during treatment the worker is either out of a job and the involvement of the employer ends or the employer evaluates the situation and tries to identify a job for the worker 3 the worker himself or herself decides not to continue working the employer may find this understandable given the personal situation of a worker employers emphasize that they cannot control the outcome of the cancer treatment some employers report that workers who returned to work after cancer are still considerably vulnerable which the employer interprets as coming from the psychological stress of cancer and its treatment it has been three months since she got back the stress was enormous she was stressed but never cried she functioned but was very stressed she wanted to know the results some employers explain that despite their efforts rtw appeared not possible because of what they referred to as the most difficult outcome death of a worker these employers explain that this was a learning experience for them and they warn that employers have to be prepared for this adverse outcome particularly because of the negative impact it has on the team and the big difference is when it does not go well when death comes because then you are stuck in some kind of a vacuum and how do you cope with that there is a wider dimension and thats the interpersonal relationships for this outcome there are no protocols but some employers refer to the important need of support for the line manager and the whole team and financial support for the remaining family factors shaping the rtw process according to the employers interviewed how rtw processes are actually detailed for the affected worker is still a function of policy related to country organisation employer and worker country variations even though income protection for the work disabled differs across countries all employers indicated they try to safeguard income either by work or welfare however large country differences in the degree of employer involvement in the different rtw phases exist policies vary from scarce sickness absence policies in for example romania and slovakia to detailed sickness absence policies such as in norway and the netherlands which require employers to take a large role in countries with scarce national policy on sickness absence employers choose either taking the primary responsibility or expecting that worker to take the main responsibility employers taking the main responsibility might focus on the detailed planning of rtw as in the following quote we are more able to manage it maybe because we face very different situations since the health conditions and domestic situations are different for each case since we are in charge we have to exactly plan how the situation will develop such employers might also focus on organizing support maybe in the sense that if he needs help we can help with some contacts help in speeding up the examination at the doctors or maybe so that he receives the best health care that can be provided other employers in countries with scarce policy emphasize being compassionate ie understanding empathic or giving space to the worker diagnosed with cancer and thereby leaving the responsibility to the worker if they are close to their workers they will find the best solutions so it depends on the employer… if he wants to help he will eventually find the legal and organisational ways to help the worker what matters is the human side in contrast in countries with more extensive national policy on sickness absence mutual investment by both the employer and the worker is expected thus what we always do is look at the full package of tasks but i let the person think about it the person has to indicate to me this i will not be able to do that i will be able to do and we try to facilitate that you have to get people in the mode that they think about this themselves employers in these countries describe the process more precise and in terms of their duties for realizing work accommodations and planning gradual rtw variations at the level of the organisation within the margins and requirements of national legislation organisations also vary in the level of comprehensiveness of their sickness absence policies and what these policies require employers to do these policies vary from a strict policy prescribing employers what to do in different phases to employers deciding themselves on ad hoc procedures there is a sickness absence protocol the employer has to contact the worker every 14 days we dont have a procedure about calling the worker at home and contacting them on certain dates and so on it stays at a personal level how each of us knows to manage it i say its about feeling also the size of the organisation matters employers of smaller companies express a of lack organisational policies but pictured their organisation as families with strong ties between the workers they have great concerns over the risk of losing their reputation and thus confidence of the consumer who often live in their direct environment job turnover is rare employers of larger organisations express to have routine systems in place to manage workers with cancer and financial buffers and options to dilute the burden for colleagues they have welldeveloped organisational sickness absence policies and most have a sociomedical team however the flexibility of larger organisations is sometimes compromised by hierarchical decisionmaking the rtw process is thus more unpredictable and flexible in smaller organizations and might be more extensively controlled in larger organisations irrespective size or sector employers refer to different social cultures in organisations some refer to an empathic culture in which during each phase the worker with cancer is monitored and receives a tailored approach it was less about look heres a policy and do it by numbers it was more about actually how are we going to get the best out of this person now and support them in their recovery……let them feel that without becoming sentimental let them say look we care about your wellbeing others refer to strictness and maintaining the competitiveness of the organisation brutality is in things and in situations especially when the system of costs becomes very strong as in multinational corporations if somebody has a cancer a worker in hr offices calls him and gives him a redundancy pay and fires him finally some employers explained that rtw is more complicated if during the sickness absence important organisational changes take place such as a merger with another organisation variations at the level of the individual employer the rtw processes also vary because the employers are different people with different skills experiences and characteristics some employers emphasize that their acquired leadership qualities and communication skills had made them fit for the job of guiding a worker with cancer and they invest more effort in each phase it was more about my leadership experience and treating someone just sensitively so i had the ability to say to m lets start with you coming back three days a week and then well work from there and if you want to come in a little later other employers have experienced cancer in their personal lives or with other workers and feel that because of these experiences they feel more secure in the decisionmaking i knew as i had my mother in that situation finally the employers personality me as a human being influences the extent to which the employer feels emotionally affected during the rtw process varying from protecting themselves against becoming too emotional phrased as not go down the basement to being affected so much variations at the level of the worker finally and within the context of national and organizational policy most employers take characteristics of the worker into account when deciding about work adjustments and other types of support workers differ regarding their disease characteristics personality and work motivation their position in the group and in their relationship with the employer before the cancer diagnosis workers also differ regarding their emotional reaction and family support generally workers who are more positively appreciated by their employer can rely on more employer support not married and her life revolved around university and also the team here so she was much more keen to try and come into work so that was a slightly different approach finally workers in lower job levels can be replaced more easily when compared with workers with heavy responsibilities the results presented above identified employers experiences of good practice when assisting a worker with cancer as a phased process shaped by factors at country organization and employer and worker level employer needs employers report five types of needs across the different countries in order to better achieve good practice in relation to a worker with cancer firstly employers express the need for structured procedures and i am in favour of procedures and rules and guidelines as the previous quote illustrates it is about rules and legislation some employers refer to legislation specific for cancer patients to fulfil this need another option discussed is to have structured procedures by trade unions in collective bargaining furthermore it is about organisational policies which importance is expressed by employers from countries without and with extensive sickness absence legislation and policies i think it would be very useful to establish return to work procedures after long sick leave we have and most of us organisations have systems to handle it sickness absence for handling people on sick leave you must have systems finally employers express the need for professional guidelines and protocols based on the literature and knowledge from practice the employer needs clear instructions on what the workers can and cannot do so that they can adjust their workplaces or give them another job i would appreciate you forming a working group who collects experiences and knowledge to formulate a guideline secondly many employers emphasize collaboration with other stakeholders among which the role of the occupational physician or occupational health specialist is highly appreciated you have to tune things with the socialmedical team and you need to understand well the responsibility of the occupational physician and of the line manager we have our p o department involved in the line management and the hr manager should know and take his responsibility and i think as being from the p o department that he should not check but monitor the process the role of the occupational health specialist is very important the occupational health specialist could come into the company and visit each workplace the occupational health specialist makes work ability assessment and draws up an expert opinion about job tasks in a certain company about what workers can perform and what cannot be performed anymore thirdly most employers refer to communication skills training a more focused training would be good or to communicate with such workers from the perspective of the employer fourthly they also like to get information on cancer and its treatment side effects the capabilities of the worker who returns and possible work adaptations with such scenarios of a worker with cancer then they are better able to deal with the diverse dilemmas and the emotional burden they experience as an employer this can be done via consultation with experts or an easytoaccess information package according to employers from diverse countries maybe if there was some package prepared which would summarize all the alternatives in cases of workers with cancer to indicate that one doesnt need to experience all of it alone something simple which can be downloaded from the internet and then distributed to line managers and colleagues to see what the different possibilities are for how it develops fifthly employers refer to the need for financial resources for them to assist workers with cancer i think ngos could help financially or in another way we do not have a union but in other sectors maybe unions could engage and help in these issues in some countries the social insurance supports financially we also realized the person could work up to 20 without payment from the company social insurance paid this just to try to get him going and that stimulates these needs fit with the finding that the process of guiding a worker with cancer is perceived as a dynamic process consisting of several phases requiring planning collaboration sophisticated communication skills diverse knowledge and financial resources discussion the aim of this study was to gather different employer perspectives on workers with cancer including employers experiences of good practice and their perceived needs to support good rtw outcomes in these workers a novel aspect of this study is that employers were from nine different countries with different welfare systems despite variations across countries six phases were identified by employers with corresponding needs for employer support the first phase encompasses the employers initial reaction to the diagnosis while disclosure of cancer to an employer is not demanded by law in participating countries employers felt it was essential to be informed so that decisions such as temporarily reallocating the workers job tasks could be made following disclosure employers gather relevant information to help them to decide about initial action while employers used their general managerial skills to gather relevant information from a worker diagnosed with cancer they expressed the need for more sophisticated communication skills the emphasis on advanced communication skills is in line with previous research in employers managing workers diagnosed with cancer 1617 during treatment andor sickness absence the employer remains in touch with the worker again requiring good communication skills when a workers rtw becomes a possibility decisions are made by employers related to rtw and adaptations and further planning is needed finally employers address followup of rtw or in the worst case of dealing with advanced noncurative disease employers views on good practice are in line with the scientific literature on how to organize rtw for cancer patients including involving problem assessment planning performing planned activities and evaluation 29 however the current study shows employers put greater emphasis on managing initial actions and sick leave than on actual rtw this is similar to the finding among belgian breast cancer survivors which shows that an intensive mental preparation by workers preceding actual rtw is important 13 a dutch study on employers managing sick leave and return to work among workers with cancer reported five phases that reflected national legislation however the current study did not explicitly distinguish a phase for early information gathering 16 collaboration with stakeholders was also expressed as a need particularly when it comes to designing rtw occupational health physicians for example are trained to translate medical problems into functional issues and fitness for work generally rtw is regarded a multifaceted process involving many stakeholders 13 14 15 16 17 overall employers in the current study expressed a need for structured procedures consistent with earlier recommendations 18 the consensus on the phases and needs between the interviewed employers across countries and organisations is clearly striking particularly given differences between countries on whether employer involvement in rtw is required by legislation as indicated in variations at level of organisation the intensity by which the six phases are addressed was more intense among employers from those countries that have well developed national rtw guidance or legislation however the current study did not identify ethical dilemmas faced by employers as found in previous studies 1216 such as feeling caught between their sincere concern for the employee and the professional realism of interests of the company this might be explained by the focus on good practice in the current study strengths and limitations this is the first study to explore the experiences and needs of employers regarding workers with cancer across countries representing diverse welfare models 30 we selected a wide variety of employers from different backgrounds and different sizes and types of companies all interviewers used the same interview guide developed collaboratively by the authors which increases validity of the data in addition during the analysis three daylong facetoface meetings took place with the interviewers and data coders to increase validity of the analysis 2628 this study has several limitations some employers were selected via professional contacts of the interviewers and about half of the employers approached did not participate therefore selection bias towards a general positive view on the workability of cancer survivors both via selection of employers and via selective report of employers in order to present a positive image cannot be ruled out this is a general difficulty in research on rtw among employers 12161820 indeed results from survivors perceptions show that they are not always positive on the role of the employer and they can perceive barriers related to support communication work environment discrimination and perception of work ability 17 the strict selection criteria leading to a balanced composition of employer types might have counterbalanced this limitation at least partly moreover we had a response rate of 2559 of the approached employers which can have caused a positive selection bias as well in addition a total of 25 interviews might not be many given that nine countries were involved but it is not a low number for qualitative research further although additional information could have been provided by additional employers the consistent findings across countries might be regarded as a sign of data saturation crosscountry variations might have impacted the data from the interviewers part translation to english might have led to important linguistic nuances being lost in translation this last disadvantage has been counterbalanced by opportunities for reviewing results by all interviewers to reduce demands for employers they were not asked for any further comments after the interview questions to conclude the findings might not represent all good practice experienced in each of the nine countries but certainly represent an important part of the employer experiences it may not be possible to generalize the findings to countries not included and countries outside europe or israel reliance on the presence of benefits for some level of income replacement for a worker on sick leave might be the explanation for the high degree of consensus among employers recommendations for further research quantitative studies are also needed to substantiate and further determine the generalization of these findings it is important to develop implement and study the effectiveness of interventions aimed at supporting employers in order to enhance sustainable work participation of workers with a history of cancer effective interventions for this patient group remain scarce 31 finally more detailed crosscountry studies are needed as other studies do show crosscountry variations in labour participation of vulnerable groups 33 34 35 36 37 recommendations for practice in order to improve the process of rtw in cancer survivors employers need support as well 20 the framework of six phases found in this study provides policymakers and employers with a tool to organize new national legislation company policy and individual guidance legislation on work adaptations and gradual rtw can aid employers in supporting rtw of cancer survivors across jurisdictions there is an increasing focus on supporting individual participation in the labour force 32 finally our findings indicate the need for training in communication and decisionmaking skills of employers related to this problem and perhaps chronic illness and work in general caring for workers with cancer should be continued beyond the hospital walls and beyond recovery of the malignancy employers are key to realize this funding information this study was performed by researchers collaborating in the h2020 cost action cancer and work network is1211 for lode godderis this contribution was possible thanks to kom op tegen kanker funded projects on rtw after cancer for adela popa the contribution to this article was based on the research conducted in the project community participation for reducing the burden of cancer stakeholders involvement in facilitating the return to work of cancer patients the project was supported by a grant from the romanian national authority for scientific research cncsuefiscdi for angela de boer angelique de rijk and sietske tamminga the contribution to this article was possible with the support of a grant from the dutch cancer society for fehmidah munir the contribution to this article was possible with the support from the national institute for health research leicester biomedical research centre which is a partnership between university hospitals of leicester nhs trust loughborough university and the university of leicester uk compliance with ethical standards conflict of interest the authors declare that they have no conflict of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

purpose this study explored employers perspectives on 1 their experience of good practice related to workers diagnosed with cancer and their return to work rtw and 2 their perceived needs necessary to achieve good practice as reported by employers from nine separate countries methods twentyfive semistructured interviews were held in eight european countries and israel with two to three employers typically including hr managers or line managers from both profit and nonprofit organisations of different sizes and sectors interviews were recorded and transcribed verbatim a grounded theorythematic analysis approach was completed results employers experience with rtw assistance for workers with cancer appears to be a dynamic process results indicate that good practice includes six phases 1 reacting to disclosure 2 collecting information 3 decisionmaking related to initial actions 4 remaining in touch 5 decisionmaking on rtw and 6 followup the exact details of the process are shaped by country employer type and worker characteristics however there was consistency related to the need for 1 structured procedures 2 collaboration 3 communication skills training 4 information on cancer and 5 financial resources for realizing rtw support measures conclusions notwithstanding variations at country employer and worker levels the employers from all nine countries reported that good practice regarding rtw assistance in workers with a history of cancer consists of the six phases above employers indicate that they would benefit from shared collaboration and resources that support good practice for this human resource matter implications for cancer survivors further research and development based on the six phases of employer support as a framework for a tool or strategy to support workers with a history of cancer across countries and organisations is warranted

19602_0

by the obesity epidemic given the substantial health and economic costs associated with obesity 3 identifying solutions to the obesity epidemic continues to be an area of significant policy and research interest a large amount of research has focused on social inequalities in obesity and bmi recent evidence finds that adults in the most deprived areas of england are twice as likely to have obesity as those in the least deprived areas 6 a similar difference is observed comparing highest and lowest education groups 6 evidence further suggests that in england inequalities in obesity and bmi according to education level have widened in absolute terms alongside the development of the obesity epidemic 7 a pattern observed in multiple other countries 8 though not all 9 research on social inequalities in bmi has typically taken a populationlevel approach and focused on estimating associations for instance examining the mean difference in bmi according to educational attainment less attention has been paid to the explanatory power of socioeconomic factors at the individual level for example the proportion of betweenperson variability in bmi that can be predicted by socioeconomic position 10 though measures of sep have been included in predictive algorithms for bmi 11 and reducing social inequality has been proposed as a way to tackle high obesity rates 12 sep appears to explain only a small amount of betweenperson variability in bmi 9 13 14 15 16 17 this is the case even when multiple indicators of sep across life are used 1314 the comparatively low explanatory power of sep accords with more general observations the variance in adult bmi explained by environmental factors shared between twins is very low in contrast to the proportion explained by genetics and nonshared environmental factors 18 this low explanatory power is observed across almost all traits and is known as the gloomy prospect in behavioural genetics 1920 attempts to directly predict individual life outcomes using sep and other survey data have produced humbling results for example a recent scientific mass collaboration showed that several socioeconomic outcomes were largely unpredictable using a range of sophisticated predictive models and unusually rich survey data 21 while the explanatory power of sep on bmi may be lower than perhaps expected 12 it could have systematically changed across time the increasing variation of population bmi partly reflects increasing inequalities between sep groups but it reflects increasing variation within these groups too 215 22 23 24 25 if the increasing variation within groups exceeds the increasing variation between groups the explanatory power of sep already low may have fallen further still determining whether this is the case is important for understanding the role of sep as a contributor to the obesity epidemic 22 and for understanding the potential for using sep in predictive algorithms however research on this question is limited studies from the usa 9 and indonesia 15 find the explanatory power of sep on bmi has decreased over time but social inequalities declined in these countries over the periods assessed thus results may not generalize to england or other countries that have experienced widening inequalities across time existing research is further limited by a focus on individuallevel and not arealevel measures of sep which may capture areabased factors such as neighbourhood walkability and fast food outlet density 26 existing research is also limited by the use of methods not tailored for prediction in particular studies have used linear regression models of limited flexibility which may not have captured interactions and other nonlinearities they have also assessed explanatory power within the same sample as used to estimate models and have not assessed predictive ability specifically a metric of particular importance for creating accurate prediction algorithms for bmi we examined trends in the explanatory and predictive power of individualand arealevel sep on bmi more formally by adopting principles and methods from machine learning we used random forest models and repeated crosssectional data from the health survey for england to examine changes in the predictive ability of educational attainment and neighbourhood deprivation for bmi and obesity between the years 1991 and 2019 a period in which obesity rates doubled in england 1 methods measures body mass index bmi was calculated by dividing weight in kilogrammes by height in metres squared height and weight were measured directly by interviewers from 1995 individuals weighing more than 130 kg were asked to give an estimate of their weight due to limitations with the scales so measurements for these individuals are based on selfreport socioeconomic position the hse contains few measures of sep that are measured consistently in each wave we focus on educational attainment occupational social class and neighbourhood deprivation each captures different dimensions of sep 31 has been widely used in the social inequalities literature 32 and is related to obesity in the uk 6 education was recorded using the national vocational qualification schema to categorize qualifications according to skill level nvq 45 is equivalent to degree or above see 33 for further example qualifications occupational social class was captured using the registrar general social class schema data on social class are available from 1994 onwards except 2010 and 2011 social class is missing in a small number of cases where occupation was not categorizable within the schema or where the participant was longterm unemployed neighbourhood deprivation was measured using the index of multiple deprivation and was categorized into quintiles the imd combines deprivation across seven domains in the hse imd data are available from 2001 only at the electoral ward level from 2001 to 2002 and lower super output area level thereafter new versions of the imd are released intermittently the imd2000 is available from 2001 to 2002 the imd2004 from 2003 to 2007 the imd2007 from 2008 to 2010 the imd2010 from 2011 to 2014 the imd2015 from 2015 to 2018 and the imd2019 in 2019 we use the imd quintile data as supplied as it precluded further harmonization covariates we included age and sex as covariates in our prediction models as the relationship between age sex and sep has changed strongly over time and as age and sex may confound the association between education and imd and bmi 734 age was available in single years prior to 2015 but only in 5year categories from 2015 onwards for consistency with earlier years for years 20152019 for each individual we randomly drew a singleyear age from their respective 5year age category mean age increased in our sample between 1991 and 2014 statistical analysis to maximize predictive ability we used random forest models known to provide similar or superior predictions to traditional regression approaches in multiple settings 3536 our analysis consisted of fitting random forest models and assessing their predictive accuracy and explanatory power random forests are a decision treebased method in which data are recursively split according to decision rules invoking individual predictor variables decision rules are chosen such that splits minimize heterogeneity in the target variable to avoid overfitting random forests use an ensemble approach where the results of multiple decision trees are averaged with each tree being fit on a subset of predictor variables and a random sample of observations as predictions are generated via successive binary splits random forests can account for nonlinearities or interactions between independent variables without requiring their explicit parameterization an advantage here given previously observed differences in social inequalities in bmi between males and females across cohorts and over the life course 7 we fit a random forest for bmi for each year of data collection and measure of sep using sep age and sex as predictor variables we then extracted model predictions and used these to calculate three metrics of explanatory power and predictive accuracy variation explained mean absolute error and probability of superiority importantly to avoid overfitting we generated model predictions using a portion of our data that was not used to estimate the random forest model r 2 provides a measure of how well sep can predict betweenperson differences while mean absolute error and probability of superiority provide summaries of how well sep can predict individuals we compared the three metrics to baseline predictions where mean bmi was used and the results of random forest models including only sex and age as predictor variables we also calculated the magnitude of the association between educational attainment and bmi by using the results of the random forest models to predict mean bmi assuming everyone in the population had the same sep we defined the size of the association between sep and bmi as the difference in predicted population mean bmi for the most advantaged and disadvantaged sep categories to calculate confidence intervals we used bootstrapping accounting for the complex survey design for the predictive accuracy and explanatory power metrics we generated predictions using the observations not selected within a given bootstrap in order to avoid overfitting as the random forest models were estimated for each year separately to more easily ascertain trends in the proportion of prediction error explained by each sep variable and the size of the association between bmi and each sep variable we smoothed the bootstrap estimates by regressing estimates upon year splines using generalized additive models gams allow for flexible smooth nonlinear associations between independent and dependent variables the change in the age variable to 5year categories from 2015 onwards may have artificially increased the relative incremental predictive power of including sep in models consequently we also ran the gam models using data only up to 2014 to assess whether trends were observable prior to the change in the data we performed a series of further analyses first as social inequalities in bmi are typically found to be stronger among females than males 4 we repeated the analysis stratifying by sex second as age was imputed in later years we reran models with age inputted as 5year categories third as obesity is of particular research and policy interest we repeated the analysis using obesity as the outcome measure fourth as random forests could potentially overfit the data we repeated the bmi analysis using simple linear regression in these models predictors were included as linear or categorical terms with no interactions included the organization used to conduct the hse changed in 1994 some previous studies using hse have accordingly focused on data from 1994 onwards 38 we present results from 1991 to 2019 but in the text report results from 1994 where results from 1991 to 1993 depart considerably from those in later years results descriptive statistics there was an increase in the overall mean and variance of bmi and the prevalence of obesity between 1991 and 2019 education levels generally increased across time the proportion of individuals with the highest education level increased from 117 in 1991 to 375 in 2019 increasing education levels led to nonlinear changes in the variance of the education measure variance decreased overall between 1991 and 2019 but peaked in 2002 descriptive statistics for the sep measures and covariates are also shown in additional file 2 table s1 predicting bmi mean bmi increased among all education groups social classes and imd quintiles across the survey period including among those with the highest sep for instance predicted mean bmi increased for the most highly educated group from 262 kgm 2 in 1991 to 282 kgm 2 in 2019 more disadvantaged sep was generally related to higher bmi and there was some evidence that social inequalities widened over time the difference between the lowest and highest educated groups was 10 kgm 2 in 1991 and 13 kgm 2 in 2019 while the difference between individuals in the most and least deprived neighbourhoods was 06 kgm 2 in 2001 and 13 kgm 2 in 2019 the trend cannot be explained by changes in age composition over time generating effect sizes using the age structure of the 2019 hse sample similar results while average bmi increased within sep groups so did its variability given this increasing variability the total prediction error increased over time regardless of the model used in 1991 using age sex and education level to predict bmi generated an average prediction error of 34 kgm 2 in 2019 prediction error increased to 4 4 while prediction errors increased in absolute size there was some evidence that each measure of sep explained a greater proportion of variation in bmi over time as measured as the proportion of prediction error reduced by including education social class or imd in the random forest model or alternatively by incremental r 2 the improvement in prediction attributable to education was 014 in 1991 and 105 in 2019 across the studied period the total reduction in prediction error when including education social class or imd in models was very small less than 11 each year equivalently incremental r 2 was low for education 076 in 1994 and 157 in 2019 highlighting this the ability of education social class or imd to distinguish pairs of individuals at higher bmi levels was also generally poor the probability of superiority derived from models including sep was 059 or lower in each year little different from the probability of superiority derived from models just including age and sex education was typically more predictive of bmi than social class or imd though the temporal increase in mean level differences between highest and lowest sep groups was greatest for imd further analyses qualitatively similar results were obtained when linear regression was used instead of the random forest algorithm or when using the 5year age group as a covariate rather than the singleyear age qualitatively similar results were also obtained when predicting obesity instead of bmi social inequalities increased over time as did the proportional improvement in prediction when including sep in models but the overall predictive power of sep was low larger social inequalities were found among women when stratifying the bmi analysis by sex populationlevel differences in mean bmi according to sep were approximately twice as large among females compared with males accordingly sep improved individuallevel predictions to a greater extent among females though improvements in predictive accuracy remained low the relative improvement in predictive accuracy across the study period was more clearly observed among females discussion summary of results the results demonstrate an increase in mean bmi and an increase in the variability of bmi between 1991 and 2019 in england as well as an increase in the prevalence of obesity mean bmi and prevalence of obesity increased across all education groups and imd quintiles and there was an increase in social inequalities over time however variability in bmi within sep groups also increased while the ability of education social class and imd to explain the betweenperson variability of bmi increased over the study period explained variance remained low and absolute prediction errors increased in size a broadly similar pattern of results was found when attempting to predict obesity sep further had limited utility in identifying among pairs of individuals the person with obesity or a higher bmi effect sizes were larger in females than males and education was typically more predictive than social class or imd explanation of findings these results are consistent with previous studies showing limited explanatory power of sep for bmi 9 13 14 15 and accord with studies showing increased variance within sep groups over the obesity epidemic 215 22 23 24 25 more generally they are also consistent with findings that shared environmental factors explain limited variance across a wide range of behavioural and healthrelated traits as well as with the results of a mass scientific collaboration study showing that socioeconomic outcomes are largely unpredictable even using rich longitudinal survey data 21 researchers in one study were able to predict 60 of the variance in bmi among older adults using deep learning methods and detailed socioeconomic demographic and other study data 39 however their analysis also included several variables directly related to health such as healthcare utilization intriguingly the observed small change in the proportion of variance explained by sep as grouplevel bmi differences have increased is consistent with a model in which the effects of risk factors for high bmi have uniformly increased in strength over the obesity epidemic 40 one study in sweden found that genetic effects have similarly increased while heritability has remained almost stable 41 however there are reasons to expect changes in the variation explained by education including the changing distribution of education itself as the population has become more highly educated and variation in the returns to education which could lead to differences in effect size eg from changes in relative access to healthy foodstuffs our results raise the question of why such low explanatory power of sep is observed one reason is that low sep is neither a necessary nor a sufficient cause of high body weight instead sep is expected to operate distally at the end of long causal chains the steps of which may be blocked amplified or attenuated in the presence or absence of other exposures for instance at a population level neighbourhood deprivation may lead to higher bmi by influencing physical activity via affecting walkability 42 but some individuals may compensate by travelling to surrounding areas or may get sufficient exercise if they do physically demanding jobs the effects of sep on bmi may thus be heterogeneous a process that would entail greater bmi variance within lower sep groups which is observed in practice 2 furthermore extremely strong effect sizes stronger than those found in typical epidemiological studies are required to obtain good predictive power at the individual level 43 as such while sep had an increasingly large effect size on bmi across time it was not sufficiently large to yield accurate predictions at the individual level our results may have implications for efforts to tackle obesity rates assuming the link between sep and bmi is causal our results suggest that reducing the social gradient in bmi could reduce but not reverse the obesity epidemic consistent with other work 2 our results show that obesity rates have increased among all social groups while inequalities within these groups have also increased over time as has been previously argued the increasing variability of bmi could mean a onesizefitsall approach may not be effective as increased variability may reflect distinct determinants 45 we should however note that predicting the effects of intervening on sep or its mediating pathways is challenging partly as it is possible that inequality itself could increase obesity rates 46 despite an increasing association between sep and bmi at the population level the results suggest limited utility of the use of sep indicators in predictive algorithms for obesity or bmi algorithms to predict obesity based on highlevel sep data are likely to have an unacceptably low sensitivity and specificity focusing only on those with low sep would miss the majority of cases including sep in models may be justified for health equity reasons however 47 without its inclusion risk will be systematically underestimated for low sep individuals while sep does not explain much of the betweenperson variation in bmi determining its predictive ability is important as it can motivate the development of more complex and specific theories and highlight the need for other nonstandard but highly predictive data genetic data are increasingly available polygenic scores for bmi now achieve r 2 of 15 48 but text or other big data could also be useful a recent study mining the content and style of essays written at age 11 explained approximtely 60 of the variability in childhood cognitive ability 49 though the ability to predict bmi and other physical health measures is unlikely to be this high strengths and limitations strengths included objective measurement of bmi and use of data spanning almost three decades of the obesity epidemic in england though for a small number of individuals with particularly high weight selfreports were used instead we examined measures of individualand arealevel sep measures that are easy to collect and have been widely studied in the social inequality literature previously nevertheless due to data limitations some dimensions of sep were not examined and the variables that were used were relatively high level and restricted to a small number of categories limiting potential predictive accuracy the measures were also based on current sep life course measures of sep or of body weight may have yielded more accurate predictions improvements in predictive accuracy may also have been greater if covariates other than age and sex were included in models as this would allow for the determination of more granular interaction effects future work should examine a larger and more detailed suite of socioeconomic data though hse is designed to be representative nonresponse increased over the study period consistent with other crosssectional health surveys and several longitudinal studies 5051 nonresponse may have been related to bmi or sep previous work has shown that among eventual hse participants individuals from more deprived areas or with highest or lowest incomes required more contact attempts on average 52 and in a major uk birth cohort obesity was related to lower participation in a midlife biomedical sweep 53 while we used survey weights differential nonresponse could have reduced the predictive accuracy of sep and biased timerelated changes we also focused on white nonstudent or foreigneducated participants for comparability across time results may not generalize to other sections of the population the hse data are crosssectional assuming that our estimates at least partly confounded we are likely to have obtained optimistic estimates of predictive accuracy relative to intervening directly on sep finally the random forest models may have been too flexible and overfit the data producing poor outofsample predictions nevertheless using ordinary least squares regression yielded similar results conclusions while absolute inequalities in bmi and obesity according to education and neighbourhood deprivation increased in england between 1991 and 2019 withingroup inequalities also increased and were large relative to betweengroup inequalities contributing to the weak explanatory power of sep though explanatory power increased over the study period it remained low which suggests that reducing inequality is unlikely to reverse the large impact on the obesity rates which increased across all sep groups since the beginning of the obesity epidemic nevertheless the possibility of heterogeneous effects of sep means that targeted attention within sep groups could be fruitful • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from abbreviations authors twitter handles david bann davidabann richard silverwood rjsilverwood charis bridger staatz charisstaatz funding the funders had no final role in the study design in the collection analysis and interpretation of data in the writing of the report or in the decision to submit the paper for publication all researchers listed as authors are independent from the funders and all final decisions about the research were taken by the investigators and were unrestricted competing interests the authors declare that they have no competing interests

background the widening of grouplevel socioeconomic differences in body mass index bmi has received considerable research attention however the predictive power of socioeconomic position sep indicators at the individual level remains uncertain as does the potential temporal variation in their predictive value examining this is important given the increasing incorporation of sep indicators into predictive algorithms and calls to reduce social inequality to tackle the obesity epidemic we thus investigated sep differences in bmi over three decades of the obesity epidemic in england comparing populationwide sep group differences in mean bmi and individuallevel outofsample prediction of individuals bmi approaches to understanding social inequalitieswe used repeated crosssectional data from the health survey for england 19912019 bmi kgm 2 was measured objectively and sep was measured via educational attainment occupational class and neighbourhood index of deprivation we ran random forest models for each survey year and measure of sep adjusting for age and sexthe mean and variance of bmi increased within each sep group over the study period mean differences in bmi by sep group also increased differences between lowest and highest education groups were 10 kg m 2 04 16 in 1991 and 13 kgm 2 07 18 in 2019 at the individual level the predictive capacity of sep was low though increased in later years including education in models improved predictive accuracy mean absolute error by 014 09 108 in 1991 and 105 018 182 in 2019 similar patterns were obtained for occupational class and neighbourhood deprivation and when analysing obesity as an outcome conclusions sep has become increasingly important at the population group difference and individual prediction levels however predictive ability remains low suggesting limited utility of including sep in prediction algorithms assuming links are causal abolishing sep differences in bmi could have a large effect on population health but would neither reverse the obesity epidemic nor reduce much of the variation in bmi

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introduction alcohol use disorder is a chronic health problem 12 with most individuals benefitting from several treatment episodes before achieving longterm remission 3 pharmacotherapies and medicationassisted therapy can be an important part of the continuum of care for aud several approved medications can significantly reduce the risk of relapse 45 despite evidence of effectiveness of pharmacotherapy for treatment of aud many studies have reported significant barriers to implementation of pharmacotherapy with salient challenges emerging at the health system organizational and provider levels in the united states 6 in addition to studies identifying training and experience of providers as barriers to use of aud pharmacotherapies 6 7 8 9 us providers also have expressed concerns about prescription prices 1011 and time constraints 611 as barriers to prescribing aud pharmacotherapies there also are patientlevel barriers to adoption of pharmacotherapy but relatively few studies have focused on this issue 6 and findings are mixed 12 regarding socioeconomic status knudsen and colleagues 10 noted providers thought their patients would be interested in but unable to afford pharmacotherapies for substance use disorders patients in a small us focus group study discussed price and medication availability as barriers to using oral naltrexone for aud 11 in the us and other countries such as sweden cost concerns may be less relevant as pharmacotherapies already are or will become more affordable and more widely available there may be differences in physicians prescribing practices that influence adoption of pharmacotherapies for aud by different population subgroups relatively little research has examined this question in the general population however a study of duallydiagnosed us veterans found approximately 70 received psychiatric pharmacotherapies but only 10 received aud pharmacotherapies 13 which suggests there may be aspects of physicians prescribing practices unique to aud pharmacotherapies it is unknown whether and to what extent patient characteristics influence physicians behaviours regarding prescription of aud pharmacotherapies but studies of other health conditions such as cardiovascular disease 14 and diabetes 15 suggest there may be substantial differences by patient ses in receipt of appropriate pharmacotherapies once they have been prescribed most of these medications require one or more pills to be taken daily to treat aud one study conducted in a large us health plan 16 found most patients used oral naltrexone for a much shorter period than recommended data from the us veterans administration 17 found the typical treatment episode for disulfiram or oral naltrexone also was shorter than recommended another large us study using prescription data provided by insurance companies also found the majority of users of oral naltrexone only filled one or two prescriptions over a 6month period 18 patients who consistently filled prescriptions were older less likely to have received prior treatment for aud and they lived in higher ses areas 18 an australian study using national pharmaceutical benefits claims data found men and patients under age 25 were less likely than their peers to fill multiple prescriptions for aud pharmacotherapies 19 other studies have detected lower rates of adherence to various pharmacotherapies by patients with comorbid psychiatric or drug use disorders 12 as well as by lowerincome patients older adults and women 20 to build on these prior studies the current project uses data from population registries in sweden to examine pharmacotherapy use in a cohort of people with aud despite public financing for healthcare that reaches everyone there are socioeconomic disparities in health outcomes in sweden for example neighbourhood deprivation is associated with increased risk of diabetes 21 heart disease 2223 and childrens psychiatric disorders 24 the swedish universal healthcare system emphasizes provision of care to marginalized groups and most treatment for substance use disorders is supported by public funds 25 even in this supportive policy context there are disparities in drug outcomes by neighbourhood deprivation 26 27 28 as well as disparities in alcohol outcomes by level of education 29 and immigrant status 30 in sweden disparities by neighbourhood ses are unlikely to be driven by restricted access to appropriate healthcare however 31 one swedish national study documented that highand moderatedeprivation neighbourhoods actually had greater access to healthcare resources such as pharmacies hospitals and clinics than lowdeprivation neighbourhoods 31 in the aforementioned us study using insurance data 18 higher arealevel ses was associated with significantly higher persistence with oral naltrexone it remains to be examined whether neighbourhood or other socioeconomic differences in aud pharmacotherapy would exist in sweden using data from a large national cohort of swedish aud patients we investigated whether disparities in pharmacotherapy exist in the context of universal healthcare our primary research question was are there differences in filling prescriptions for aud pharmacotherapies according to neighbourhood deprivation or other indicators of disadvantaged social status based on prior research 18 we hypothesized aud patients who are residents of deprived neighbourhoods would be less likely to fill a prescription for pharmacotherapy than their counterparts living in more affluent neighbourhoods we also expected to see disparities for individuals with low ses 10111418 and for foreignborn residents 30 methods design we used a longitudinal design to follow an open cohort of swedish people who received either inpatient or outpatient care for aud during a 7year period to assess relationships of neighbourhood deprivation and patient demographic characteristics with filling prescriptions for aud pharmacotherapy data to define the cohort we extracted data from several linked national swedish populationbased registers each person in sweden has a unique 10digit identification number this was replaced by a deidentified serial number in order to preserve anonymity while permitting registry linkages more detail on the registers is provided below the regional ethical review board for lund university granted approval for this study cohort definition based on alcoholrelated international classification of disease codes 32 cases of aud registered between july 2005june 2012 were identified using all hospitalizations in the swedish hospital discharge register and all clinicoffice visits in the outpatient care register both of these registries are nationally inclusive the relevant icd10 codes included both alcohol abuse and alcoholrelated somatic diagnoses we identified 62549 individuals with aud during the study period measures outcomesreceipt of pharmacotherapy was based on the swedish prescribed drug register to identify all prescriptions for disulfiram naltrexone acamprosate and nalmefene picked up by patients in the aud cohort between 20052012 the primary outcome was ever picking up a prescription for one or more aud pharmacotherapies an important question is whether findings represent physician differences in prescribing pharmacotherapy according to levels of neighbourhood deprivation or patient characteristics or whether findings illustrate reduced prescription compliance by socially disadvantaged patients using data from the primary healthcare registers for 75 primary healthcare centres in midwest sweden between july 2005december 2007 we ascertained a secondary outcome prescription compliance which was defined as picking up a pharmacotherapy prescription known to have been issued in primary care as a validity check we ascertained this secondary outcome for a subsample of 1186 patients from the aud cohort who were prescribed one or more of the pharmacotherapies at a primary care visit during the study period predictorsneighbourhood deprivation was calculated for geographic areas defined by the swedish government statistics bureau statistics sweden known as sams sams boundaries are defined by natural borders such as rivers or highways and they often contain homogeneous building types the average population is approximately 1000 residents small geographic areas are consistent with how people define their neighbourhoods 33 over 97 of the population can be geocoded to a sams neighbourhood deprivation was defined using aggregated data from the total population register the neighbourhood measure included data for all residents ages 2564 as these workingage residents are key to defining an areas ses as in prior studies 263134 indicators included the proportions of residents with less than 10 years of education incomes less than half the national median unemployed residents and individuals on financial assistance neighbourhood deprivation for the sams of residence in 2005 was classified into three groups based on the national population mean and standard deviation low deprivation was below one standard deviation from the mean moderate deprivation was within one sd of the mean and high deprivation was above one sd from the mean as in previous studies 34 in our cohort of aud patients only 146 were in the low neighbourhood deprivation group and 257 were in the high deprivation group a large majority of aud patients stayed in a neighbourhood of the same level of deprivation between 2005 and 2006 neighbourhood deprivation was not available after this point other indicators of disadvantaged social status also were drawn from the total population register we included family income in 2005 highest level of education and country of origin covariatesindividuallevel demographics drawn from the total population register were age and gender additional covariates were drawn from the hospital discharge and outpatient registers comorbid drug use disorders were based on icd10 codes for mental and behavioural disorders due to use of psychoactive substances other than alcohol or tobacco comorbid mental healthpsychiatric disorders were based on icd10 codes for mental behavioural and neurodevelopmental disorders mood disorders and anxietystressrelated disorders among others number of aud registrations in the hospital inpatient and outpatient registers was included as an indicator of severity 35 analyses we used unadjusted and multivariable alternating logistic regression models to assess relationships between neighbourhood deprivation and pharmacotherapy only 35 of neighbourhoods contained more than 8 individuals with aud so multilevel analysis strategies were not appropriate we also chose not to use multilevel models because the secondlevel residuals were not normally distributed alternating logistic regression accounts for the dependence of cases within neighbourhoods when estimating regression coefficients and it also provides the pairwise odds ratio an indicator of neighbourhood differences that are not accounted for by deprivation or other common unmeasured environmental factors 36 the pwor represents the increase in the odds of filling a pharmacotherapy prescription for aud given that another aud patient randomly selected from the same neighbourhood also fills a prescription it is higher than 10 if picking up prescribed pharmacotherapy within a given neighbourhood were more frequent than would be expected under random distribution across neighbourhoods in sensitivity analyses we generated additional adjusted models with the first using only cases with incident aud during the study period because newlydiagnosed patients may have higher adherence to pharmacotherapy 18 and the second using only cases without cooccurring dud because naltrexone is used for treatment of opioid dependence as well as aud 5 finally we assessed associations between neighbourhood deprivation and other indicators of disadvantaged social status with picking up prescriptions for each of the pharmacotherapies separately results during the study period 537 of aud patients picked up pharmacotherapy prescriptions of those 251 only picked up one prescription 160 picked up two prescriptions and 589 picked up three or more prescriptions patients first pharmacotherapy prescriptions were split between disulfiram 300 naltrexone 31 and acamprosate 38 with nalmefene at less than 1 a large proportion of patients who picked up a prescription did so for more than one medication 680 of these patients picked up at least one prescription for disulfiram during the study period compared to 487 for acamprosate and 397 for naltrexone patient characteristics associated with filling a prescription are in table 1 adjusted models revealed people with aud who were living in neighbourhoods with moderate or high levels of deprivation were significantly less likely to pick up pharmacotherapy prescriptions than their counterparts in affluent neighbourhoods in this cohort of aud patients people with lower incomes those with less education foreignborn patients and women also were significantly less likely to pick up prescriptions additionally older patients patients with a greater number of aud registrations and those with cooccurring psychiatric diagnoses were significantly more likely to pick up pharmacotherapy prescriptions the pwor indicates picking up prescribed pharmacotherapy within a given neighbourhood was significantly more frequent than would be expected under random distribution across neighbourhoods in the validity check using data from primary care a total of 1890 prescriptions were issued to aud patients and 1569 were picked up most indicators of disadvantaged social status were not significantly related to prescription compliance although those in the lowest income quartile were significantly less likely to pick up an issued prescription for aud pharmacotherapy than patients in the highest income quartile women also were significantly less likely than men to pick up aud pharmacotherapy prescriptions issued in primary care when analyses were limited to individuals with incident aud or without a known history of dud results were very similar to the overall findings supplemental table 3 shows regression models for each medication separately findings for neighbourhood deprivation were consistent for acamprosate and naltrexone however people with aud living in neighbourhoods with moderate levels of deprivation were significantly more likely to pick up prescriptions for disulfiram than those in affluent neighbourhoods patterns for other indicators of disadvantaged social status were consistent across the three pharmacotherapies discussion in this cohort of patients receiving either inpatient or outpatient care for aud approximately half picked up a pharmacotherapy prescription during the study period there were significant differences in picking up pharmacotherapy prescriptions by neighbourhood deprivation with those in moderately deprived neighbourhoods showing approximately 10 reduction in the odds and those in highly deprived neighbourhoods showing approximately 25 reduction in the odds compared to those in lowdeprivation neighbourhoods the pattern of results was consistent for incident aud cases as well as for the subgroup of aud patients without comorbid drug problems these results for sweden are similar to earlier findings from the us 18 by contrast there was not strong evidence of socioeconomic disparities in prescription compliance in the subgroup of aud patients who were issued prescriptions in primary care results from this subgroup analysis suggest factors other than patient compliance may be driving disparities in picking up prescriptions for aud pharmacotherapies in addition to disparities by neighbourhood deprivation we observed lower rates of picking up prescriptions for aud pharmacotherapy for patients with lower ses budhiraja and landberg 29 observed significant increases in alcoholrelated mortality for swedes with less than ten years of education with relatively little difference between those with intermediate education and those with college education disparities in aud pharmacotherapies could contribute to longterm disparities in alcoholrelated mortality among socially disadvantaged groups lower rates of pharmacotherapy for foreignborn aud patients may be due to a variety of factors including lower integration with primary or specialty psychiatric care 37 as well as communication challenges that may reduce the likelihood a physician would initiate the detailed discussions that should accompany prescription of aud pharmacotherapy 5 there also may be unique barriers to using aud pharmacotherapy by foreignborn patients such as distrust of health care providers 38 and this deserves further study women were less likely to pick up pharmacotherapy prescriptions in the full dataset as well as in the subset of primary care cases to whom we know prescriptions were issued these findings differ somewhat from those of an australian study in which men were less likely than women to pick up more than one naltrexone prescription to treat aud 19 further research should investigate whether aud is more stigmatizing for women than for men in sweden older patients those with more aud registrations and those with cooccurring psychiatric diagnoses were significantly more likely to receive aud pharmacotherapy morley and colleagues 19 also found older australians were more likely than younger patients to return for a second aud pharmacotherapy prescription and kranzler and colleagues 18 found a similar pattern for naltrexone prescriptions picked up in the us in a study of 12000 swedes assessed for sud between 20022008 grahn and colleagues 1 found patients with psychiatric comorbidities reported a significantly greater number of voluntary treatment episodes our findings suggest physicians may be prescribing aud pharmacotherapies to help patients with nonremitting alcohol problems who may not be sufficiently served by other treatment modalities 11 physicians also may prescribe aud pharmacotherapy in concert with pharmacotherapies for other complicated psychiatric comorbidities 39 although we did not assess this here in one us study 9 in a subset of sampled alcohol and drug treatment programs that used pharmacotherapies for either substance use disorders or psychiatric conditions average rates of adoption of aud pharmacotherapy were quite low which was in stark contrast to medication prescribing practices for psychiatric conditions it also was lower than rates of dud pharmacotherapy at the same facilities 9 in the present swedish study the rates of aud pharmacotherapy were much higher than data suggest may be the case for the us and detailed examination of swedish healthcare system factors that promote the use of aud pharmacotherapy may help improve care delivery in other national contexts for example medication cost may not be a salient issue for swedish aud patients as financial assistance and cost caps help keep the patient burden lower than in the us 40 furthermore the healthcare system is designed so there are qualified prescribers in all geographic regions of sweden 40 in the us and other countries there are geographic disparities in availability of qualified aud treatment providers 741 one limitation is that we do not have nationallyinclusive data on prescriptions issued in the inpatient or outpatient care settings thus it is not clear whether our findings represent differences in prescribing practices differences in patient compliance or both when we linked the prescription registry data with information from primary healthcare providers in a smaller geographic area we found high patient compliance as over 80 of issued prescriptions were picked up this suggests geographic and socioeconomic variability in pharmacotherapy may at least in part reflect differences in prescribing practices there are some limitations pertaining to measurement of the outcome and exposure variable as well as our case ascertainment definition regarding the outcome nalmefene was approved in europe for treatment of aud in 2013 and our study period ended in 2012 thus the few aud patients who received nalmefene are likely to have been receiving treatment for a comorbid dud the number of cases receiving nalmefene was very small so findings are driven by the other pharmacotherapies future studies will be informative about the use of nalmefene for aud treatment in sweden also neighbourhood deprivation and individual ses were measured at the beginning of the study period and they may have changed by the time someone received either inpatient or outpatient treatment for aud or when they received their first pharmacotherapy prescriptions unfortunately we do not have neighbourhood data available after this point which is a limitation of the present analyses our data suggest dramatic changes in neighbourhood ses are not common in sweden however finally given our case definition of aud these findings represent patients with more severe aud who have developed physical health problems due to prolonged heavy drinking future research should examine whether physical health problems are related to prescriptions for and adherence to aud pharmacotherapies as some medications are contraindicated for patients with severe hepatic issues 5 there are many benefits that accrue from aud pharmacotherapy 1842 future research should determine whether longterm benefits are equally conferred across population subgroups or whether disparities in alcohol outcomes widen due to a mismatch between clinical need and pharmacotherapies received by patients 43 interventions with physicians and other healthcare providers who can prescribe medications may help increase use of pharmacotherapy as part of the aud treatment regimen targeting these interventions and other forms of outreach to clinics in deprived neighbourhoods and to those that serve women and foreignborn residents may help prevent relapse and reduce the burden of aud among disadvantaged population subgroups in sweden notes pharmacotherapy for alcohol use disorder includes naltrexone disulfiram acamprosate and nalmefene or odds ratio ci confidence interval pwor pairwise odds ratio from alternating logistic regression reflects differences between neighbourhoods table 3 odds ratios for filling pharmacotherapy prescription issued to primary care patients with aud notes pharmacotherapy for alcohol use disorder includes naltrexone disulfiram acamprosate and nalmefene or odds ratio ci confidence interval pwor pairwise odds ratio from alternating logistic regression reflects differences between neighbourhoods supplementary material refer to web version on pubmed central for supplementary material

background and aimpharmacotherapy can be an important part of the continuum of care for alcohol use disorder aud the swedish universal healthcare system emphasizes provision of care to marginalized groups the primary aim was to test associations of neighbourhood deprivation and disadvantaged social status with receipt of aud pharmacotherapy in this context designdata from linked population registers were used to follow an open cohort over 7 yearsparticipantsalcoholrelated icd10 codes reported for all hospitalizations in the swedish hospital discharge register and all clinicoffice visits in the outpatient care register between 20052012 were used to identify 62549 cases with aud measurementsthe primary outcome was any aud pharmacotherapy naltrexone disulfiram acamprosate nalmefene picked up by patients between 20052012 vs none based on the swedish prescribed drug register neighbourhood deprivation was defined using aggregated data from the total population register indicators of disadvantaged social status income education country of origin also came from this source findingsabout half of the cases 537 picked up one or more aud pharmacotherapy prescriptions in adjusted models people living in neighbourhoods with moderate or0

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secondary migration is a term used in us refugee policy to refer to refugees moving from the us state where they were initially resettled to another state during their first 8 months only in those 8 months can the benefit package that refugees receive through their resettlement agency follow them to their new location and be distributed through a successor agency eight months is the timeperiod specified in the us refugee act of 1980 for the stateadministered refugee cash assistance and refugee medical assistance programs if a refugee moves after the initial 8 months then those benefits are not available to that refugee in the new location secondary migration represents a diversion from the intended pattern of resettlement managed by the federal and state refugee resettlement programs as legislated through the us refugee act for example this act stipulates an intended distribution of refugees among the states and aims to … insure that a refugee is not initially placed or resettled in an area highly impacted … by the presence of refugees or comparable populations nonetheless the refugee act acknowledged secondary migration by mandating that local affiliates plan for … the secondary migration of refugees to and from the area that is likely to occur for purposes of this study we defined secondary migration as moves out of state in any time period postresettlement we defined relocation as moves within state in any timeperiod postresettlement the us office of refugee resettlement reported that much of the secondary migration of refugees takes place during their first few years after arrival in the united states and that their geographic distribution then stabilizes the initial distribution of these refugees in the united states is largely determined by family member sponsorship and by sponsoring voluntary agencies upon arrival most refugees are resettled nearby the voluntary agency or sponsoring religious institution that will be providing them with service and support subsequent refugee arrivals from africa have tended to flock to communities of african refugeesturnedpermanent residents in the united states finding within these communities benefits to help their adjustment and shared experiences and culture existing research on secondary migration studies on a diverse range of ethnic minority refugee groups have identified the familial social and economic factors associated with moving again after initial resettlement a study of southern italians in the united states noted that immigrants moved to form communities of their own ethnic background these communities may help to shorten the adjustment period provide protection against hostility and rejection and maintain cultural traditions they also provide practical support such as assistance in securing housing and employment counseling and language translation zavodny found that the presence of other foreignborn nationals was the primary determinant of recent immigrants location choices within the united states comparatively economic conditions were found to play a minor role studies of indochinese secondary migration found that californias generous health and welfare programs combined with the sizable indochinese refugee population in san diego accounted for the refugees moves forbes explained this propensity in terms of three factors lack of ties to place of initial settlement proven ability to migrate and dissatisfaction with employment that is often below the home country level of employment a study of the hmong communitys initial resettlement to chicago between 1978 and 1987 concluded that their illiteracy lack of formal education and marketable skills and lack of english language contributed to their difficulty living in a highly technologically developed city and to their subsequent successful secondary migration to california minnesota and wisconsin a study of mexican and chinese immigrants to the united states showed similar factors driving their secondary migration a study of ethiopian refugees in the united states noted that these migrants are attracted to … areas with a strong economy high income levels good employment and educational opportunities and the presence of large african communities few studies have examined how immigrants have fared after secondary migration one study found an insignificant effect of geographic mobility on wage rates among asian central american and european immigrants who arrived in the united states after 1964 as compared with the native population another analysis of secondary migration which tested an interstate version of the spatial assimilation model using merged longitudinal data from a survey of income and program participation found that immigrants benefited from their moves both in terms of employment and earnings those with higher levels of acculturation saw additional economic gains when they moved to states with smaller immigrant populations the family therapy literature has described the significance of differing experiences and attitudes of family members amidst the refugee and migration experience including new adaptive modifications to family functioning in transnational families however secondary migration and relocation have been understudied from a family perspective burundian and liberian refugees ten thousand burundian refugees from tanzanian refugee camps were resettled in the united states beginning in 2007 the 1972 burundians are mostly hutu and fled a violent campaign from the tutsicontrolled government living in exile in tanzania for three decades they experienced ongoing political and criminal violence sexual assault poverty unemployment dependency no freedom of movement family breakup and poor education for children in addition to warrelated trauma and loss many burundian families cope with separations from loved ones due to shortcomings of the refugee resettlement system as well as other serious challenges to family functioning associated with social adjustment following prolonged stay in refugee camps and with extreme poverty from 1989 until 2003 liberia suffered a series of conflicts among armed groups an estimated 200000 people were killed in the fighting and hundreds of thousands were forced to flee to neighboring nations or overseas according to the us committee for refugees and immigrants over 71000 liberian refugees lived in refugee camps in ghana cote divoire and other neighboring countries between 1992 and 2004 the united states resettled approximately 23500 liberian refugees who fled the civil war in liberia like burundians these refugee families experienced separations as well as economic social and cultural pressures in resettlement liberians generally express a strong allegiance to the united states and the american way of life they are grateful to the us government for bringing them here and giving them hope for their childrens future though many remain concerned about the us history of slavery and the devastating impact it has had on liberia and its people a family ecodevelopmental framework for the investigation the purpose of this study was to address the following research questions 1 who moved again why and with what consequences 2 how did moving again impact family risk and protective factors 3 how might policies and programs better respond to the complexities of refugees moving again to frame our investigation of the family dimensions of secondary migration and relocation we applied family ecodevelopmental theory which envisions youth in the context of family systems and community networks interacting with educational health mental health and social service systems we also drew upon resilience theory trauma theories and migration theories in the refugee field there are a number of small and mostly crosssectional quantitative studies and these have identified possible protective resources such as family and social support parental wellbeing and lower caregiver distress connection to the large community and to the culture of origin based upon these theories we devised a conceptual framework to guide this research on refugee families in resettlement this family ecodevelopmental framework posited that war migration and resettlement expose refugees to family and ecological risk factors protective factors also exist in refugees family and social environments these protective factors mitigate the family and ecological risks for negative individual behavioral and mental health consequences thus we conceptualized secondary migration and relocation from a multilevel crosscultural and resilience perspective which we believe is needed to understand the individual familial community educational and developmental factors that are involved we will briefly summarize how this framework focused on risk and protective factors was used to approach refugee families experiencing secondary migration and relocation risk factors were defined as family and ecological characteristics that cause increased vulnerability to individual negative behavioral or mental health consequences for family members risk factors may include conditions of resettlement war or cultural norms protective factors were defined as family and ecological characteristics that stop delay or diminish negative individual behavioral and mental health consequences for youth or adult family members protective factors can include withinfamily resources familytoothers and community protective factors the framework considered that risk and protective factors interact in complex ways with one another and with other individual familial and contextual factors to impact individual mental health and behavioral outcomes no known studies have looked at the interaction between protective resources risks and secondary migration and relocation this framework was used to inform this investigations qualitative data collection in several ways one it helped to identify domains of interest for the interviews and observations two it helped to formulate questions used in minimally structured interviews three it helped in identifying themes as part of a grounded theory approach to qualitative data analysis methods we conducted a 3year multisite longitudinal ethnographic study of burundian and liberian refugees resettled in chicago il and boston ma study subjects were 73 atrisk refugee adolescents their families and service providers interviewed within the first 3 years following resettlement atrisk was defined as refugee youth with one or more of several specific factors that have been empirically associated with mental illness or behavioral problems in published studies of migrant youth discussions with the participant begun with a small number of introductory questions the conversation proceeded in whatever direction allowed the participant to speak most meaningfully to the research questions from his her personal experience shadowing field observations involved the ethnographer accompanying the family or its members on hisher normal daily routine in a variety of sites shadowing observations allowed the ethnographers to directly witness the interactions between protective resources risks culture and service sectors over time the interviewers were burundian liberian and american fieldworkers trained and supervised by the principal investigator and coinvestigator data were collected and analyzed based upon wellestablished approaches to ethnography and qualitative analysis because we were trying to capture changes over time for each of the families we applied a case study research design whereby the data for each family were read sequentially so as to identify factors that changed over time the initial study questions were refined through an iterative process of data collection and analysis that followed standardized qualitative methods utilizing a grounded theory approach to data analysis until a model emerged of the overall sample of 73 families this paper reports on a case series of the 22 families that moved during the initial 1year study period from february 1 2008 to february 1 2009 in these 22 families the average age of participating parents was 43 the average age of participating youth was 15 and the average number of children per family was five thirteen of 22 of parents were married none were divorced 522 were separated 122 was widowed and 222 were never married parental education levels ranged from illiterate less than high school and high school each of the 22 families lived in refugee camps before their arrival in the united states results table 1 provides data on the demographic characteristics of the families that moved the places where they moved and their stated motivations for moving nearly onethird of participating families moved during the study period of these 1322 migrated out of state and 922 migrated within state twenty of 22 families that moved cited housing as a motivation for migration specifying the need for larger andor more affordable housing seven of 22 families cited work opportunities as motivation for moving four of these families found full employment following their moves while 2 families found only partial employment and 1 family found none seven of 22 families listed family reunification as reason for migration eight of 22 families reported moving for community reunification 522 families sought increased neighborhood safety when deciding to move and 222 families also cited educational reasons including a better school district and an afterschool study hall program in the new apartment building thirteen of 13 of the families that moved out of state and 19 that moved instate pursued lessurban locations six of 13 of the families that moved out of state moved to warmer climates in the study sample most relocations occurred among liberian families and most secondary migration occurred among burundian families of the 10 refugee families initially resettled in boston 5 relocated and 5 moved out of state of 12 refugee families initially resettled in chicago 4 relocated and 8 moved out of state the average time between initial resettlement and move was 18 months among liberian refugee families the average time between initial resettlement and moving was 24 months and among burundian refugee families the average time between initial resettlement and moving was 15 months family narratives relocation casea liberian family arrived in chicago from a refugee camp in the ivory coast jay the teenage son was born in the refugee camp jay came to the united states with his mother nina along with her other three children in chicago the mother met a new man robert and they had a child together although they wanted to marry they delayed marriage for fear of losing public aid robert was employed in a factory and nina worked as a housekeeper nina was illiterate and never finished elementary school one of ninas daughters dropped out of high school and moved in with her boyfriend away from chicago whom she knew from the refugee camp her other son dropped out and took a minimumwage job jay befriended someone at church who offered to sponsor his education at a chicago private school where he was thriving seeking a lower cost of living and cheaper housing robert moved to another illinois city found a job in a factory and prepared the way for his new family while the children moved to their new home nina stayed in chicago for several months in order to finish her job she then moved to the new city to join her family including roberts teenage son by another woman jay and his sister were expected to learn to respect and listen to their new father they were told that their father abandoned them by having children with another woman in africa so robert is their real father now according to nina the new neighborhood was safer with quieter streets and without gangs like in chicago the family had no relatives in the new town but there were many liberians from their tribe and they felt part of a liberian community the family was more financially secure as housing was less expensive than in chicago and the family had a townhouse with three bedrooms an improvement from their chicago apartment although at first nina did not have a job she was sure she would find one mostly nina said i am happy to be living with robert and to have some emotional security now within 3 months she found a job in a warehouse i dont like this new place said jay i dont like how quiet it is nina thought he would adjust in time he made two or three friends although none of them were close jay was going to church without his family he began going to church in the refugee camp like many other youth raised in the refugee camps who became more regular church attendees than their parents he attended public school but was being teased by others students for dressing and looking different he did not like the new school and felt uneasy in the new city his parents told him jay we know you liked chicago but we left because of the living situation over there here you live in a very neat place you are well taken care of you should appreciate this jay was expected to listen and not to complain or protest secondary migration casea burundian family migrated to chicago in 2007 from a refugee camp in tanzania where they lived for 35 years the parents frank and gloria were unemployed in chicago but they and their six children received aid from their resettlement agency from their church they also received clothing childcare home furnishings and money during their first year in america when they really needed these kinds of financial social emotional and spiritual supports the family regarded the church as a kind of second home both parents were uneducated and their 16yearold girl jane struggled with having been placed in the ninth grade in chicago after only completing the fifth grade in tanzania her parents were not actively involved with her education saying there is nothing we can do we dont have anything to offer we have never done this with school neither the agency nor the church did much to help the parents to connect with the teachers staff or other parents at school then when the resettlement agency noticed the churchs deposits in the familys bank accounts the agency cut their rent money and the other help they provided with furniture and household necessities the voluntary agencies are themselves under intense financial pressure and only lend support if the family has no other sources of income or money saved frank never expected that the agency would find out that he had money he was unaware that agencies regularly monitor their refugees bank accounts after a church representative tried to intervene on behalf of the family the agency began blaming frank he was not supposed to have any money and was supposed to report whatever he had frank in turn blamed the church they should have stayed out of it because they should respect authority and not do anything that would make him look bad the resettlement agency eventually reestablished paying the rent but the ordeal seriously disturbed frank adding to already growing tensions at home with gloria over finances the family did not know what to do should they stay or go they were so attached to the church that they did not want to leave but their situation of not earning money was not acceptable to frank who took matters into his own hands and decided on his own that they should move he decided to move to the southern united states after just one year in chicago according to frank i didnt have a job in chicago and i didnt feel i could take care of my family i heard i would find a job in the south i also wanted to join my family there i wanted to find a cheaper house and i wanted warmer weather despite the tensions with the church there were still warm feelings on both sides at the goodbye dinner our burundian field worker noted everybody in the church was cryingyoure talking about 250 members of the churchit was just unbelievable you know its like your brother or sister amazing some were trying to stop them but in the end of course they moved and they did help them to movepacking and loading the truck even now they are staying in touch with them within a month of arriving at their new locations frank found work in a factory gloria was employed within 6 months cleaning their new church the family found a threebedroom house for us 450the same rent they paid for a twobedroom apartment in chicago they had money to cover basic expenses and they also found assistance through a resettlement agency despite being past the initial 8month period of agency assistance still they complained about paying for rent and childcare because they had never paid for these things in tanzania it was a strange concept our burundian field worker said they understand the american way but they still feel like its too much money they say for how many more years do we need to pay why do they keep taking money for them when you live in a house it is yours this was one of many topics that the agency typically covered in lectures but that often do not get understood by the burundian refugees the family lived near glorias brother gloria said people here are more friendly we actually see the people next door we share things talk to each other its friendlier even if i dont pick up my child from school i know they will just take him and take care of him indeed neighbors provided the family with free childcare while frank and gloria were at work they felt like now they could go outside and connect with people around in chicago they did not even know their neighbors although jane still struggled academically her grades were improving she spoke well did her homework and went to the library the fieldworker observed she knows what she wants and where she wants to go her siblings were also doing well they regularly attended church and prayed at home the parents kept a disciplined house and tried to keep the children focused on their schoolwork recently our burundian field worker received a call from jane who said she wanted to come back to chicago for college she knew she could reconnect with members from the chicago church she could stay with them they would not let her be alone in chicago the impact of moving on family risk and protective factors the grounded theory model that was derived through analysis of the interview and observation data collected on the refugee families that moved is depicted in table 2 it specifies the family and ecological risk and protective factors that changed with secondary migration and relocation overall the analysis found that secondary migration and relocation of refugees in resettlement had a mixed impact upon family and ecological risk and protective factors although the multiple risks that refugee families faced did not disappear moving typically resulted in improvements in the family protective resources that mitigated these risks thus increasing the families stability the sections that follow provide additional illustrative details from the case series to illustrate the impact of moving upon family risk and protective factors family and ecological risk factorsas a consequence of secondary migration and relocation most risk factors remained the same however some existing risk factors were enhanced and some new risks emerged for many families the risks that remained largely the same after moving included family separation unemployment poverty need to support family in africa parents not speaking english strained spousal and parentchild relationship overcrowded housing dissatisfaction with school services unsafe neighborhood and not feeling at home many families moved to join family members living in other states after their resettlement agency was not able to bring their family to live with them however many refugees who moved continued to be separated from family members either in other us states or abroad and expressed frustration one liberian father stated the us doesnt get it you dont separate people the most important thing is to be together resettlement agencies just dont understand that its not their priority reunifications with family still abroad were going to be far more difficult to arrange most families that moved did so to reduce their financial expenditures especially for rent for example a burundian family in boston was 1 month behind on rent and received a letter from the landlord stating that he would start the eviction process within 14 days the father stated i get social security of us 500 per month and my wifes job ended the rent is us 850 per month this familys ongoing struggle to afford food forced them to move to a smaller space in a poorer neighborhood plagued with violence and crime another father who moved his family out of state said truly the housing is better … we are paying less for more space in a wellkept and wellmanaged building a mother said that since moving they have what is most important to them … a job and living with family those families that moved to suburban and rural environments had to face other difficulties related to transportation a family that moved from chicago to a small midwestern city found employment but the father stated its rough tough hard my main concern is its very hard for to move around all families that moved lost the material and emotional support of their local sponsors resettlement agencies and social service agencies they also left ethnic and religious communities friends and support networks for children the disruption of relationships with their friends school church and neighborhoods was often painful many youth pointedly said that they did not want to move and that they missed their friends in their new locations these youth were considering ways to come back to chicago or boston either to live with another family or by getting married or by going to college as a consequence of moving youth bear yet another set of losses on top of that their sense of belonging was divided even further youth heard two different kinds of messages from adults which bear upon moving from their parents they were told what to do including being told you have to move even when they packed to leave children found that often their possessions were not included one girl had to choose what was most important for her she left behind her bed and clothes in contrast from their teachers at school they were taught that they had freedom and could make choices they might have had no say in the decision to move but when it came to college they said they wanted the freedom to choose like other american teenagers many families coming from rural settings in africa described not feeling at home in large cities where there was one building after another no open spaces and you do not know your neighbors not even the persons living next door they desired to move to a suburban or rural setting many parents from burundi stated they wanted a place that had the atmosphere of a refugee camp where children could safely be out on their own without adult supervision for other families not feeling at home specifically meant moving to a warmer climate several families were able to satisfy these desires by moving to southeastern states while no families indicated that they moved primarily because of their childrens schools some burundian refugee parents expressed dissatisfaction regarding school services and cited school services as a potentially important reason to move given that no families looked into new schools before moving it is not surprising that moving had mixed results regarding their satisfaction with school services no families reported that moving improved their childrens educational experience and none reported any significant changes in this realm family and ecological protective factorsfamilies that moved reported enhanced protection in multiple areas including the ability to support family in africa improved housing family solidarity family pride and agency neighborhood safety and feeling more at home when families found employment and more affordable housing on their own parents reported feeling empowered and successful in terms of their moves having chosen their new homes themselves rather than having been assigned to them by resettlement agencies they often felt a renewed sense of ownership over their futures our burundian fieldworker noted they are making progress this progress is their own making now before it was the resettlement agency now it is them employment provided not only financial security but also generated greater respect for the parents within their families and community for being breadwinners this sense of pride and agency was important because for burundian families in the study sample moving was often regarded as something to feel ashamed of an admission of defeat and a time when other families could see how few possessions you had for this reason many burundian families moved at night without telling anyone after having moved and improved their financial and living situation including their ability to financially support next of kin in africa then they felt that they had reestablished the respect of their family and community among liberians in the study sample moving was often viewed as a kind of accomplishment on their journey to becoming americans they moved because they were ready to move and to face the challenge together as a family while we found that parents generally did not approach the decision to migrate with a focus on their children liberian parents often involved children in the process of decisionmaking and supported them in taking leave and in entering a new environment parents built up their childrens anticipation about moving to a new and better place giving the entire family a new sense of hope our liberian fieldworker noted the family is all happy together and celebrating it it brings the family closer to each other as a consequence of secondary migration and relocation some protective factors were diminished but these were replaced by new protective factors and others were enhanced the protective factors that were diminished but replaced include support from sponsors peers religious community social services schools and the ethnic community parents reported that in their new locations they were able to find new persons and organizations that in most cases they regarded as even more supportive this was largely because most moved into enclaves with relatives or friends who had already established relationships with supports and organizations overall the parents were more satisfied with their new arrangements than their children who made new friends but still missed their old friends and classmates on the other hand every family was able to identify new helpful supports in their new locales finding that the new communities could be even friendlier and more supportive than prior ones one father who moved his family out of state said he … likes the new place because … it has many other burundians and africans one of the most important areas of enhanced protection concerned the refugees supporting their nextofkin in africa this is because all the refugee families we followed saw themselves as part of an extended family with members living in their home country and other countries of exile the refugee families in the united states felt highly obligated to send money to other less fortunate family members thus they needed to optimize their financial situation in the united states such that they were increasing their incomes and decreasing expenditures especially rent they did this irrespective of the resettlement agencies requests to not send money home until they have met their financial obligations in the united states which included paying for rent their plane tickets to the united states childrens school fees and expenses of daily living from the refugee families point of view the resettlement agencies had it all wrong by not getting them jobs or by placing them in expensive apartments they were interfering with the families most fundamental obligation to support members of their extended family for some the family back in burundi had become the main focus and they forgot about their life here for some it became an excuse to justify why they were not succeeding in the united states many moved because they saw it as the only way to rectify this situation after moving and improving their finances being able to fulfill their financial obligations to extended family contributed to their sense of agency as parents they felt like they were more in charge of their situation it gave them power to feel that they could do more they said i feel good i dont have to worry about those burundians now parents could focus more on improving life for those here when they could manage it families from more rural settings in africa sought suburban or rural settings in the united states they learned that the cost of living was less expensive and that a less urban pace of life was more comfortable for them because they had not chosen their initial resettlement city themselves they took the opportunity to choose a place that better fit their needs and desires families from africa also tended to move to warmer climates a burundian family that moved to the southern united states described its new home as follows good schools life is more african oriented more neighborly neighbors watch out for kids care about them oldfashioned country way of living not cold we like the place some families that migrated said that their new situation was better because the new school took more responsibility for children than the old school for example some parents did not have to transport their kids to school because they were picked up from home or translation services were available for refugee children however we did not find any instances of parents becoming more involved with their childrens education after moving moving did not seem to cause traumatic memories related to violence exposure to reappear however it did remind persons from some families of the many times they had to move for example the burundian families had been moving since 1972 to rwanda congo zaire tanzania and the united states for some the most difficult memories were when they migrated to the united states and discovered that they were put in different us states like chicago and arizona one reported i thought finally we were going to be together and instead arizona and chicago is like in a different country i just lost them again upon moving one spoke what many felt weve been doing this all our lives i guess this is how it has to be discussion moving is an important issue all for refugees resettled in the united states including those from african countries not all african refugee families move but enough have moved that most families either know family and community members who moved or have considered moving themselves secondary migration and relocation should be a focus for policymakers programmers practitioners and researchers for two principal reasons one refugees secondary migration and relocation reveal shortcomings in us refugee resettlement two refugees secondary migration and relocation reflect refugee families approaches to seeking greater family stability the most common stated reason for refugees to move both instate and out of state was housing these families sought more affordable housing than they were provided upon initial resettlement they were concerned that they were not able to afford to pay high rents especially in light of their obligation to send money to family in africa when they learned that they could live for less money elsewhere it was difficult for them to turn down opportunities to move another common reason for refugees to move was unemployment refugees who did not speak english and did not have marketable skills were not able to find jobs when they heard from other refugees about jobs being available in other locations moving appeared to be their best option for building their lives in the united states families also moved out of state for purposes of family and community reunification many refugees become separated from other family members either during war flight refuge or resettlement as a consequence many refugees being resettled in the united states lived in different states or countries from their loved ones understandably they wanted to be together when family members lived in other states refugee families often found that the only available solution was to move when family members lived abroad the solutions were much harder to come by regarding community reunification they desired to live nearby other burundian people who were not necessarily family members but with whom they could enjoy being together and offer support to one another families also moved because they came from largely rural settings and warm climates and were resettled in intensely urban settings and cold climates once they recognized that there were other places to live in the united states that better suited their family lifestyles they chose to move to these places we found some differences regarding moving in the study sample between liberians and burundians one more burundians moved than liberians two more burundians moved out of state whereas more liberians moved in state in our opinion this trend reflects several important differences between the two subgroups studied burundians did not speak english were newer arrivals and faced greater difficulties in their adjustment having lived in refugee camps for 30 years most of the burundians moving out of state cited reasons of needing work family and community reunification and feeling at home overall the study findings indicated that many refugee families chose to move because it was one of the few available ways for them to better their lives looking at moving through the lens of a family ecodevelopmental framework demonstrated that moving often improved refugee families lives through enhancing and adding some protective factors even though many risk factors remained when families were able to significantly enhance protective factors through the simple act of moving then it should not be surprising that many chose to do so we predict that over time more african refugees will especially from the burundian group and predict that given the difficulties involved in refugee resettlement only amplified by the global economic crisis that many from other refugee groups will also move this is a significant and neglected pattern in refugee resettlement that calls for cogent responses from policymakers practitioners and researchers if policymakers desire to diminish or prevent the movement of resettled refugees then state refugee resettlement offices and resettlement agencies must more effectively secure employment for refugees facilitate family reunification and provide affordable housing if initial settlement points in cities with high costs of living such as chicago and boston are intended to be families final destinations then governmental and voluntary organizations should provide families with the basic elements they need to succeed including affordable housing and acceptable employment if on the other hand these organizations intend for initial settlement to be merely an entry point into the united states then the government should make provisions for refugee secondary migration and relocation within the united states to help refugees facilitate their successful final resettlement in the current standard of practice resettlement organizations do not directly encourage nor otherwise counsel refugee families concerning secondary migration and relocation nor financially support them beyond the initial 8 months this approach follows from the refugee act mandated approach to financing and managing refugee resettlement our findings call into question some components of this approach and suggest that voluntary agencies and state offices of refugee resettlement could take several steps to better address the issue of secondary migration and relocation one the us government should consider extending the case management service period for refugees beyond 8 months so that refugees who move may continue to receive support from resettlement agencies as needed our findings suggest that if it were 18 months then most families who moved out of state would still be eligible to receive services two because secondary migration cannot be completely prevented government and voluntary agencies should aim not to eliminate but to better manage secondary migration and relocation this presents an opportunity for family therapists and other psychosocial workers to help families in need and to develop innovative service or training programs that reflect a family ecodevelopmental and crosscultural perspective in collaboration with resettlement agencies religious institutions schools or government family support and education initiatives such as were developed through the cafes initiative should be developed to assist families with the dilemma of whether or not to move they could help parents to make the best decisions for their families and help them to implement those decisions in a way that fulfills the best interests of their family it is especially important that parents be helped to better consider the implications of moving for their childrens education and development this and other roles for family workers will be discussed in the section below there are no readily available solutions to several causes of secondary migration and relocation regarding family reunification us policies should and do prioritize reunification such that refugee families can choose to settle nearby their family members however multiple difficulties complicate this sometimes nieces and nephews are regarded by the family as sons and daughters as is typical of african notions of kinship but these are not compatible with americans kinship which is biologically determined and corresponding governmental policies sometimes family members have to choose between being resettled with either the mothers or the fathers family sometimes all family members do not have the required documentation or are not all present at the screening for resettlement that determines their eligibility sometimes information is falsified on the part of the families which does not allow them to claim their relatives when coming to the united states sometimes a family does not know about relatives in the united states until arrival these causes of family separation may not be preventable or resolvable but at the state and local level it should be possible to develop more family friendly approaches to helping refugees to gather information discuss together and problem solve their dilemmas and choices regarding the geographic destination of resettlement it is not feasible to propose that all refugee families from rural warm areas should be given options to resettle in a more suburban or rural setting and in a warmer climate not all southern states have the economic resources and needs to support large numbers of incoming refugees the refugee act of 1980 mandated that refugees be resettled throughout the entire country they need to be able to go where they can find work that will enable them to be financially stable innovative models of urban gardening may help to ameliorate this difficulty findings from this study suggest that not enough is known about the secondary migration and relocation of refugee families in the united states and that more research is needed one priority would be to examine us refugee families as part of larger transnational families given that this is how they view themselves another priority would be to follow families longitudinally after moving and to assess for changes in risk and protective processes and individual and family outcomes a third priority would be to develop intervention strategies for state government and communitybased service organizations to assist families that either have moved or may move each of these areas calls for welldesigned mixed methods studies the more detailed and accurate is our knowledge about the secondary migration and relocation of refugee families the more specific and targeted could be changes in policies programs and practices implications for family therapists working with refugees and immigrants family therapists may be able to help refugees and immigrants to address some important issues for families considering moving or having moved within the united states what form this work takes would depend upon many factors including sociocultural differences location funding and timepoint in resettlement and adjustment different forms of service or training of workers would be possible in a resettlement agency a school a church or a clinic which are the most common places for psychosocial work with refugees and immigrants it is important to remember that most refugees and immigrants do not identify family therapy or mental health as a need so how to engage them is often the principal challenge because moving is a part of ordinary life experience family therapists or other workers should not hesitate to bring up the topic with refugee and immigrant families family work may explore family members beliefs and attitudes concerning moving attitudes are likely to differ for men and women or boys and girls looking at secondary migration and relocation from a family systems perspective can shed light on the differing responses from different family members and perhaps help work toward building more understanding and acceptance one key issue is family decisionmaking regarding moving typically in burundian families the man decides alone whereas in liberian families the man and woman make the decision together only rarely have the children been consulted children are supposed to listen to what they are told and have little say regarding moving wivesmothers typically have more responsibilities than men over the children leaving them having to manage the new situations family therapists might want to advocate for more shared decisionmaking and flexible gender and generational roles though this is likely to be met with resistance from the husbandfather if families are viewing moving through a shortterm lens focused on solving immediate crises family work can help them to think more long term given that moving is often a form of problem solving helping families to explore other ways of problem solving is potentially useful refugee and immigrant families often face increasing amounts of family tension and conflict as they proceed in their adjustment to us life this often has to do with different rates of adjustment and acculturation of husbands and wives parents and children if families can find other ways of responding to these demands and diminishing tensions and conflicts the need to move may feel less urgent family therapists can also explore how family history interacts with secondary migration and relocation in potentially significant ways one issue that merits exploration is the reawakening of memories of prior moves and family separations another issue is exploring the familys sense of home that they are trying to reproduce in exile whether that be their original home or even the sense of home that they had in the refugee camp one key need is providing families with information they do not know what their options are or how to get help another key issue is communication between families and the voluntary agencies too often communication is oneway from agencies to families and the message being sent is not the one that is received when there are misunderstandings families do not know how to productively address them and to appeal for better services teaching families how to relate with organizations including how to advocate for themselves is an important need for example for some families seeking family reunification they could be helped by openly discussing where they want to live and learning how to advocate with the agency for the transfer of their case before the initial 8 months is over lastly the needs of children and the impact of moving on their development and education is the issue least considered by families but an area where family therapists can contribute one critical issue concerns helping parents to understand and manage the new pressure upon them to be more active in parenting than they have ever been before including monitoring and supervision of youth and involvement in education because parents receive very little guidance and support for their new roles they often look to moving as a way of diminishing the demands being placed upon them there is a clearly a role for parenting education and support interventions that can help parents to adjust to this change in expectations and roles so as to diminish educational disparities and other negative outcomes in youth table 1 profiles of families that moved

the purpose of this study was to understand the secondary migration and relocation of african refugees resettled in the united states secondary migration refers to moves out of state while relocation refers to moves within state of 73 recently resettled refugee families from burundi and liberia followed for 1 year through ethnographic interviews and observations 13 instances of secondary migration and 9 instances of relocation were identified a family ecodevelopmental framework was applied to address who moved again why and with what consequences how did moving again impact family risk and protective factors how might policies researchers and practitioners better manage refugees moving again findings indicated that families undertook secondary migration principally for employment affordable housing family reunification and to feel more at home families relocated primarily for affordable housing parents reported that secondary migration and relocation enhanced family stability youth reported disruption to both schooling and attachments with peers and community in conclusion secondary migration and relocation were family efforts to enhance family and community protective resources and to mitigate shortcomings in resettlement conditions policymakers could provide newly resettled refugees jobs better housing and family reunification practitioners could devise ways to better engage and support those families who consider moving

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i introduction in the recent years the publication of news information has migrated from the traditional means of newspapers radio and television to the wider audience offered by the internet with the rise of the dataintensive science 1 the analysis and monitoring of news information has given birth to the discipline called topic detection and tracking 2 which aims at segmenting identifying and following information mainly from raw textual information news analysis is now going beyond and image information is also investigated across all varieties of media 3 the analysis of news information is key to a wide variety of tasks from sociology and journalism to politics and economy 4 it could help the comprehension of users behaviors such as what information a category of users can be exposed to 5 it could also bring new quantitative tools to overcome the limitations of technocratic measures in the investigation of freedom of information 6 even if we know that media competition can lead to a lower quality of information 4 we can hope that public broadcasting services tend to convey an official character and be a reliable baseline for social analysis social networks analysis directly delivered from video content analysis is the contribution of this paper the social networks are constructed from face detection and tracking of video content from the nhk news 7 broadcast and enriched with segmentation and domain knowledge after discussing the related works in the next section we will present our data in section iii with characteristics and preprocessing section iv will then present the networks we have extracted with insights in section v because this paper presents preliminary results we will discuss our observations and future works in section vi before concluding ii related works our system focuses on faces detected in news video and new deep learning approaches are very promising 7 even reaches betterthanhuman levels of precision in face recognition we use a simpler approach inherited from 8 but provide face tracking in return many interesting works approache news analysis in a data intensive way from text analysis one of the most impressive approach on exploiting news data comes from 9 in which the authors combine news topic threads and demoscopic information to retrieve videos and generate a new summary video to explain prime ministers resignations an nlp framework is designed in 10 to characterize news providers programs and newsmakers over many channels the work from 11 is a notable effort in creating networks from news data they generate actoractionobject networks over years of news with great potential for building narrations and understanding of a news landscape the relevancy of network modeling for social and political studies does not need to be proven anymore 12 and beyond classical metrics 13 networks have been shown efficient for topics and concept analysis 14 and multiplex networks have been explored to analyse news data 15 particularly character networks have been broadly analyzed from literature 16 from tv dramas 17 and even a website is dedicated to the social analysis of game of thrones 18 news data has been one main target for visual analytics applications although we do not yet address visualization in this paper the following examples are all inspiring model to orient our analysis it is brought to help exploring large transmedia news as in 3 and 19 from which not only text but also visual information is used faces are also used in the case of 20 which fuses many criteria and modalities to support users exploration of stories in the corpus and introduces a network of topics similarly to 21 analysis derived from large scale data 22 also includes political figures cooccurrence analysis represented as networks iii face detection and tracking to understand well the interpretation we can make of the data we need to draw an accurate picture of what we are looking at this section details all preprocessing that is done before computing any social network after describing the data we introduce the segmentation of news the face detection and tracking a some domain knowledge a description of the data our video dataset consists in the dailycollected niitvrecs archive from 23 the capture covers a period between march 17 2001 andfebruary 27 2013 of the 4366day long period 4259 news programs have been collected cumulating about 2102 hours from the nhk channels daily news 7 broadcast the few missing captures concerning mostly the beginning of the time period are due to system setup most of the programs usually dure 30mn and only a few of them fall below or beyond this format b news segmentation news are specific programs that can be segmented in different news topics we thank the authors of 24 for lending us data in which news topics are derived from textual information synchronized with the news to summarize the process a topic boundary corresponds to a point between sentences where the keyword distribution is distinct between preceding and following windows of sentences as a result we have a segmentation of the news by topic based on semantics analysis although we do not have the semantic information of these topics this gives us time boundaries which will turn useful for analyzing peoples apparition on screen overall taking into account the differences of lengths among programs this summarizes in a distribution of an average 137 topics per day as illustrated in fig 1 however this segmentation implies that topics are not consecutively segmented and gaps may occur between two topic detections so topic detections cover in average 726 of the shows because the beginning and end of the news are ignored by the topic segmentation in addition gaps between news topic average 51 seconds and can stretch up to 207 seconds in which faces may still be detected additionally a standard shot segmentation derived from color histograms thresholds is provided to help the facetracking process this is a contiguous segmentation without gap inbetween corresponding to video cut editing c facetrack extraction now we can extract faces from the video shots as in 25 roughly decomposed in the following steps detection we first apply a detection of faces in all images using offtheshelves techniques such as the violajones face detector 8 this incidentally results in a feature space describing each detected face to reduce the number of false positive results we set the minimum size of a face at 60 × 60 pixels tracking we now need to group together the detected faces of a same individual into one single facetrack this is done with by generating tracking points within detected faces a tracking point is a same point identified across different frames we generated them using the klt point tracker 27 tracking points can belong to one detected face or to two faces or to the background based on a confidence grouping measure these points are differentiated and matched from a starting image with the following image given their temporal order the process has also been made robust against distortions such as flash lights and occlusions 25 this results in multiple face instances regrouped in facetracks there can be multiple facetracks across a same video sampling the facetracks for each facetrack we create a mean face that is a representative face in the image feature space based on the kfaces method 25 to do so the facetrack is divided in k subtracks of equal size for each the middle face is taken altogether forming a set of kfaces the mean face is then a mean point in the feature space described by the kfaces hence k influences sampling with a larger k for better representativeness to ensure a best quality of the output we use k 20 matching the facetracks facetracks can finally be matched based on their mean face euclidian distance in the feature space the whole process has detected over 30 million faces and 174778 facetracks were extracted we need now to identify and recognize groups of facetracks and clustering appears as the natural following step however clustering implies many new issues that we have not yet addressed this work yet we can still use a different approach to construct our networks that is of face retrieval the faces of 139 characters have been annotated during the evaluation campaign of 25 giving a ground truth for retrieving matching facetracks these faces are the faces of well known people among the japanese media scene including celebrities and politicians for which we had the highest precision of retrieval and identification in total over 5 thousands facetracks were annotated and 16714 facetracks of the 139 different characters were retrieved this corresponds to 2984 days of news program over the whole archive having matching persons covering a total of 36 hours of face tracks the coverage of the facetracks averages 24 of a program reaching the maximum of 389 of a program the ground truth has been provided during the 2010 period for which the facetracks appear slightly denser the average screen apparition per person is 157 min but there is a lot of variation between people and a few people seem to hold most of the screen time as a result the tracks work as follows everyday we have a news broadcast and every broadcast contains news segments and facetracks of different people we then observe an average of 238 seconds of cumulated detections per topics with in average 128 persons detected per topic thankfully this shows that we can reasonably expect people to overlap across topics although 80 of our topics do not show more than one person detected looking closer at the distribution of interday occurrences of people in topics we can see that most of them appear on screen mostly on a daily basis with bigger gaps then is an example this is sometimes referred as a characteristic of bursty data 28 meaning that over the whole period of time the is a lower probability for two persons to be detected together than by random making these links very interesting we can also notice that most of the people we are tracking seem to take part in similar topics during the 20082011 period incidentally the politics class includes 23 international leaders the japanese prime ministers hereafter referred as pm governing during the whole period of capture are of course represented allowing us to create time frames covering their cabinet yoshiro mori was the first pm in the timeline but his mandate only covers a few weeks from the beginning of the capture so himself is not included in the persons subset finally we obtain 11 time periods the different time bar charts we present in this paper reflect these different periods as colored backgrounds as for example in the timelines of the different pm in figure 5 although pearsons correlations between the three measures are very high we can use the ranking of the top 10 percentile to extract persons of interest d about the 139 persons a background checking gives us supplemental information explaining their occupation of screen space out of the obvious known figures and the aforementioned pm i ozawas maehara k shii and k okada are famous politicians s takeda and s nakarai are two presenters from nhk t horie is a businessman h matsui is a baseball player and w abe is active on the music scene iv different networks in this section we will define and present our different networks with their preliminary analysis from this point on we will mostly focus our interpretations on the political scene and use the networks as its mean of understanding most of the following networks use the persons as the same set of nodes but with different families of ties a network of people overlapping on screen our first network connects two persons when two facetracks overlap in time this means that we create a link between two persons when they have been detected simultaneously on screen these links are enriched with the screen duration of the overlapping of tracks as weights this network presents 35 nodes and 44 edges with a main connected component of 2941 this connected component is only composed of politicians with one business person its worth noting that j koizumi the top individual among all other metrics only presents here a degree of 2 four nodes stand out in terms of betweenness centrality and 2 nodes in terms of degree however no clear convincing cut of communities is shown by louvains algorithm 29 a few links stand out in terms of screen duration connecting y noda and s tanigaki in 2012 i ozawa b network of people appearing in a same shot this second family of ties defines links between people appearing in a same shot this network roughly extends the previous network with the difference that people do not need to appear on screen together because shot duration greatly varies depending on the cut of the video we cannot use it as a meaningful metric to weigh edges instead we will consider the number of different days that include these shots the network presents 49 nodes for 75 edges with a main component of 4171 the maximum kcore 30 presents a very intricate subnetwork of 18 nodes it includes the pm and the main anchorman later referred as the main actors all the other nodes are politicians including i ozawa getting their full list and description may go beyond the scope of this paper but it is interesting to notice that n yamaguchi stands out as the only politician not directly connected to any of the pm the main component presents a wider range of types of people including 3 athletes 3 business persons and o bin laden a louvain segmentation does not present a clear cut of denser subgroups in this network if we remove the main actors we can interestingly observe two communities of politicians one centered on m fukushima and n yamaguchi and the other one on k okada however one should carefully interpret the meaning of these links given the low amount of common shots three edges stand out with links displaying between 5 and 8 days of connections t aso and s tanigaki n kan and y hatoyama j koizumi and kim jong il if we consider links connecting two persons over one day only as casual and discard them we can reveal a network of stronger ties of persons with recurrent interactions in this network i ozawa displays the highest betweenness centrality followed then by the different pm the following network connects individuals when they have been detected during a same topic based on the segmentation described in section iiib this means that two persons are connected when they took part of a same media event the graph connects 107 people over 507 links with a main connected component of 96499 this graph presents characteristics closer to complex networks with a long tail distribution of node degrees c networks of people appearing during a same topic knowing that codetection during a news topic is the reason linking nodes we should first remove the journalists occurring a lot in the dataset in order to focus on other peoples interactions the resulting graph presents a maximal kcore gathering 15 japanese politicians and the 7 pm in a subgraph g k12 with a density d g k12 079 fig 7 right a degree and a centrality analysis will bring focus to the same people identified in the previous networks to go beyond we will look at the graph without the main actors leaving 67 nodes for 221 edges this graph clearly presents community structures and by running a louvain algorithm we obtain a very interesting clustering result the two main partitions clearly present international politicians and national politicians we are now able to spot the nonpm japanese politicians who fig 8 details readable on zoom the network derived after filtering nodes from fig 7 edges width encode the number of common topics red edges represent connections between japanese and foreign politicians node scolor correspond to the different louvain clusters from which we notice the japanese and the international politicians national politicians with strong foreign links are circled in purple and foreign politicians with strong national links in dark red payed an active role in international matters by highlighting them we do so by counting the ratio by counting the number of their ties with international representatives and threshold them based on their cumulative probability distribution 31 as a result we find y edano s tanigaki s maehara m fukushima y sengoku i ozawa t kanzaki m khomura with the same process on the other side we can identify yu jiang jiabao wen and lee myungbak as having redundant apparition on topics with national politicians the case of lee myungbak seems to have particularly raised a great interest among national politicians totalizing 5 connections d time slicing the topic network thanks to well defined periods of time corresponding to pm cabinets we can use topic segmentation as a support to observe not the overall network but each slice involving the persons interactions over the different cabinets to compare the political landscapes of each cabinet we pick out the top 2 or 3 japanese politicians in ranking of centrality and number of topics who are neither a pm nor have been detected during the preceding cabinets we then scan through all cabinets to verify in which cabinet the person has been detected or not as a measure of political interaction we can count the number of topics of each politician in which they have been detected with others during the cabinet in total we have collected 21 prominent politicians which will be used to compare cabinets one to another based on this subset of 21 7 pm we can finally estimate a rough proximity between cabinets as shown in fig 9 the periods from abe 1 to noda known for the series of resigning pm shows the highest proximity one to another and interestingly to koizumi 1 however koizumis two following cabinets appear very different suggesting that he set a very different mediapolitics scene during this time v some observations this exploration led us to some understanding of the mediapolitics scene presented by nhk news 7 based on this data together with the knowledge we provide the different pm stand out like no one else they can be directly identified in all aspects of the data first purely quantitatively speaking they occupy most of the media scene during their own cabinets then in the different networks they also occupy a very central place the different timerelated analysis makes it especially obvious during their cabinets we also learn by looking at individual pm most of them show some level of activity before their mandate and we can observe two opposite cases on one side abe is actually more central than koizumi himself during koizumi 3 on the other side noda came out of nowhere before becoming pm despite of hatoyama and aso appearing quite strong nodes in the different networks they never appeared on screen together even if they were heading two consecutive cabinets in period of time where the mediapolitics scene of consecutive cabinets is very similar maybe because they are the leaders of two opposite parties a person by person analysis would be too long to detail in this paper but the network exploration allows us to draw hypothesis on the important figures of the japanese media scene at the different periods of time then enabling a quick inspection of the individual video segments that qualify nodes and edges to get the precise story strikingly one very particular politician comes out all along this study i ozawa who is famously known as the shadow shogun getting into details into ozawas role in the japanese politics is a fascinating work on its own 32 but put in short he is known for all the connections and roles he has played behind the scene building alliances and often changing side although never he became pm to delve into this kind of details the domain knowledge should be more precise eg encoding the politicians affiliations at time t nevertheless we cannot get pass the fact that ozawa is utterly present in the media he is connected to different politicians through so many topics making him a central figure over the 12 years observed another very interesting point which is worth noting concerns the imperial family the japanese constitution forbids the imperial family to take any part in politics and observing the links surrounding the members of the family are of high interest to survey their actions our system finds very little connections and they mostly concern the revision of the imperial household law because of the issue concerning the succession to the imperial throne vi discussion and future work the different network views provide a powerful tool to understand the media situation but we also need to draw the limits of the definition of these networks as for now the topic association brings the most meaningful construction of links even if no actual semantics has yet been introduced in the system it is equally important to understand how the different preprocessing parts may have strong influences in later interpretations the screen overlap network has the strongest family of links in terms of social ties but it is also the most subject to controversy in two ways first because of the bursty characteristics of our data the limited but reliable subset of people and parameters of our facedetections make the amount of screen codetections limited then because many detections concern split screens which in in turn often means an opposition of ideas on a same subject hence defining a sort of negative link something we would like to investigate in the future we want to distinguish this case from the screen cooccurence which holds the different meaning of people standing in the same room at the same time the same comment may also be made on the shot cooccurrence network which finally extends the latter with a lighter meaning for example some shots occur behind the anchorman switching from one topic to another sometimes leading to false positive links besides the system showing a good accuracy 25 some face occurrences may remain untracked but we can still draw our conclusions thanks to the large period of time we observe since we are discussing the data itself our future work will extend the set of people to all faces detected in the dataset not limited to the tagged individuals we also put effort in enhancing the precision of the detection and the addition of semantic information derived from the topic detection will be a great improvement this paper only scratches the surface but the analysis of news data craves for application of many network analysis techniques for example the different overlaying families of links also form a multiplex network as in 33 we can draw multiplex networks as in 15 with people interacting through cabinets and hopefully find cohesive groups of politicians the dynamic of links is also of great interest and ∆cliques 34 is a promising lead in addition to finding outliers we will be interested in groups of political actors who regularly appear together among similar topics vii conclusion this work has introduced the production and analysis of face detection and tracking data over twelve years of news broadcast we have detailed the datas characteristics and brought a few outliers together with the use of topic segmentation and some limited domain knowledge we have derived many networks each presenting a different point of view on the data the combined views of these networks shows interesting insights on the story behind the data an arguably clear picture of the mediapolitics landscape during the different cabinets also isolating key players at different levels rather different to the classical topic detection and tracking approaches of news data this work brings up if not confirms the relevance of network analysis derived from news data by itself this is also an interesting framework for many potential contributions to the current challenges of social network analysis including but not limited to multiplex and multiattributed network analysis dynamic networks and their combination finally this work has given us useful directions that will help us design visualization tools which we wish to put as quickly as possible in the hands of domain experts sociologists and journalists for an indepth analysis of over 12 years of news

in the age of data processing news videos are rich mines of information after all the news are essentially created to convey information to the public but can we go beyond what is directly presented to us and see a wider picture many works already focus on what we can discover and understand from the analysis of years of news broadcasting these analysis bring monitoring and understanding of the activity of public figures political strategies explanation and even prediction of critical media events such tools can help public figures in managing their public image as well as support the work of journalists social scientists and other media experts news analysis can be also seen from the lens of complex systems gathering many types of entities attributes and interactions over time as many public figures intervene in different news stories a first interesting task is to observe the social interactions between these actors towards this goal we propose to use video analysis to automatise the process of constructing social networks directly from news video archives in this paper we are introducing a system deriving multiple social networks from face detections in news video we present preliminary results obtained from analysis of these networks monitoring of the activity of more than a hundred public figures over a decade of the nhk news archives

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introduction covid19 has severely impacted social and economic development as well as individuals work and family lives as the covid19 pandemic continues to develop medical workers on the frontline face increasing difficulties to balance their daily working and family lives moreover frontline medical workers live with the constant threat of death and often witness many deaths this situation can be difficult to change over a long period of time and posttraumatic growth among workers may be particularly inhibited in the context of conflict stress and trauma the relationships between familywork conflict and posttraumatic growth the results have not been consistent and the specific underlying mechanisms remain unclear therefore the current study sought to examine the impact of familywork conflicts on posttraumatic growth and explore the mediating effect of positive psychological capital and perceived social support in this process as well as explore the impact of emotional regulation strategies on this process impact of familywork conflict on posttraumatic growth familywork conflict is a role conflict in which family and work pressures are in some way incompatible manifesting as conflict between fulfilling family responsibilities and the overall requirements timeinvestment and pressures of work familywork conflict includes both the time conflicts involved in caring for the family and completing work tasks and the pressure of family roles hindering the completion of work responsibilities the covid19 pandemic has caused changes in working status for many individuals significantly exacerbating the conflict between family and work in some cases and it has also directly affected individuals mental health one previous study reported that familywork conflict was a significant factor contributing to poor health in women while many medical workers have made outstanding contributions in the fight against pandemic workers have also made great sacrifices regarding family care the pressure of familywork conflict during continuing pandemic and interference with the working status of medical workers increases the dual physical and psychological risks and increases the likelihood of psychological trauma such as anxiety obsessivecompulsive disorder depression and panic posttraumatic growth refers to positive psychological changes experienced after overcoming a challenging life crisis individuals who experience traumatic events often exhibit not only negative psychological responses but also positive changes in their appreciation of life personal strength relationships with others spirituality and outlook on new possibilities covid19 is a negative life event for medical workers which can trigger traumatic experiences and familywork conflict can strengthen the impact of negative life events and inhibit the occurrence of growth many medical workers have experienced immense pressure and uncertainty during the covid19 pandemic as well as psychological trauma related to the risk of death which has caused some medical workers to undergo a process of selfreconstruction previous studies have reported that the realization of posttraumatic growth is affected by many factors including individual assessment control helplessness availability of personal resources and transactional stress familywork conflicts can consistently induce these factors such as feelings of helplessness and transactional pressure which can restrain posttraumatic growth therefore we proposed hypothesis 1 under the background of normal pandemic prevention and control medical workers longterm familywork conflicts will hinder the realization and improvement of posttraumatic growth familywork conflict and posttraumatic growth the mediating roles of perceived social support and positive psychological capital the job demandsresources model and conservation of resource theory argue that work requirements including familywork conflict are closely negatively related to work resources such as perceived social support and positive psychological capital while perceived social support and positive psychological capital are positively related to positive factors under pressure thus we speculate that the effects of familywork conflict on posttraumatic growth are likely to be achieved through perceived social support and positive psychological capital perceived social support is the perceived availability of resources including support provided by individual social networks such as support from spouses colleagues friends and family familywork conflict is negatively related to perceived social support which can help individuals reduce stress and adopt positive behaviors to cope with stress in the process of posttraumatic growth and improvement individuals typically integrate positive changes such as enhancing personal and social resources independence and efficiency into their lives according to the model of posttraumatic growth proposed by tedeschi perceived social support can help individuals with trauma to view things from different more helpful and adaptive perspectives and to develop new schemas similarly in the conceptual model proposed by schaefer and moos perceived social support is regarded as a critical environmental resource used to understand the positive outcomes of life crises and transformation positive psychological capital refers to a psychological state of individual positive development which is a relatively new personality construction in positive organizational behavior mainly manifested in selfefficacy hope optimism and resilience in a study of nurses the results revealed a significant negative correlation between family work conflict and resilience in stressful situations optimism resilience selfefficacy and hope are all strategies that can help traumatized individuals recover from stress and achieve positive changes in particular hope about introducing expectations and goals for the future can help individuals shift their attention from practical difficulties and fear of negative outcomes to problemsolving behavior exerting a direct positive impact on posttraumatic growth at the same time perceived social support as a perceived external support resource and positive psychological capital as an internal positive resource can improve the posttraumatic growth of individuals the positive effects of both factors on posttraumatic growth can be explained by adaptive strategies other studies have also confirmed that perceptive social support and positive psychological capital which act together as an individuals internal resources and perceived environmental resources play a mediating role between psychological factors of trauma and posttraumatic growth therefore we propose hypothesis 2 positive psychological capital and perceived social support play mediating roles between familywork conflict and posttraumatic growth the moderating role of suppression some previous studies reported that the impact of familywork conflict on posttraumatic growth is not simply a stable negative predictive relationship gross and john proposed two mood regulation strategies cognitive reappraisal and suppression in their model suppression is considered to be a reactioncentered emotional regulation strategy which regulates emotional responses by controlling emotional expression behaviors that are about to occur or are occurring in stressful situations suppression may be used in an attempt to change or avoid negative thoughts and feelings previous studies have reported that mood regulation strategies are often important regulatory variables affecting psychological changes in task conflict situations for example suppression can moderate the effect of social anxiety on positive emotion similarly we speculate that suppression moderates the impact of familywork conflict on positive psychological capital and perceived social support affecting the improvement of posttraumatic growth according to the above argument and speculation when an individuals level of suppression is high their perceived social support and positive psychological capital levels decrease slowly with increased familywork conflict thus high suppression maintains the level of perceived social support and positive psychological capital under conditions of increased familywork conflict contributing to the realization and improvement of posttraumatic growth strong negative emotions are typically stimulated in familywork conflict situations and suppression is likely to inhibit the expression of negative emotion first suppression strategies minimize the effects of negative stimuli by ignoring negative stimuli and avoiding paying attention to or recalling negative stimuli second suppression has a buffering function by reducing the expression of negative emotions in stressful situations suppression can prevent the expansion of negative emotions playing a protective buffer role for emotions third regarding suppression as a targetoriented strategy positive cognitive style has been examined using negative stimuli for a wide range of thoughts including a sense of mission recognition of the importance of community and the occurrence of familywork conflict from family concerns and care which can be adopted as ways of helping individuals experience positive emotions and attitudes when the suppression level is low individuals do not suppress negative emotional expression when negative emotions are experienced as overflowing the individual experiences an increasing influence of negative emotions which can lead to a gradual increase in stress on the one hand positive psychological capital and perceived social support can alleviate the individuals response to pressure on the other hand the individual can also be exhausted by constant stress therefore with increased familywork conflict the levels of perceived social support and positive psychological capital decrease sharply which is not conducive to the realization and improvement of posttraumatic growth thus we proposed hypothesis 3 suppression plays a moderating role in the relationships among familywork conflict psychological capital and social support besides high suppression can buffer the negative psychological impact of familywork conflict materials and methods measures familywork conflict the fiveitem familywork conflict scale was used to measure participants family interference with work conflict example items included the demands of my family or spousepartner interfere with workrelated activities and familyrelated strain interferes with my ability to perform jobrelated duties participants were instructed to evaluate each statement against their own situation on a fivepoint likert scale the familywork conflict index was calculated as the total score of these five items with higher scores representing a greater degree of familywork conflict posttraumatic growth the posttraumatic growth inventory was used to assess the general tendency to experience difficult events that produce perceived benefits focusing on various benefits that may be found or explained the inventory contains 21 items divided into five dimensions appreciation of life personal strength new possibilities relating to others and spiritual change participants responded on a sixpoint scale from zero to five higher scores indicate more posttraumatic growth positive psychological capital the 26item positive psychological capital questionnaire was used to measure the general positive psychological state of individuals during their growth and development the questionnaire was divided into four dimensions selfefficacy resilience hope and optimism participants responded to each item on a 7point likert scale with higher total scores indicating a higher level of psychological capital perceived social support multidimensional scale of perceived social support is a selfreport method for subjective evaluation of social support twelve items were used to measure the degree to which individuals perceive support from various social support sources such as family and friends items included my family really tries to help me and i can talk about my problems with my friends participants responded on a 7point scale from one to seven the total score of the scale represents the overall social support and higher total scores indicated a greater degree of social support suppression suppression was measured using the items of the suppression dimension of the emotion regulation questionnaire four items were used to measure the emotion regulatory process by suppression strategy which included i control my emotions by not expressing them and when i am feeling negative emotions i make sure not to express them each item was scored on a 7point likert scale from one to seven higher scores indicated greater use of suppression strategies procedure this research has been reviewed and approved by the committee of protection of subjects at renmin university of china we collected data on familywork conflict posttraumatic growth positive psychological capital perceived social support and suppression among medical workers in a city in china the survey was conducted from october 14 to 24 2020 after providing informed consent medical workers were instructed to participate in an online survey via a questionnaire platform the survey included the familywork conflict scale the posttraumatic growth inventory the positive psychological capital questionnaire the multidimensional scale of perceived social support and the suppression dimension of the emotion regulation questionnaire upon completion of the online questionnaires medical workers were asked to fill out their demographic information statistical analysis spss statistics 210 software was used for statistical analyses including correlation analyses and linear regression analyses to further test the moderated mediation effect the bootstrap method was applied and process model 4 was used the mediating and the moderating effects were integrated into the same analytical framework to verify the moderated mediation model results preliminary analyses table 1 shows the descriptive statistics and correlations among all variables the results revealed that posttraumatic growth was significantly negatively correlated with familywork conflict partially verifying hypothesis 1 positive psychological capital and perceived social support were significantly positively correlated with posttraumatic growth to different degrees familywork conflict was negatively correlated with positive psychological capital and perceived social support there was no significant correlation between suppression and familywork conflict indicating that the two factors were independent the mediate effect of positive psychological capital and perceived social support in linear regression familywork conflict negatively predicted posttraumatic growth to examine whether positive psychological capital and perceived social support mediated the correlation between familywork conflict and posttraumatic growth the bootstrap method was applied and process model 4 was used further analysis revealed that positive psychological capital and perceived social support played mediating roles in the path from familywork conflict to posttraumatic growth the bootstrap method was used to test the significance of mediating effects with 1000 bootstrap samples the results revealed that familywork conflict had a significant indirect effect on posttraumatic growth through positive psychological capital familywork conflict had a significant indirect effect on posttraumatic growth through perceived social support thus hypothesis 2 was supported the moderate effect of suppression the results revealed that the interaction between familywork conflict and suppression had no significant predictive effect on posttraumatic growth the regression coefficients of the three models are presented in table 3 to further analyze the moderating effect of suppression we constructed a moderating effects diagram of suppression when participants exhibited high suppression the mediating effect of positive psychological capital was lower than that for participants with low suppression the results revealed that high suppression can buffer the negative effect of familywork conflict on positive psychological capital 4 and figure 4 shows that the mediating effect of perceived social support under conditions of high suppression was lower than that under conditions of low suppression the results revealed that high suppression can buffer the negative effect of familywork conflict on perceived social support thus hypothesis 3 was verified the analysis of results shown in table discussion the current study examined the roles of positive psychological capital perceived social support and suppression in familywork conflict and posttraumatic growth among medical workers during the covid19 pandemic the results revealed that familywork conflict negatively predicted posttraumatic growth and reducing familywork conflict effectively enhanced posttraumatic growth furthermore positive psychological capital and perceived social support were found to play a mediating role in this process and familywork conflict decreased positive psychological capital and perceived social support further reducing posttraumatic growth moreover suppression played a moderating role in this process and a high level of buffer the harm of familywork conflict to positive psychological capital and perceived social support with a high level of suppression the negative effects of familywork conflict on positive psychological capital and perceived social support were reduced thus reducing the negative effect of familywork conflict on posttraumatic growth the most important implication of the current findings is that under the severe pressure of covid19 prevention and control and the reality of substantial conflicts between family and work medical workers with low levels of suppression in a state of constantly heightened constantly to express their emotional expression were less able to resolve practical difficulties rather because negative emotions were experienced as overflowing make it continue in the negative or pessimistic thoughts a high degree of suppression can significantly alleviate the negative effects of familywork conflict on positive psychological capital and perceived social support these findings suggest that when medical workers are subjected to severe familywork conflicts efforts to restrain the expression of emotions can help maintain their level of positive psychological capital and perceived social support thus improving posttraumatic growth although this result conflicts with a previous report that suppression is associated with low selfesteem and is detrimental to establishing intimate relationships with others and thus to individual growth it is consistent with the conclusions of previous studies in some stress or disaster scenarios for example some studies have found that the transformation of posttraumatic stress disorder to posttraumatic growth leads to more emotional expression suppression strategies in the current study this may have occurred because medical workers who had experienced pandemic trauma were still experiencing high familywork conflict by adopting a high level of suppression strategies individuals may have been able to buffer the negative consequences of familywork conflicts effectively protecting their internal positive states and external support resources moreover our results also suggest that the applicability of suppression strategies can be discussed in a wider range of applications and may be related to environmental features particularly cultural factors a previous study reported that in countries with more individualistic cultures the role of suppression is typically negative whereas in countries with more collectivist cultures suppression tends to have positive influences on emotional experience interpersonal relationships and psychological and social adaptation which can weaken or even reverse negative relationships with positive outcome variables this finding was supported by the current results in collectivist cultural contexts individuals are often required to exhibit restraint and remain calm and selfdependence involves a tendency to adopt inhibition strategies to achieve interpersonal harmony therefore high levels of suppression may be encouraged and praised if this behavior persists over a long period of time the stress state can become aggravated thus in this continuous stress state the individuals positive psychological capital and perceived social support may also be damaged which is not conducive to the realization of posttraumatic growth in the face of pandemic trauma and objectively intensified familywork conflict medical workers controlling emotions by suppressing emotional expression avoiding emotional expression in positive or negative mood states and hiding emotions can effectively alleviate familywork conflict in turn this process can promote selfefficacy resilience hope and optimism among medical workers helping to maintain the feeling that there are others around to share happiness and sorrow with and who can offer help and support which facilitates the maintenance of good interpersonal relationships further investigation of crosscultural dynamics and the complexity of this model will be required to elucidate these issues in more detail consistent with previous crosscultural studies the current findings support the positive effects of suppression which is consistent with previous crosscultural studies and extending the findings of previous studies of suppression the current results also revealed negative effects and path mechanisms of familywork conflict on posttraumatic growth the results revealed that positive psychological capital and perceived social support played mediating roles in the negative impact of familywork conflicts on posttraumatic growth this conclusion fits with the logic of the jdr model and cor theory familywork conflict and work requirements can impair positive psychological capital perceived social support and other work resources which is not conducive to the growth and development of the individual furthermore individuals can fully utilize personal resources and with the help of external factors cope with highpressure environments to achieve good outcomes the current study has several limitations and the findings should be treated with caution first the survey was conducted ∼6 months after the outbreak of pandemic and as pandemic developed the various conditions and performances of medical workers may have changed accordingly thus it may be useful to further track the study population and extend the current findings second the current study only involved academic research and interventions with medical workers have not yet been conducted to promote appropriate psychological adjustment based on the relevant conclusions of this study third the current study only used selfreport measures and did not assess personality traits involved in posttraumatic growth and suppression strategies in the future a variety of assessment methods can be added and the corresponding influencing factors can be added to make the research results more effective therefore based on the current findings in the context of the covid19 pandemic we propose the following recommendations first medical workers should be encouraged to use methods to avoid familywork conflict reduce negative emotion expansion and enhance positive cognition and effectively use suppression strategies to enhance their individual internal strength and external resources second rather than focusing excessive attention on medical workers themselves we should avoid exacerbating the pressure they experience and depleting their psychological resources and should direct more care to the families of medical workers helping to effectively resolve difficulties and needs in the family data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by committee of protection of subjects at renmin university of china the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

under the impact of covid19 the status and mechanisms of posttraumatic growth among medical workers facing challenges related to familywork conflict are of great concern in view of the complex relationship between familywork conflict and posttraumatic growth the present study sought to explore the specific relationships between familywork conflict and posttraumatic growth as well as the specific roles of positive psychological capital perceived social support and suppression we recruited 1347 participants the results revealed that positive psychological capital and perceived social support played mediating roles while suppression strategies moderated the mediating effect compared with the low suppression group the negative impact of familywork conflict on positive psychological capital and perceived social support was reduced in the high suppression group thus a higher level of suppression was more conducive to posttraumatic growth the current study enriches and expands the findings of previous studies in theory and provides practical ways to promote posttraumatic growth in medical workers

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introduction the economist amartya sen introduced the concept of capabilities in the 1980s as a way of thinking about wellbeing that departed from the narrow utilitarian approach which has come to dominate modern economics the concept has been developed into what is now widely known as the capability approach a framework which accommodates social economic and political analysis and which holds that the wellbeing of a person ought to be assessed in the space of capabilities the capability approach has become increasingly influential in how we understand and evaluate social and economic development and the ways that this impacts upon human beings across the world in this paper we seek to review some of the strengths of the approach and also explore ways in which it can be broadened to address one of its main 2 centre for development studies university of bath uk email 3 institute of development studies at the university of sussex uk email 1 wed working paper 0943 critiques that it is founded in a weak conception of society and the social the capability approach contains three main concepts functionings capabilities and agency functionings are the valuable activities and states that become a persons wellbeing such as a healthy body being safe being educated having a good job being able to move and visit people sen defines functionings as the various things a person may value doing or being capabilities refer to the freedom one has to do these valuable activities or reach these valuable states sen defines the concept of capability as the various combinations of functionings that the person can achieve capability is thus a set of vectors of functionings reflecting the persons freedom to lead one type of life or another… to choose from possible livings or in an alternative definition capabilities are the substantive freedoms a person enjoys to lead the kind of life he or she has reason to value the notion of capability has thus become closely related to that of freedom which sen defines as the real opportunity that we have to accomplish what we value sen distinguishes this opportunity aspect of freedom from the process aspect which is the freedom involved in the process itself this relates to the concept of agency which for sen is the ability to pursue goals that one has reason to value this way of viewing agency provokes two simple but key observations that will provide points of departure for our later discussion of a social conception of wellbeing the first is that freedoms to and from are entirely defined through our relationships to other persons the second is that what we value is built from the meanings that we share with others our emphasis on the social character of shared meanings draws our attention to the fact that in some of sens writing there is a tendency to conflate doings and beings they are often talked of in the same breath with insufficient space for consideration of how we are to understand the relationships between the two in this paper we argue that the socially constructed meanings that are essential for all human life are what translate our havings and doings into states of being these social meanings provide us with basis from which we know what we value and judge how satisfied we feel about what we are able to achieve from this viewpoint a persons state of wellbeing is socially and psychologically coconstituted in specific social and cultural contexts this entails that the reality of tradeoffs between competing conceptions of wellbeing has to be confronted and that therefore such social conception of wellbeing is also profoundly political sens capability approach a key normative argument of the capability approach is that social arrangements should aim to expand peoples capabilities that is their freedom to undertake or achieve valuable doings and beings and in doing so those arrangements should respect peoples agency applying this idea to the evaluation of public policy a policy would be considered successful if it led to an expansion of peoples freedoms to do or be what they have reason to value and had not infringed on their freedom to be agents of their own lives a social policy which for example brought improved health care but which involved a government forcing those who did not agree with the policy to comply with it would not be considered successful from the perspective of the capability approach even if it had expanded peoples opportunities to live healthier lives sen argues at length in development as freedom that freedom should be both the ends and means of development the first major manifestation of the influence of the capability approach was signalled by the publication of the human development report by the undp in 1990 in the subsequent annual hdrs the analysis and measurement of human development has grown in sophistication during the last decade the capability approach has enjoyed further widening popularity across the social sciences in philosophy and even in theology in economics it is used as an alternative to the neoclassical economic framework and its narrow vision of human behaviour focused on individual utility maximisation human development measures are used in poverty and inequality analysis as an alternative to monetary measures in political sciences the capability approach is used to highlight the economic and social influences on politics such as the impact of economic inequality on political participation in philosophy the capability approach has put the idea of positive freedom at the centre stage theologians engage with the approach as a theory in social ethics that bears many similarities to theological ethics we can summarise a number of the ways in which the capability approach represents a new approach in the social sciences first it argues for human beings and their quality of life to be the central focus of policy whereas previously there has been a tendency for the means to promote the quality of life to be treated as ends in themselves second it conceives human freedom and the ability to make decisions that affect ones life as central to human dignity whereas before policy interventions and their associated analytical frameworks have tended towards treating humans as objects and recipients of policies third the capability approach reestablishes ethics at the heart of the social sciences and policymaking whereas previously analysis and policy thinking have tended towards overprivileging technical reasoning and a technocratic approach fourth the capability approach is an approach and not a theory it therefore allows for significant flexibility in interpretation and use and in doing so it often provides a way of reframing many of the problematics of the social sciences4 despite its far reaching potential for the social sciences and policymaking the capability approach does not come perfectly formed its main weakness we argue arises largely from its distinctive liberal foundation and the character of its emphasis on freedom it exalts a particular conception of human freedom as the ultimate value of human life yet we must comprehend freedom in relation to its telos or its aim rather than an individualised form of wellbeing as we perceive in sens arguments we argue here that a broader and more socially informed telos is required this encompasses both the good of oneself and others including future generations analytically and as both gore and evans have pointed out the capability approach as advanced by sen ultimately conceives of human freedom in an individualistic light this logically relates to the ethical individualism of the approach where individual freedoms provide the yardstick for evaluating social arrangements yet as human beings we live together and by doing so we create irreducibly social goods which sustain human life for better or for worse we argue that a more complex and social ethic is required for the evaluation of a more rounded and social conception of human wellbeing since failing to include irreducibly social goods in such an evaluation pays insufficient attention to the fabric of society that makes human life possible the frameworks of meaning that we use for individual reasoning are a fundamental form of irreducibly social good that the capability approach must seek to take better account of despite the fact that reasoning is central to the capability approach the approach does not offer a coherent and systematic treatment of the meanings that enable and shape reasoning and of the powers which influence it sen recognises that what some people have reason to value might conflict with what others have reason to value and this leads him to resist offering a list of core valued human freedoms but what some people have reason to value might be detrimental to the freedoms of others and more broadly they may not be for the good of society in the grandest functionalist sense the challenge of human society is for human beings to find ways of organising and structuring their relationships with each other so that we are able to successfully live together the forms of shared meaning which shape these relationships are a vital element of the structuring of our societies as bourdieus explanation of habitus suggests these meanings operate at conscious and unconscious levels they are conveyed by our cultures and are manifest with increasing degrees of formalisation in societal institutions which appear in a variety of forms from societal norms and formal laws to the written and unwritten rules of organisations at a basic level such meanings and relationships must enable us to meet the challenges of winning food and shelter from the planet but also moving beyond that to live together in a meaningful way which some would argue must necessarily involve the effort to minimise human suffering this does not suggest that human society at any time in history has been successful in minimising suffering and indeed a key observation here is that the struggle to live together can in itself generate violence and consequently human suffering taking the extreme example of the vision of human society after an unspecified environmental catastrophe presented by mccarthy in his novel the road many wars have been justified on the grounds that they are the route to future peace and prosperity the values of freedom and of living together can conflict with each other and as such any analysis of the ways in which we construct our wellbeing must necessarily explore the ways in which different social meanings are at play in the tradeoffs that must be made between valuable freedoms and the challenges of living together while the capability approach has much to offer to the social sciences assessing policies only in terms of individual freedoms as its central message has become is we argue extremely restrictive for how we understand the day to day struggles that people undertake in pursuit of their wellbeing in order to better appreciate these decisions deliberations and struggles we need a social conception of human wellbeing this must acknowledge both its objective and subjective dimensions it must take account simultaneously of its individual and collective character and it must allow us to apprehend both its dynamic and static dimensions key strengths of the capability approach human beings as ends the essence of the capability approach can be summarized in a very simple sentence the standard of living lies in the living and not in the possession of commodities as we have noted the approach emerged as a radical critique of increasingly narrow utilitarianism which had become dominant in economics and particularly where it conceived poverty and inequality in terms of the income that households command or the commodities they possess sen gives five reasons for which incomes and commodities viewed narrowly are inadequate for assessing quality of life 1 heterogeneity physical and biological differences between human beings will mean that they will have different requirements if their needs are to be met 2 environmental diversity differences in physical environments will mean that human beings in different places will require different combinations of commodities if their needs are to be met 3 variations in social context the different social arrangements that prevail in different societies will affect the translation of incomes or commodity into human development outcomes 4 differences in relational perspectives eg differences in customs and habits mean different commodity requirements for achieving the capability to appear in public without shame 5 distribution within the family eg the family income might be used to buy food and school equipment for boys but not for girls none of this argues that incomes and commodities are not important and ongoing research on the social and cultural construction of wellbeing across four different developing countries confirms that in all of the societies and cultures studied income is very important for peoples wellbeing 5 but income is not all and the research goes on to confirm that it is recognised as a means to further human ends this point has been the major message of the human development reports to policy makers development is about people and not just about per capita incomes and goods in the words of the first report the basic objective of development is to create an enabling environment for people to enjoy long healthy and creative lives this may appear to be a simple truth but it is often forgotten in the immediate concern with the accumulation of commodities and financial wealth development is thus not about what people have but about what they are able to do and to be with what they have such as living long and healthy lives being educated having a voice to participate in decisions which affect their lives there is little human progress if a country has grown wealthier but the majority of its population are unable to enjoy anything resembling a good life because of inequalities in access to the services that would provide them with adequate health care or education it is possible for high economic growth rates to generate economic prosperity and then mask a dynamic of social change that produces greater poverty and distress but despite the capability approachs powerful message growth of incomes per capita has a remarkable ability to reassert itself as the core point on the agenda of policymakers 6an alternative set of measures that have attracted growing attention across the social sciences and in policy circles are measures of subjective wellbeing or happiness the capability approach however stands ambivalently in relation to subjective evaluations of quality of life it does not ignore the capability to be happy as a valuable capability that people may have reason to value 8 but it warns of the dangers of using happiness as an adequate indicator of quality of life a person may be made to feel happy as an adaptation to cope with their dire life circumstances in some aspects of their lives slum dwellers in calcutta have been found to report themselves happier than middleclass europeans despite that they live in squalid accommodation trying to make ends meet on a daily basis somewhat contradictorily given the emphasis on the reason to value the capability approach argues that what matters is the quality of the life that people are actually living defined by its objective conditions and not how they subjectively wed working paper 0943 feel about their lives this flirts with the problem of accusing the poor of experiencing false consciousness this is dangerous territory as there are many well recognized problems with the simplifications and tendencies that are induced by the false consciousness approach such an approach enables researchers and policy makers to discount or devalue the meanings and understandings that form the basis for poor peoples decisions and actions and in doing so opens the way for forms of paternalism where there is an assertion of superior values and meanings which arise from higher authority or from a position of more enlightened understanding what would seem more appropriate are those approaches which engage with peoples perceptions more constructively in terms of adaptive preferences or what psychologists refer to as response shift both the adaptive preferences and response shift literatures focus our attention on understanding the malleability and changing nature of the meanings that people operate with to assess their quality of life and which represent a basis for their actions neither of the approaches suggests that the meanings that some people operate with are more authentic than those of others but that such meanings are socially constructed through our relations to others nor do they deny the possibility that some meanings serve the interests of existing distributions of power within a given society human freedom and agency in addition to placing human beings at the centre of economic and social processes the capability approach has brought concern for human freedom to the fore this is of tremendous importance since it directly challenges the depoliticising tendencies of much development thinking but it is also a doubleedged sword in the early 1980s another prominent approach on the international development policy agenda was the basic needs this shared a similar objective to the capability approach of resituating human beings and their quality of life at the heart of development policies its protagonists defined it as an approach that attempts to provide the opportunities for the full physical mental and social development of human personality and then derives the ways of achieving this objective the capability approach adds to this but questions the sense of separating basic needs from recognition of the importance of human freedom and agency it is argued that the basic needs agenda was pragmatically restricted to lower order basic needs because this is what was wed working paper 0943 politically and intellectually feasible at that time but as maslow himself latterly recognised the notion of a hierarchy of needs is indefensible and the relationship between lower order needs such as food and shelter and higher order needs such as freedom and agency is more complex in peoples lives than a simplistic hierarchy would suggest human freedom lies at the core of the capability approach in its focus on capabilities and not functionings for social evaluation sen often refers to the starving childfasting monk example both have the same level of functioning both are undernourished but one has the freedom to eat if he chose to and the other hasnt this is one of the major innovations of the capability approach in the social sciences to bring this idea of positive freedom to social evaluation this is what sen calls wellbeing freedom ones freedom to achieve those things that are constitutive of ones wellbeing the success of policies depends on promoting this wellbeing freedom in other words the aim of policies is not to push people into achieving things that are valued by others or reaching states that are considered valuable by others but to give them the opportunities to achieve what they value while the approach warns against the crude imposition of values by higher authorities it does not help us understand where the values of the free individual come from according to sen the capability approach makes a twofold contribution to the social sciences in the areas of wellbeing evaluation and assessment of freedom on the one hand it shifts the focus from the space of means in the form of commodities and resources to that of functionings which are seen as constitutive elements of human wellbeing on the other it makes it possible to take note of the set of alternative functioning vectors from which the person can choose the capability set can be seen as the overall freedom a person enjoys to pursue her wellbeing sen concludes that this freedom can be seen as being constitutive of the goodness of the society which we have reasons to pursue or as he has more recently summarized this approach focuses on the substantive freedoms that people have rather than only on the particular outcomes with which they end up for responsible adults the concentration on freedom rather than only achievement has some merit and it can provide a general framework for analysing individual advantage and deprivation in a contemporary society wed working paper 0943 using that conception of freedom the human development reports have erroneously translated the more academically obscure concept of capabilities into the more commonly recognised concept of choices and in doing so have greatly contributed to confusion the report defines human development as both the process of widening peoples choices and the level of their achieved wellbeing such simplification associate choices with whatever choices people wish to make as such it overemphasises the liberal foundations of the capabilities approach and with it increases the possibility of the approach being perceived as libertarian in its outlook what is at stake here in this poor translation is the meaning that we ascribe to freedom in any given social and cultural context that is as the capability approach suggests there may be an abstract notion of freedom that we can regard as universal in as much as it can be generally defined to be applicable to any human being in any society but freedom as people experience it can only be manifest in the relationships with others in specific societies it is those relationships and the meanings that shape them that make it possible for us each to judge whether or not we are free thus in specific societies the meanings that operate in respect of freedom also incorporate meanings about what we must do and be in order to live together from this perspective and if we are to value differences in cultures then we must recognise that the specific behaviours and actions that represent freedom in one cultural context could represent social irresponsibility in another this does not open the way for unbridled cultural relativism but highlights the need for a framework which recognises universal principles but does not use these as a means of automatically devaluing specific cultural forms and values if development is about giving people opportunities to do and to be not what they wish but what they have reason to value one needs to explore what it is that we have reason to value sens formulation the capability approach refrains from taking a particular position regarding the valuable capabilities that public policy should promote it is in that sense that the capability approach as enunciated by sen is deliberately and fundamentally incomplete this we suggest is because his development of the approach focuses more on the challenges of freedom than on the challenges of living together this incompleteness has been the core area of divergence from martha nussbaums version of the approach what she calls the capabilities approach she argues that this incompleteness causes the capability approach to encounter the same deficiencies as the preference approach for just as people can be taught not to want or miss the things their culture has taught them they should not or could not have so too they can be taught not to value certain functionings as constituents of their good living she argues that some content must be given to the capabilities that people have reason to choose and value so that equal freedom for all can be respected she reasons that what people consider valuable can be the product of structures of inequality and discrimination and that not all human freedoms are equally valuable she proposes a list of ten central human capabilities but despite being more directive than sen in defining what people have reason to value her capabilities approach remains centred on human freedom as she writes in relation to her list such an approach does not ignore the value of choice since what we aim at is to make them capable of choosing to act in these ways not simply to push them into so acting this means that we will define our goal in terms of capabilities not actual functioning and that one of the capabilities we must most centrally consider in each area of life is the capability of choosing sen has no objection to nussbaums project of eliminating the incompleteness of his approach but he fears that this might become the only route and may be tremendously overspecified his objections are not concerned with listing important capabilities but with fixing one predetermined list at the theoretical level doing so he argues would be to deny the possibility of fruitful participation on what should be included and why this emphasis on the possibility of fruitful participation is another way in which freedom is central to the capability approach people are not passive objects of generous social welfare provision but are active subjects of transformation there is no genuine development without respecting peoples freedom to make decisions about their lives it is the people themselves who decide what kind of development they would wish to happen people are to be empowered so that they themselves may define their local priorities as well as choose the best means to meet these for example referring to the choice between cultural tradition and poverty on the one hand and modernity and material prosperity on the other hand sen writes that if a traditional way of life has to be sacrificed to escape grinding poverty or minuscule longevity then it is the people directly involved who must have the opportunity to participate in deciding what should be chosen this agency aspect is particularly expressed wed working paper 0943 through public debate and participation in democratic decisionmaking to specify the valuable ends of policies and to determine the means to achieve these the centrality of an ethical foundation a third major contribution of the capability approach to the social sciences is to have reestablished their normative foundations there is no separation between ethics and economics between facts and value judgements the process of development itself is a valueladen enterprise for what counts as development is built on different visions of a good future and is inevitably based on a particular class of values the capability approach thus reasserts the centrality of value judgements about the good life and the good society judgements which since adam smith neoclassical economists have progressively buried beneath mathematical functions and apparently benign axioms in his book ethics and economics sen describes the ethical foundations of economics that he is trying to recover with his capability approach economics has had two rather different origins both related to politics but related in rather different ways concerned respectively with ethics on the one hand and with what may be called engineering on the other … the engineering approach is characterized by being concerned with primarily logistic issues rather than with ultimate ends and such questions as what may foster the good of man or how should one live the ends are taken as fairly straightforwardly given and the object of the exercise is to find the appropriate means to serve them such reflection on the ends of policymaking and human action more generally is one of the hallmarks of the capability approach it is founded on a principle of ethical rationality the rationality underpinning policy decisionmaking entirely bears upon the goodness of the objectives a goodness that is never clearcut and is always openended this contrasts with instrumental rationality which had become dominant in the applied social sciences which bears upon deciding the best means towards a single objective whose value is not questioned as sen puts it a decision taken according to instrumental rationality would then be similar to a decision expert whose response to seeing a man engaged in slicing his toes with a blunt knife is to rush to advise him that he should use a sharper knife to better serve his evident objective the capability approach does not wholly reject instrumental rationality it is useful but only when there are clearly defined goals that have already been submitted to ethical reasoning and when there are no disagreements about the means this is however an unlikely circumstance in the real world and is reminiscent of the neoclassical assumptions of the conditions for perfect competition competing meanings goals and views on wellbeing are a political reality and as such politics and reasoned public deliberation might more accurately be understood as processes of adversity accommodation and partisan mutual adjustment even if for example health care is agreed to be a condition for human wellbeing which every human being should have access to opinions will still remain divided on which kind of healthcare and whether it should be provided through universal public provisioning or private health services majone complements lindbloms thesis by clarifying that in these inevitably political processes it is possible to identify a role for expert evidence and academic argument but ultimately the process of choosing the best means to reach the agreed objective will have embedded in it value judgements about the good society although policy decisionmaking cannot escape the need for value judgements many economic policies for both developed and developing countries have been presented as an unavoidable technical solution to a problem this turn of the social sciences of course has also been reinforced over the long haul by the bureaucratisation of public policy and the embedding of technocratic expertise within bureaucracies but this still does not fully obscure the fact that hidden behind this screen of depoliticisation technocratic discourses disguise value judgements about the good society an approach not a theory a final strength of the capability approach is that is not a social development theory and even less a theory of justice in its essence it does nothing more than propose that we evaluate social arrangements in the space of capabilities reviewing the capability approach alkire states that its major insight lies in the affirmation that the objective of both justice and poverty reduction should be to expand the freedom that deprived people have to enjoy valuable doings and beings t he capability approach is a proposition and the proposition is this that social arrangements should be evaluated according to the extent of freedom people have to promote or achieve functionings they wed working paper 0943 value if equality in social arrangements is to be demanded in any space and most theories of justice advocate equality in some space it is to be demanded in the space of capabilities the capability approach thus limits itself to focusing on the informational basis for ethical judgements and does not advocate some specific way of identifying what people might have reason to value in another overview article robeyns sees the capability approach as primarily and mainly a framework for thought as a broad normative framework for the evaluation and assessment of individual wellbeing and social arrangements she argues that poverty inequality wellbeing development marginalization or oppression are not social phenomenon that the capability approach seeks to explain but seeks to conceptualise in the light of individual freedom this is why she argues the approach cannot be ranged under the heading theory referring to the links between the capability approach and theories of justice sen argues that the idea of capability refers to characteristics of individual advantages but that it fall s short of telling us enough about the fairness of or equity of the processes involved the capability approach limits itself to finding an alternative evaluative space for assessing human wellbeing and is not concerned with the fairness equity and efficiency of the processes involved in expanding freedoms in his most recent article entitled what do we want from a theory of justice sen further reinforces this position he distinguishes transcendental and comparative approaches to justice the former focuses on identifying perfectly just societal arrangements and the latter on ranking alternative societal arrangements he argues that the transcendental question of what is a just society central to a theory of justice is not a good starting point for a useful theory of justice he opts in favour of the comparative approach which the capability approach underpins he gives the example of health care in the united states to illustrate his argument that a comparative approach to justice would be already a great step forward in making the us a better or more just society and one does not need a theory of justice for promoting justice being an approach instead of a theory not only adds to its potential range of application but it also renders it nonpartisan it is an evaluation framework that is not attached to a political programme about building a particular type of societal arrangements that would serve one or other view of what is just or unjust the only criteria for judgement of these arrangements whether dependent on free markets or state direction would be whether they expand the capabilities that people have reason to value in this sense the capability approach can be consistent with a variety of different theories9 freedom and the telos of living well together as we have argued above the translation of capabilities or freedoms into choices is problematic at political and policy levels also referring back to the false consciousness conundrum there is the issue of understanding whether the persons lack of functioning is the result of choice or not how can we observe that a malnourished person is so out of choice or out of circumstances sen acknowledges this ideally the capability approach should take note of the full extent of freedom to choose between different functioning bundles but limits of practicality may often force the analysis to be confined to examining the achieved functioning bundle only the capability approach also acknowledges that the focus on freedom might not be necessary in situations where noone would reasonably choose not to exercise a capability such as for example the capability to live in a malariafree environment moreover there are some situations in which it does not make much common sense to talk about freedom to choose between different functioning bundles such as situations of extreme deprivation or threats of violence even if it accommodates exceptions the capability approach does not recognize that reaching a certain state of being and freedom of choice might not always be good for the person or good for society in his pioneering work on human scale development manfred maxneef categorized some forms of needs satisfiers that people use as inhibitors pseudosatisfiers or violators this kind of recognition has been further developed by more recent work by tim kasser and others who argue and then provide evidence for the view that some of the individual choices that are entailed in a materialist lifestyle are actually harmful to wellbeing as such it is possible to envisage situations where a focus on freedom of choice might result in people lowering their wellbeing in terms of our living together in society the commitment of the capability approach to freedom without giving it contents or a telos is not tenable as political anthropology has wed working paper 0943 demonstrated lawmaking and norm enforcement is present in all societies from the simplest to the most sophisticated and encouraging people to function in one particular way or another takes ethical priority over giving them the opportunity to function as they so choose the concept of externalities used by economics further points to the limitations of a nonteleological conception of freedom just as government intervention is reluctantly accepted in neoclassical economics when externalities need to be corrected we must consider what the role of government would be in taking actions against peoples choices which have adverse consequences for the wellbeing of others and for the good functioning of society there is a growing body of evidence and argumentation that individual freedoms can sometimes have negative impacts on the greater wellbeing of all whether in the present or in the future the most prominent example is in the literature on environmental change where it is now largely accepted that co2 generating lifestyles of some are having and will have drastic consequences for the wellbeing of others through adverse climate change10 avner offer in his work the challenge of affluence explores a number of other ways in which processes of social change associated with the growth of affluence in the uk and usa can be understood to cause individual choice to focus on short term hedonistic gains in doing this he argues these processes serve to erode important institutions of commitment in our societies and this is reflected in the growth of social problems experienced by affluent societies he also argues that the inequality which arises out of myopic and selfserving behaviour produces social arrangements that are damaging to the wellbeing of those at the bottom end of the distribution given that individual choices almost always have consequences for others given that an individual never lives alone and that human choices are deeply interconnected with others lives a political and policy focus on individual capabilities rather than on the consequences of particular functionings could result in important wellbeing losses for some this makes the ethical individualistic stance of the capability approach unsustainable wed working paper 0943 ethical individualism postulates that individuals and only individuals are the ultimate units of moral concern 90 robeyns argues that the capability approach is ethically individualistic in the sense that social structures and institutions have to be evaluated in virtue of the causal importance that they have for individual wellbeing as sen puts it even if the freedoms individuals enjoy are inescapably qualified and constrained by the social political and economic opportunities that are available to us these arrangements or institutions remain nevertheless to be investigated in terms of their contribution to enhancing and guaranteeing the substantive freedoms of individuals the reason for the capability approachs commitment to ethical individualism is that a focus on groups or institutions may hide forms of oppression and inequalities within the group however if limits to the freedoms of some people results in wellbeing improvements for many others either presently or in the future then this information cannot be omitted from the evaluation space of wellbeing or included only implicitly to the extent that they subsequently affect individual freedoms looking historically it is clear that present freedoms have often been won at the cost of great sacrifices of freedoms in the past the ideas of the french revolution liberté egalité fraternité for example are now celebrated throughout the world for their intrinsic value but the costs of the revolution on thousands of lives were considerable despite the violence through which these ideas came to be impressed on society they have now become valuable in their own right even if the struggle for them led to a reduction of many individual freedoms at the time recognizing the interconnection between each persons wellbeing in both space and time highlights the limitations of ethical individualism for assessing wellbeing because of its interdependent and dynamic character because of its spatial and temporal dimensions the wellbeing of one group of individualspersons in the present is often founded in the illbeing and struggle of others before them or of others in other places the construction of a persons wellbeing intrinsically contains an interpersonal or intersubjective dimension as we stated at the outset our freedoms to and from are entirely defined through our relationships to others moreover what one as an individual considers a valuable capability is profoundly built on the meanings that we share with others in society 11 as we have noted it is those shared meanings that allow us to translate our havings into doings and then into beings the same doings can have different wellbeing outcomes depending on the social meanings that are play in the relationships within which the person finds herself for example having to work hard can have strong affirmative value for a persons wellbeing in terms of her sense of competence but equally her work may be regarded by others as demeaning in bangladesh although weaving requires both considerable skill and hard work the muslim adoption of caste thinking means that weaving is regarded as a low status activity thus though weavers may enjoy their work and take personal pride in it they have to accommodate societal views and meanings which encourage them to consider their work otherwise thus weavers in bangladesh live with conflicting evaluations of their being the pride in their skills one the one hand and the acceptance of the low status it confers on them in society on the other it is these social meanings which constitute and are transmitted through the cultures that we live in which guide us as to what is to be valued and what is not our ability to decide on what valuable functionings constitute our wellbeing is shaped by our conscious and subconscious exposure to irreducibly social shared meanings 12the social meanings through which we can conceive of wellbeing must also be recognised as being dynamic they are in a process of ongoing construction and modification through all our relationships in society at all levels such as our relationships with members of our families our relationships through the political discourses of our nation states and our relationships with actors in the globalised media this means that our notions of wellbeing are ever changing we adapt our ideas in the short run through direct negotiations with others and in the longer run through our participation in changes in tastes and norms at national and global level this dynamic social generation of meanings is not sufficiently taken into 11 this also lies at the core of the self determination theory developed by the psychologist richard ryan and others and which is concerned with the the processes of internalization through which external regulation and values become integrated into the self see also deci and ryan consideration by the capability approach but rather is seen primarily in terms of positive or negative constraints on individual freedoms our argument leads to the conclusion that the problem here lies with the conception of the individual that is at the heart of the schema following the spirit of the enlightenment this individual is seen as analytically separable from society rather we argue the capability approach can be improved by conceiving of the person at the centre of the analysis as a social human being in this view society must be conceived of in the person and the person must be conceived of in society from the perspective of a social conception of wellbeing this means that how we understand to be valuable freedoms to or freedoms from is dependent upon shared meanings and what we are prepared to agree upon in society in order to live well together conclusion as we have noted above the capability approach rests on the notion of reasoning but reasoning depends upon the meanings that we share and that are constructed through our relationships in society what is judged as valuable or not is set against a background of meanings which is a truly irreducibly social good that cannot be reduced to any individual property 13 this leads us to a final observation on a weakness of the capability approach as it currently framed which is its analysis of the processes of value reasoning as noted above sens version of the capability approach refuses to commit itself to specifying what valuable freedoms public policy should promote it is through public reasoning or public discussion that each society is to determine which freedoms it should promote and to address the question of how people are to live together locally nationally or globally and to choose the most adequate social arrangements that will guarantee such good living together however sens writings remain silent regarding the possible conflicts that may arise from peoples different conceptions of wellbeing the diversity of people was at the core of the capability approachs arguments that resources were an inadequate space for wellbeing evaluation this means that social human beings wed working paper 0943 engage differently with each other and with the wider structures of society but this diversity also means that people are differently able to conceive of to pursue and to achieve wellbeing the exploration of social an economic difference carried out in the empirical work of the research group on wellbeing in developing countries confirms that not all visions of wellbeing and the strategies that people may wish to adopt to achieve it will necessarily be compatible with each other a quick look around us suggests that we cannot all simultaneously achieve all our wellbeing goals and at the same time maintain a coherent and inclusive society a social wellbeing framework and methodology give insights into the ways in which some peoples views of wellbeing conflict with others and how in some circumstances the pursuit of wellbeing by some results in the denial of the opportunities for wellbeing for others a social conception of wellbeing is therefore also profoundly a political one there are tradeoffs to be confronted it is important to consider the political dynamics of such processes and tradeoffs in more detail our ability to consent to live together in social collectivities depends in large part upon participants in value reasoning being able to reach accommodation of each others systems of meaning and value we must expect however that such full accommodation cannot always be yielded that is that there will be essential contestation recognising this we can understand that the systems by which value reasoning is conducted become a matter of prime importance recognition of the politics of a social conception of wellbeing suggests that we must give special attention to the political systems that articulate the substantive politics of everyday life and the political conditions through which people construct their wellbeing from the wed research we can recognise that bangladesh is a successful society according to conventional indicators of development such as progress in meeting the millennium development goals but that these successes have been contradicted by deteriorating wellbeing conditions for many people and particularly the poorest this disjuncture helps us understand why the country is currently experiencing conflict and political breakdown despite its conventional development success the capability approach contains great potential for the social sciences and public policy it resituates human beings and their wellbeing as the end concerns of economic and social processes it is founded on the intrinsic dignity of human freedom and peoples ability to be subjects of their own lives it reestablishes the ethical foundations of the social sciences it offers a framework for truly multidisciplinary analysis and by falling short of being a social theory it allows for a large range of applications and interpretations despite this enormous potential there are also some serious concerns all of which relate to the social and political nature of wellbeing in particular the capability approach understates the practicalities of conducting value reasoning and the conflicts that may arise for example israeli jews value the capability to live in the land that is now israel because of their shared meaning about the symbolism of the promised land but palestinians equally value the capability to live on the same land because of their shared meaning about the right to live where they have been living for centuries a social and political conception of wellbeing calls for a reformulation of the capability approach which takes these conflicts into account and which accommodates the view that some peoples gains are others losses for not all good things always go together

the paper discusses the potential and pitfalls of sens capability approach it discusses areas where the capability approach has made a significant contribution to the social sciences however the paper argues that the approach fails to take into account the social construction of meaning it is these social meanings which gives us a basis from which we know what we value and judge how satisfied we feel about what we are able to achieve from this viewpoint a persons state of wellbeing or illbeing is socially and psychologically coconstituted in specific social and cultural contexts this entails that the reality of tradeoffs between competing conceptions of wellbeing has to be confronted and that therefore such social conception of wellbeing is also profoundly political

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introduction social isolation can arise from many causes disruptions to our daily social connections result in people adapting to some level of social isolation quarantine procedures used to control virus outbreaks can result in extended social isolation for example numerous citywide quarantines were put in place in china and canada during the 2003 outbreak of severe acute respiratory syndrome in the united states individuals with sars were placed in individual quarantine similarly many villages in west african countries were quarantined in the 2014 ebola outbreak since the new sars outbreak covid19 in december 2019 many people in numerous countries have been required to quarantine for weeks to months where they were obligated to work at home homeschool children and drastically decrease social interaction resulting in prolonged periods of enforced social isolation the impact of such widespread social isolation is not yet well understood some research has however focused on the potential impact of meaningful social relationships in humans the association between positive social relationships and health has been clearly established individuals who are well integrated into society typically display lower mortality lower rates of chronic diseases and healthier overall behavior similarly being socially connected positively impacts psychological emotional and physical wellbeing a metaanalytic summary of the literature found that inadequate social relationships is linked with an increase in risk of premature mortality that is similar to wellestablished healthrisk factors such as decreased physical activity and increased obesity good interpersonal relationships could help enable social influence on individual choices and behaviors by providing a structure that encourages individuals to choose better healthrelated behaviors for example social relationships can help one maintain a more consistent sleep routine that can result in better stress management and longterm health benefits however the functionality of this type of social structure could be undermined by a quarantinelike scenario such as those implemented to control the spread of covid19 the purpose of this mini review is to assess recent findings pertaining to sleep and sleep habits under covid19 quarantine conditions within the broader context of the social isolation research area to identify the relevant literature we used google scholar and psycinfo we also searched the citations within the literature we identified and the cited by index in google scholar to locate additional relevant studies together these search methods provided a substantial base of literature to inform our assessment of social isolation and sleep social isolation and loneliness research examining the impact of social isolation is often intermixed with research on perceived loneliness while the concepts of social isolation and loneliness are sometimes used interchangeably they can be viewed as two separate scientific constructs perceived loneliness is defined by ones inability to fulfill personal social desires individuals are at greater risk of experiencing perceived loneliness when they have few social networks conflicts in their current family or intimate relationships or social connections that are not close enough to be considered a social relationship it is important to note that an individual can be lonely but not be socially isolated and vice versa while the focus of the current paper is on social isolation it is important to note that feelings of loneliness are likely part of the broad impact of social isolation resulting from the covid19 quarantines although one can be socially isolated and not experience the emotion of loneliness this is unlikely for most people by nature humans are social entities and when they are isolated from human contact or experience feelings of loneliness health risks and sleep problems increase in the case of social isolation due to the covid19 quarantines it is likely that many individuals maintained some level of family connections but experienced a decrease in other social contact in addition many individuals could have maintained some level of social relationships using social media it seems likely that most individuals had some level of social contact during the covid19 quarantines nonetheless most would have experienced a dramatic decrease in their normal social interactions research suggests that socially isolated individuals are at a greater risk for increased stress and higher mortality and morbidity some research equates experiencing social isolation with the same health risks as smoking 15 cigarettes or drinking six alcoholic beverages a day social isolation is also highly comorbid with mental disorders like depression anxiety and dementia however research also indicates that interaction with as little as one other individual can greatly reduce the health risks associated with social isolation suggesting that the specific characteristics of the social isolation environment can affect the broader impact on individuals the exact social isolation conditions resulting from covid19 quarantines varied across different individuals and countries some individuals could have been isolated with their families while other individuals could have been living alone but using social media to maintain some social contact similarly some countries repeated quarantines over time while other countries had longer sustained quarantines in place as such the social isolation with the resultant feelings of loneliness experienced during covid19 quarantines is unique and presents an environment unlike the types of social isolation seen in previous studies sleep and sleep habits precovid19 pandemic studies have shown that social isolation negatively impacts sleep furthermore a recent review of the prepandemic literature on social relationships and sleep concluded that increased quantity and quality of mutually supportive relationships are positively related to sleep it is also well established that sleep and sleep habits can be negatively impacted by psychosocial stress as occurs during prolonged social isolation as seen in the covid19 quarantines sleep is a health behavior that is highly predicated on a consistent routine and thus could be compromised as a result of the changes in lifestyle during a quarantine the implication of this relationship could be significant given the evidence in the scientific community that links poor sleep to poor health outcomes sleep disturbances unrelated to an underlying medical condition are associated with increased cardiovascular disease cancer and obesity as well as to allcause mortality sleep disturbances also negatively impact psychological functioning immune response and mood regulation in addition sleep habits are a better predictor of mental health and wellbeing than other healthrelated behaviors such as physical activity and diet sleep loss can also have more acute effects on health for example a single night of simulated shift work results in higher blood pressure among young adults at risk for hypertension and alters respiratory sinus arrhythmia when completing complex tasks as such maintaining good sleep habits and adequate sleep would be an important component of good mental and physical health both in the shortterm such as during a quarantine but also lifelong it is important to note that sleep quality is at least as important to good health as sleep quantity sleep quality is often the better predictor of mental health and wellbeing and is more closely associated with health affect and life satisfaction than sleep quantity particularly in persons sleeping between 6 and 8 h a night in addition both social isolation and perceived loneliness negatively impact sleep quality it has also been shown in older individuals that social isolation predicts poor sleep quality 6 years in the future therefore understanding the interaction between sleep and social relationships is important in understanding how humans social nature impact our health and wellbeing social isolation and sleep during covid19 understanding the impact of governmentmandated quarantines that extended across many countries and millions of people on sleep is crucial due to the many links between sleep health and wellbeing because modern technology has enabled forms of communication that make total isolation less likely the covid19 quarantines may not have resulted in total social isolation for many people however the quarantines would have caused unique challenges leading to changes in daily life for most people furthermore recent research indicates that people experienced increased feelings of depression and anxiety during the covid19 quarantine which could negatively impact sleep and sleep habits for many individuals metaanalyses and large multicountry studies a number of review articles and multicountry studies have focused specifically on sleep and sleep patterns during the covid19 quarantine one metaanalysis examining sleep habits across 13 countries found that 357 of the participants experienced sleep disturbances another metaanalysis examined gender differences in sleep problems across 19 countries and found that 24 of female participants and 27 of male participants experienced sleep problems during the quarantines several multicountry studies included specific information about sleep habits that was not easily captured in the metaanalyses one multicountry study found that over 50 of the participants delayed their sleep and wake times with more than a third of the participants reporting increased sleep disturbances in addition they concluded that poorer sleep was associated with increased depression and anxiety symptoms another multicountry study reported that equal numbers of participants indicated no change in sleep as worsening sleep in this study the people most likely to report increased sleep disturbances were women people between the ages of 31 and 45 and people who were less physically active one multicountry study found that sleep was seen as less restful and of lower quality during the quarantine than prior to the quarantine and that decreases in sleep quality were negatively correlated with perceived social isolation depression and anxiety finally a multicountry study that included many high school students found that most changes in sleep patterns occurred within the first 2 weeks of the quarantine more specifically they reported that the differences between sleep duration on weekdays versus weekends disappeared with total sleep time increasing by about one hour during the quarantine particularly for the adolescents these largescale studies provide a good foundation for understanding the impact of social isolation during the covid19 quarantine on sleep and sleep habits these studies reported that people often indicate worse sleep quality or sleep problems during the quarantine however there were also some people particularly older adolescents who increased their sleep time in addition there were differing reports on the prevalence of sleep problems in females and males primary studies other studies though individually less encompassing than the reviews and multicountry studies provide important information about the impact of social isolation during the covid19 quarantines on sleep in this section we focus on primary studies that were published more recently and were not captured in the metaanalyses described above to provide a broad picture of what the current literature is showing many sleep scientists used sleep quality or similar constructs to document changes in sleep during the covid19 quarantines many studies across numerous countries reported a worsening of sleep quality increasing sleep problems or increasing problems with insomnia during quarantine conditions however some studies found that sleep quality did not worsen across all participants of these studies a common trend was that younger people or college students reported less sleep problems during the quarantine in addition to qualitytype measures many researchers examined changes in sleep patterns during the covid19 quarantines delays in sleep timing which frequently included a concomitant increase in sleep quantity were commonly found across many countries the delays in sleep timing included later bedtimes midsleep times and wakeup times often resulting in less social jetlag one study found that the number of college students reporting seven or more hours of sleep a night increased from 84 to 92 for weekdays during the quarantine not surprisingly there was variability in the responses from participants about time in bed during the pandemic one study reported that although average wake time was delayed some participants reported a decrease in total sleep time while a different study focusing on adults over 60 years old found that about 27 of participants reported more sleep than usual while about 15 reported less sleep than usual during the pandemic another study found that average time asleep did not change during the pandemic however there was greater prevalence of both shorter and longer sleep than the recommended 78 h a night another area of sleeprelated research during the covid19 quarantines concerned the potential impact of variables related to the characteristics of the individual participants this included differences between females and males personality types stress and mood variables in general women were more likely to experience worse sleep quality and worse insomnia than men across many countries in addition women were more likely to experience increased feelings of distress and loneliness during the quarantines in contrast one study found that although women reported more anxiety than men their sleep quality did not differ lower quality sleep and insomnia were correlated with depressive symptoms and feelings of loneliness feelings of anxiety a more negative mood and negative affect and worry furthermore some studies divided the participants into groups depending on sleeprelated variables or personalitytype variables one study divided their participants into three groups based on sleep quantity and delayed sleep times they concluded that those participants experiencing a reduction in sleep quantity or delayed sleep times also experienced more stress anxiety and depression during the quarantines another study divided their participants into three groups based on adaptivetype personality profiles they found that persons with highly adaptive personalities exhibited less perceived stress and better sleep quality while persons with a maladaptive personality profile experienced the highest perceived stress and poorer sleep quality conclusion and implications the drastic increase in levels of social isolation during the covid19 quarantines was accompanied by changes in sleep sleep quality suffered particularly in women interestingly the timing of sleep changed with some people especially younger adults shifting their bed and wake up time to later in the day while often increasing the time asleep this suggests that many people curtail their sleep to meet the time demands of their workplace or education settings and that the quarantines provided flexibility thus allowing some individuals to better match their sleep to their chronobiological drives it is also important to note that not everyone experienced an increase in sleep quantity during the quarantines some people particularly those who reported feelings of depression anxiety loneliness or stress experienced less sleep as well as worse sleep quality as noted earlier social isolation could include feelings of loneliness for some people unfortunately this manuscript could not address this issue since few studies on sleep during the covid19 quarantines examined loneliness those studies that did suggested that feelings of loneliness were related to increased incidences of disturbed sleep however future research is needed to better document the potential impact of loneliness on sleep under social isolation conditions as would be expected sleep and sleep habits varied across individuals during the covid19 quarantines some of the differences in sleep disruptions were related to individual characteristics such as differences between females and males or a different adaptation in sleep behaviors for younger adults than other adults there are other variables that could have moderated the impact of social isolation on sleep such as social support studies indicate that during the covid19 quarantines perceived social support served as a buffer for the negative impact of the quarantines on sleep stress anxiety and depression a lack of social support can also cause a decline in selfcontrol ability which in turn could lead to poorer decisions regarding sleep habits this sequence of events could contribute to worse sleep under social isolation conditions for individuals who experience less social support another potential moderating variable is exercise which has been shown to be related to sleep quality and quantity unfortunately exercise was not a common measure for the quarantinebased studies on sleep and thus could not be assessed here other potential moderating variables could be family and work obligations preexisting medical conditions or neurological conditions unfortunately these types of constructs were not commonly measured in the quarantinebased studies on sleep additional research is needed to document the interactions between potential moderating variables and the impact of social isolation on sleep the literature reviewed here suggests that a complex multidimensional relationship exists that connects social integration and sleep in general social isolation during the quarantines negatively impacted sleep for many individuals which could then have shortand longterm consequences on health given that interventions in one health area could positively impact other health areas it is important to consider the potential impact of developing interventions that address the range of sleep problems that can emerge during social isolation conditions this can include interventions from governments workplaces and healthcare professionals that incorporate educational efforts treatment of insomnia chronobiological therapies and cognitivebehavioral therapies that can help individuals more readily adapt to social isolation the current mini review supports the importance of understanding the broader impact of social isolation on sleep as well as the need for additional research it is important to note that social isolation could occur in a variety of settings other than a pandemic including isolation because of personal decisions to withdraw from others disruption in a normal social group such as when losing a job mental disorders retirement aging and when working primarily from home government workplace and healthcare interventions are needed that are broadly accessible by the public to assist individuals in better managing their health behaviors including their sleep habits when experiencing social isolation conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

although researchers have investigated the impact of social isolation on wellbeing the recent quarantines due to covid19 resulted in a social isolation environment that was unique to any examined in the past because sleep is one of the endogenous drives that impacts short and longterm health and wellbeing it is important to consider how social isolation during the covid19 governmentmandated quarantines affected sleep and sleep habits a number of researchers have addressed this question during the last 2 years by examining several concepts related to possible changes in sleep during the quarantines to best understand these recent results the current mini review provides a background on the prepandemic literature on the effects of social isolation and loneliness with a focus on sleep and then summarizes the recent literature on sleep and sleep habits in general sleep was negatively impacted for many people during the pandemics but not all one group that seemed to benefit from the pandemic in terms of sleep patterns were younger people who could more easily adapt their sleep times to match their internal chronobiology given the potential broad impact of sleep on health and wellbeing better understanding how social isolation impacts sleep is an important consideration for individuals work organizations and governments

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introduction child abuse and neglect among aboriginal and torres strait islander populations is a particular concern in australia with aboriginal children significantly overrepresented in the child protection system in 201516 the rates of substantiation and child removal to outofhome care among aboriginal children were respectively nearly seven times and nearly ten times those of nonaboriginal children 1 the extreme disadvantage experienced by much of the aboriginal population such as deep poverty racism insecure housing poor nutrition parental separation poor mental health drug and alcohol problems low educational attainment high unemployment welfare dependency and chronic illness is implicated in high rates of child abuse and neglect 23 these vulnerabilities have their genesis in the complex trauma histories of aboriginal people of colonisation and dispossession racism and child removal compounded by family and community violence incarceration and premature death the complex nature of risk exposure in aboriginal communities and the seriousness of consequences of multiple adversities underline the need for effective family support services to mitigate the negative consequences and potentially disrupt intergenerational pathways into profound disadvantage the national framework for protecting australias children 20092020 stresses the need of early interventions to address family issues early in a childs life 4 home visiting programs home visiting programs have emerged as a promising prevention strategy for vulnerable families delivering support to pregnant women and their infants in their homes a homebased service is designed to increase access provide opportunities to involve family members in an environment that supports the building of a trusting relationship between mothers and nursevisitors 56 the goal is that by intervening early in the infants life typically during pregnancy new parents will be assisted in establishing a nurturing parenting style to achieve specific program objectives programs differ in terms of the type of families served targeted outcomes the underpinning theory of change qualification of home visitor the types of services and support offered and the length and intensity of home visit schedule 5 6 7 nurse home visiting program in central australia the australian government in an initiative designed for aboriginal families to improve pregnancy outcomes enhance child health and wellbeing and assist mothers in their own development funded the delivery of an adapted model of the olds nurse family partnership for mothers of aboriginal children 8 the nfp was chosen as one of a small number of homevisiting programs with evidence of capacity to reduce child abuse and neglect and improve other outcomes 9 the initiative was promoted as a communitylevel early investment in the future of aboriginal children program delivery commenced at three sites in 2009 in alice springs central australia at wellington and cairns by mid2017 the anfpp had been expanded to an additional three sites across the country and to a further seven sites by june 30 2018 10 across all anfpp sites aboriginal community workers were included as part of the home visiting team the primary modification on the nfp model to date there have been no published outcome evaluations of any of the anfpp sites or more broadly of infant home visiting for a remote first nations population the aim of this study was to examine the effect of the central australian family partnership program on child protection outcomes among children in the program specifically on the rates of child protection reports investigations substantiations and the annualised number of days in outofhome care the fpp was delivered by a large aboriginal communitycontrolled health service in central australia a decision was made to deliver the program to multiparas women not just firsttime mothers a departure from the nfp the service did not wish to limit access to the program which was hoped would benefit aboriginal mothers and their infants referral pathways into the fpp were not restricted all pregnant women who met the inclusion criteria of i location in the town of alice springs between 10 and 22 weeks gestation ii the expectant mother was aboriginal iii the mother had not previously participated in the fpp were eligible most referrals came through the central australian health service midwifery program but selfreferral and referrals from other services also occurred 11 reasons for nonreferral are not known method study design this evaluation adopted a retrospective and prospective comparative cohort design adjusting for pertinent baseline differences the outcome of interest was involvement with the child protection system as a measure of child maltreatment study design was constrained by the contextprogram evaluation proceeding alongside service delivery in a remote community setting commencing after service delivery had begun furthermore mr nick pascual director of child and family health australian department of health advised that our plan to conduct a randomised control trial of the anfpp could not proceed due to rejection of the rct design by an aboriginal health research ethics committee our study was approved by the research steering committee of the central australian aboriginal congress aboriginal corporation the human research ethics committee of the university of south australia and the central australian human research ethics committee data sources and data items deidentified datasets used for the study were derived from the pirs the northern territory birth registry and the northern territory child protection an independent data linkage unit was engaged to deidentify all datasets assigning a unique project specific linkage key to all children across the three data sources the research team only had access to deidentified data pirs was the data source for health service clients aboriginal status localities during pregnancy pregnancy outcome and fpp enrolment status which were used to determine eligibility for the fpp clients localities were also used to describe their level of vulnerability measured by the number of locality changes and area socioeconomic quintile at the time of the childs birth the coding of localities as in or out of the program catchment area was completed by staff from the central australia health service and clients locality at the time of the childs birth was extracted and provided to an independent geospatial coder to allocate a socioeconomic index using the index of relative socioeconomic advantage and disadvantage 12 these were then grouped into quintiles with q1 the most disadvantaged and q5 the least disadvantaged the northern territory birth registry provided descriptive variables that represented potential confounding factors or moderators of program outcomespecifically the number of previous liveborn children of each mother and mothers employment status at the time of the childs birth for all fpp and control children the northern territory child protection data contains complete records of involvement with the statutory child protection system in the northern territory records covered all child protection reports investigations substantiations and outofhome care placements from the time of the childs birth to 31122016 measurementdefinition a child protection report is recorded in the nt child protection administrative system when a member of the community makes a report or notification to the statutory child protection department to signify that they have reason to believe that a child is at risk of harm and in need of protection 13 the focus of reports to cp is familial abuse and neglect a child protection investigation is commenced if a cp report reaches a threshold of concern during a cp investigation the department obtains more information about the child who is the subject of a report and makes an assessment about the risk of child abuse or neglect likelihood of harm and the childs protective needs information may be gathered by checking information systems undertaking discussions with agencies and individuals interviewing sighting the child andor interviewing the caregiversparents 13 a child protection substantiation as an outcome of an investigation means that there is reason to believe a child has been is being or is likely to be abused neglected and subject to serious harm and an appropriate intervention by child protection services will be determined an active response can include referral to family support or other services direct supervision and support an application to the courts for a protection order andor removal of the child and placement in outofhome care 13 outofhome care placement can range from overnight care to long term placement placement can be with relatives other than parents foster care residential caregroup home in australia the child remains with their birth family as a priority and if removal is deemed necessary returning the child to their birth family is a common goal 4 adoption is extremely rare and parental rights cannot be compulsorily removed 113 statistical analysis the statistical analysis was conducted on an intentiontotreat basis means and frequencies were used to describe the socioeconomic characteristics of the fpp and control women two sample ttest and chi square tests were used to compare characteristics between groups generalised linear modelling was used to estimate the relative risk of involvement with child protection by type of involvement among fpp and control children multivariate models included mothers sociodemographic characteristics which were statistically significantly associated with the rate of involvement with child protection in the univariate analyses we examined the possible differential effect of the fpp on child protection outcomes of maternal attributes identified elsewhere as important we did this by grouping participants by age group and then by parity and conducting multivariate analyses all analyses were performed using stata 120 results mothers sociodemographic profile table 1 describes mothers sociodemographic characteristics characteristics found to be statistically significantly different between fpp and control mothers were age age distribution parity and house move category there was no difference in the sex or age distribution of children born to fpp and control mothers involvement with the child protection system involvement with the child protection system from the childs birth to 31122016 among fpp and control children is reported in table 2 this covers reports investigations and substantiations expressed as mean annualised rate and the mean annualised days in oohc placement per child these are unadjusted rates and as such comparison between fpp and control children are not the focus what is of particular interest is which characteristics affect cp system involvement best assessed from control group rates higher annualised rates were observed in children born to mothers of lower socioeconomic quintile to mothers not employed at the time of child birth and those experiencing a higher rate of house moves all denote a more vulnerable population no clear relationship was observed between cp system involvement and either age of mother or parity in terms of oohc placement the pattern in relation to irsad quintile was extremely pronounced as was employment and house moves mean annualised days in care were lower in fpp than in control children while we note these rates are not adjusted for baseline differences this pattern was observed across almost all subcategories differences were statistically significant for all children children of firsttime mothers those born to mothers in the lowest socioeconomic quintile not being employed and those having the rate of house move of less than 05 per year unadjusted cumulative incidence of oohc placement from birth is illustrated in fig 1 cumulative incidence was nearly identical in the fpp and control group to the fourth month of age and then started to diverge with greater incidence in the control than the fpp group by five years of age the incidence of outofhome care placement was 9 among control children compared with over 7 among fpp children the difference in the incidence curve of the fpp and control children unadjusted for baseline differences was not statistically significant in table 3 we report the adjusted rate ratios of cps events and of annualised days in oohc in fpp compared to control children this is reported by mothers age group and parity and adjusted for irsad quintile mothers employment and rate of house moves for children of mothers �20 years the rates of a cp report investigation or substantiation in fpp children were all substantially and statistically significantly lower than in control children for children of older mothers the rates of a cp event were not statistically significant different between control and fpp children among children of firsttime mothers the rates of a cp report investigations or substantiation in fpp children were also substantially and statistically significantly lower than in control children where the child was not the first child of the mother there was no significant difference in the rate of a cp event between the fpp and the control group regarding the effect of the fpp on annualised days in oohc the adjusted rate of days in oohc was lower for fpp than control children across all age groups this was statistically significant among children of mothers �20 years in terms of mothers parity only children of firsttime mothers in the fpp group had statistically significantly fewer annual days in care than control children adjusted risk ratios of being ever involved with the cps between fpp and control children by mothers age group and parity are presented in table 4 for mothers aged �20 years and firsttime mothers risk ratios were less than 1 for all types of child protection system involvement but did not reach statistical significance discussion as far as we are aware this is the first reported evaluation of child protection outcomes in an application of an adapted nfp model in a first nation population in a remote setting for children of young or firsttime mothers fpp children had statistically significantly lower rates of involvement with cps and fewer days in care per year than those not in the program our findings are consistent with the results of the randomised trial of the nfp in new york state in the usa olds and colleagues reported that during the first 2 years of the childrens life the percentage of children with reports of child abuse or neglect was 5 among those born to nfp teenage mothers compared to 15 among those born to control teenage mothers 14 among children of older mothers these proportions among nfp and control children were very similar 14 a randomised trial of the nfp in the netherlands reported that by age three and a half years there was a higher proportion of children with reports of abuse and neglect among control than among nfp children 15 an impact of child maltreatment is consistent with the underpinning theory the fpp was adapted from the nfp model which is grounded in theories including human attachment human ecology and selfefficacy 16 these promote the importance of a nurturing family environment of womens confidence in the face of obstacles and ability for sensitive responsive and engaged caregiving in the early years of the childs life the program content seeks to reduce risks and promote factors for positive child development outcomes including a reduction in child abuse and neglect 16 the model also has epidemiologic foundations for targeting disadvantaged women but particularly low income first time teenage mothers in a systematic review of home visiting programs to prevent child maltreatment segal and colleagues found that programs with consistency in terms of the theory of change the target population and the program content were more likely to achieve positive outcomes 17 a further exploration of the fpp the nature of program adaptions and how well they reflect the complex needs of the local aboriginal community warrants separate investigation a limitation of this study is the use of a nonrandomised study design resulting in significant differences in the characteristics of control and fpp women this trial design was dictated by the need to evaluate an existing program and an unwillingness by aboriginal ethics committees to support a randomised control trial of a program viewed as likely beneficial we have proceeded with the secondbest approach of including all children of women who had been eligible for the program the fpp group enrolled in the program and an eligible but nonreferred group then applying multivariable analyses to adjust for potential confounders we acknowledge that bias can still arise from unobserved but important differences we note that some bias in referrals is almost certain with more first time and younger mothers more likely to be referred into and to take up the program which we have also addressed through grouping the analysis by age and parity the use of child protection data within the nt jurisdiction means that cp involvement outside of the nt jurisdiction will not be captured the potential for bias from this source is small as this applies to both control and fpp children finally there is always the risk of surveillance bias given greater system contact of fpp children it is uncertain what impact this might have while it might increase the likelihood of a notification through greater service contact if the fpp is known to be working with a family it might reduce notifications by others if they feel the family is already being supported that is we hypothesise possible counteracting impacts that would likely leave a very small net effect 18 despite the study limitations the consistency of our results with other nurse home visiting studies lends weight to the reported findings conclusion the results of improved child protection outcomes of the fpp in firsttime and young mothers and in outofhome care placement for all fpp children are a hopeful indicator of better mother child relationships this might be expected to have a powerful influence on the life trajectory for children especially in these highly vulnerable populations while the observed outcomes are positive further evaluation using a randomised design would be desirable to test these findings data curation debra gent formal analysis ha nguyen debra gent

the nurse family partnership program developed in the usa designed to improve mother and infantchild outcomes has reported lower rates of child protection system involvement the study tested the hypothesis that an adapted nurse family partnership program implemented in an aboriginal community in central australia the fpp would improve child protection outcomesthis was a retrospective and prospective cohort study drawing on linked administrative data including birth registry primary health care client information system fpp program data and child protection data participants were children of women eligible for the fpp program an exposed and a control group of women eligible but not referred liveborn between 132009 program commencement and 31122015 child protection data covered all reports investigations substantiations and outofhome care placements from the time of the childs birth to 31122016 generalised linear modelling was used to estimate the relative risk rr of involvement with child protection and type of involvement report investigation substantiation outofhomecare placement among fpp and control childrenfpp mothers n 291 were on average younger were more likely to be firsttime mothers and experiencing housing instability than control mothers n 563 among younger mothers �20 years fpp children had statistically significantly lower rates of involvement with child protection arr report 049 95 ci 029 to 082 arr investigation 034 95 ci 019 to 064 arr substantiation 045 95 ci 021 to 096 and experience fewer days in care

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introduction for some time in brazil and in the world water virtually has two sources of scarcity the pollution that changes the water quality and restrictions on the amount available due to growing demand changes in the hydrological cycle and inefficient use in general it is understood that the scarcity of water due to pollution is a more frequent problem in the south and southeast regions of brazil which concentrates the major industrial and agricultural uses higher population contingent and treatments whose efficiency is uneven therefore this article is based on the fact that existing practices in the study area have an impact on changes in the quality of water supplied to the different municipalities the environment that contextualizes this article is characterized by changes and transformations because on the one hand there is the cultural heritage of interaction between people and their activities and the physical environment which is difficult to be modified and on the other hand due of inheritance the differentiated values that the physical environment has for different populations and needs to be modified because the legal environment imposes new dynamics both in urban as in rural sector in this context this study aims to present socioeconomic aspects of the municipalities from the basins 3 and 4 of paranapanema river and the basin of pirapó river which suffered severe process of forest clearing due to the introduction of raw materials and heavy farming implements typical of the green revolution and the presence of large cattle in highly sensitive environments like caiuá sandstone which are in a legal environment that has a series of rules imposing new relationships with nature to verify the practical and assuming that the socioeconomic development of each watershed is different we conducted a field research with a statistically representative sample to identify both the socioeconomic features of the population in urban and rural households as the understanding of the respondents about the environmental problems surrounding them this study is organized into five sections the first relates to this presentation and the second is related to the context of analysis the next section presents the methodology and the fourth section shows some results of the field research finally we present some conclusions the background of the analysis until the mid 1980s the management of water resources was fragmented sectoral and focused on corrective actions agricultural and urban practices were not very concerned about environmental impacts and deterioration of rivers however changes in the legal environment with the national policy for the environment the constitution of 1988 and the national water resources policy have imposed new relationships with the physical environment as one of the policies that guide the minimization of impacts on water resources the law 9433 of january 8 1997 known as the water law either the national water resources policy which aims to ensure to the current and future generations the availability of water according to quality standards suitable the rational and integrated use of water resources including waterborne and waterway transportation with a view to sustainable development and the prevention and defense against critical hydrological events occurring naturally or resulting from inappropriate use of natural resources with this act the river basin became the management unit which became more integrated and centrally focused that water is a limited natural resource has multiple uses such as public water supply industrial agricultural irrigation electric power generation recreation and preservation of aquatic life furthermore private waters were converted into the public domain ie may be used only by granting the right to use in the same act the river basins become the focus of policies outlined by the river basin committees in the state of paraná the state law 12726 of november 26 1999 follows the same principles of the federal law in spite of these undeniable normative progresses in most brazilian states the directions of water policies are under the jurisdiction of various state departments which means in practice that the integrated coordination is still incipient or nonexistent and or conflictual furthermore there is a cultural heritage that extends over time on cultivation and cattleraising techniques and use of raw materials which are difficult to be broken as a result problems and environmental impacts extend and intensify with degradation and intensive use of land and water even due to the high degree of dependence of the ways of producing which changes the access to water resources in quantity and quality as well as the hydrologic cycle in space and time one of the aspects to be taken into consideration as the focus of this article is that environmental degradation is caused by inadequate uses and practices that drive both greater exploitation of water resources as well as their pollution which in turn generate greater social and environmental imbalances specifically in the study area the agricultural modernization in the 1970s and 1980s which aimed to intensive and extensive grain production for export and the formation of large agroindustrial complexes the result was the rapid removal of forests siltation of rivers and the deterioration of water sources particularly those that supply the urban areas as well as the emergence of gully erosion that destroyed regions and required substantial public investment in the urban sector inadequate or nonexistent treatment of industrial and domestic effluents contributes to the decrease in the quality of water resources in this context the study focuses on basins 3 and 4 of paranapanema river and on the pirapó river their urban and rural characterization and the identification of environmental problems perceived by the studied families presented in the following section features of the studied river basins located in the north of the state of paraná the basin of pirapó river and the basins 3 and 4 of paranapanema river covers an area of 1169127 km² and encompass 56 municipalities the river basin paranapanema 3 reaches a total of 15 municipalities in an area of 540016 km² which are equivalent to 27 of the studied area it is formed by the drainage area of 12 tributaries that flow into the paranapanema river between the mouth of the tibagi river near the lake of the hydropower plant capivara and the mouth of the pirapó river the river basin paranapanema 4 reaches a total of 15 municipalities in an area of 629077 km 2 or 31 from the studied area is located to the west of the river pirapó with 15 tributaries of paranapanema river until the mouth of the ribeirão do tigre most of these basins are located in sandstone caiuá that as paraná about 80 is for public supply from region covered by the caiuá aquifer which is done through groundwater the pirapó river basin has pirapó river as the major component the source of the river is in the municipality of apucarana about 1000 meters above sea level flows northward and covers an extension of 168 km to its mouth at paranapanema river approximately 300 meters above sea level in the municipality of jardim olinda approximately 60 direct tributaries comprise the basin the bandeirantes do norte river is its largest tributary has its source in the municipality of arapongas and has an extension of 106 km this river basin is located in the serra geral system the water catchment in these river basins is mainly used for human consumption in the case of pirapó for industrial use in paranapanema e and pirapó and finally for irrigation in paranapanema 3 moreover the coverage of the treatment of sewage is low according godoy and sousa the total population of the three basins is 1362109 inhabitants from these 87134 live in the rural sector and 1274975 in the urban sector the pirapó river basin concentrates most of the population with 956806 inhabitants and 909776 are in the urban sector while 47030 are in rural sector urban households are 447756 of which 320328 are in the pirapó 62534 are in the paranapanema 3 and 64894 are located in paranapanema 4 the existing farm units in the three river basins amount to 28147 in a total area of 1659796 hectares from these 15176 farm units are located in the pirapó basin 7256 units are in the paranapanema 4 and in the paranapanema 3 basin there are 5715 properties regarding the individual size of the farms 7745 are micro farms and 14991 are small ie those categories are 22736 farm units there are 2800 properties classified as large highly concentrated in the pirapó river basin the river basin paranapanema 3 is characterized by having a high rate of deforestation since the 1980s currently remains about 5 of remaining coverage of which 4 is protected by the conservation units of integral protection temporary crops are featured at 2750 properties which occupy an area of 229229 ha and permanent crops are in 792 properties and occupy an area of 61075 ha the region has a predominant use of intensive agriculture in 90 of the territory based on the occupied area the main activity is the cultivation of cane sugar which stand out municipalities of porecatu followed by santo inácio and centenário do sul soybeans is the second largest activity according to the occupied area especially in the municipalities of cambé followed by primeiro de maio and alvorada do sul the paranapanema 3 river basin has 4731 farm units and 340961 ha are managed by the owners lessees cultivate an area of 24312ha and settlers are responsible for 9380ha of farms the river basin paranapanema 4 is occupied almost entirely with artificial pastures and grasslands occurring small areas of intensive agriculture and forest coverage the number of owners is 6030 whose area corresponds to 479519 ha in this basin highlights the area of settled from the agrarian reform program of the federal government amounting to 46724ha lessees handle with 18521 ha it has 1448 properties with temporary crops and area of 140655 ha paranavaí is the municipality that stands in the temporary crops because it has 443 farms with temporary crops in 32360 ha the second city that stands out is alto paraná with 164 properties with temporary crops and area of 11071 ha permanent crops are present in 869 properties and 89915 ha in this basin stands out again paranavaí which has 157 properties also noteworthy diamante do norte with 128 properties and 2823 ha of permanent crops the most significant products in planted area are firstly the sugarcane which highlights cruzeiro do sul followed by guairaçá and inajá cassava has the second highest planted area highlighting alto paraná and terra rica and santo inácio do caiuá the river basin pirapó gathers 15176 properties of which 12693 properties and 645265 ha are managed by the owners in this basin is the largest area with lessees with 59928 ha or 83 of the total basin area there are also 5574 properties with 3714 properties and temporary crops with permanent crops in this basin the municipality of marialva has 718 properties with temporary crops and 28197 ha and 701 farms with permanent crops and 6131 ha another municipality that stands out is apucarana with 664 properties with temporary crops and 596 properties with permanent crops another important municipality is rolândia which has 548 properties and 27621 ha with temporary crops and mandaguaçu with temporary crops in 329 properties totaling 5327 ha among the most significant products in area and production soybean is first in the municipality of arapongas which has an area of 19200 ha with this culture and produced 53760 tons followed by apucarana and astorga the cane sugar is the second and has the largest acreage in colorado followed by jaguapitã and lobato gathered gdp gross domestic product which is the sum of the values generated within each municipality total of the three river basins is r 18173979 thousand of which 756 originate from the pirapó basin paranapanema 3 participates with 129 and paranapanema 4 with 115 the tertiary sector in all basins stands out over 62 draws attention that the agricultural gdp of pirapó basin is 47 the basins concentrate industries that generated 6409 on the average r 321690 in 2010 which are highly concentrated in the pirapó basin consequently the pirapó river basin stands out on economic aspects of the basins by having the main city in the region maringá which focuses sharply the population employment and wealth generated in the region a summary of the socioeconomic and environmental conditions is presented in frame 1 in general the socioeconomic data released by the competent agencies indicate the characteristics of the basins and the concentration of activities and population however due to its lag in time it is necessary to deepen the analysis of existing practices and their understanding of the environmental problems related to water resources in the cities studied for this we carried out a field research whose methodology is presented below methodology the methodology includes three stages the classification of municipalities in the respective river basins analyzed the elaboration of a database for analysis of the general characteristics and the calculating of samples sampling and application of a questionnaire the classification of municipalities in the appropriate river basin to perform the classification of municipalities in the river basins we use the data provided by the state department of environment and the environmental institute of paraná iappr which allowed us to evaluate the amount and size of the municipalities located in more than one basin because a municipality may be in two basins after discussion in the research group we adopted the criterion that a municipality would be framed in the basin that contained more than 50 of their land for the example shown colorado was within activities of livestock soybeans sugar cane corn and wheat have expanded and consolidated the modern agro sugar mills meat and dairy processors sundry cultures expand strengthening productive chains urban centres concentrate processing plants sectors of clothing are rapidly expanding formal employment have significant weight in the regional industry environmental management the use of pesticides stands above the 150 kg ha year 50 of the municipalities have no formal structure for environmental management actions use of pesticides is below 100 kg ha year there are no actions to minimize anthropogenic actions only in one municipality of the ten there is no municipal secretary focused on the environment amount of pesticides is on the average of the state from 100 to 118 kg ha year none of the 22 municipalities of the basin has exclusive secretary to the environment issues as it was intended to conduct a field research and attempt to bringing the economic issues to an understandable level to all members of the group we have done several meetings in order to address the various fields of study the first trial was conducted with the staff from geography in which it was decided to choose the cities for field research based on the way of dependence of water resources infrastructure and services for that we collected data from the national water agency about the catchment points of raw water for the water supply to the urban sector with this the municipalities were characterized by the source of supply the system and which subbasin are supplied these data were compared with the population the industrial gdp agricultural gdp gdp per capita per capita income we carried out several tests and not come to any conclusion then we tried to differentiate by use of surface water or groundwater resources which also failed to differentiate we conclude that there is a set of factors that reinforce or were reinforced by soil type and therefore interfere with the demand of water resources what can be said is that the greater the activity and the largest concentrated population the greater the demand table 1 presents some data by basin it was found that in all municipalities of the studied basins the supply of water resources exceeds existing demand the problem encountered is regarded to the access because in some municipalities investments in infrastructure to expand the supply of services is needed whereas both the form of use of water resources as the availability did not differentiate municipalities basins further meetings occurred at the research group sampling and application of a questionnaire in the third phase a range of factors led to the choice of municipalities it was decided to select three municipalities in each basin while in the pirapó basin four municipalities were selected because necessarily by the historical studies conducted by the group maringa should be included in addition as a determinant it was decided in a meeting of the group of researchers that the link the various studies would be the points of hydrological data collection done by the group of chemical engineering and geography according to information exchanged among researchers in paranapanema 3 there are three collection points regarding drainage density municipalities that interfere with point 1 are rolândia and cambé point 2 is also influenced by these municipalities and prado ferreira and bela vista do paraíso the collection point 3 is directly influenced by miraselva and guaraci then there was the choice of miraselva bela vista do paraíso and cambé in the river basin paranapanema 4 municipalities that interfere with each collection point is at point 1 nova esperança alto paraná and cruzeiro do sul at point 2 uniflor paranacity and santo antônio do caiuá in addition to the previous and in the point 3 include paranavaí guairaçá and terra rica thus paranavaí and terra rica interfere in the same collection point whereas paranavai has higher drainage density was chosen therefore alto paraná paranavaí and terra rica for the pirapó river basin depending on the monitored points picked up paranacity arapongas maringá and considering that the river bandeirantes do norte is the main tributary of pirapó interfering in some sites we chose colorado from the choice of the 10 municipalities the sample based on the number of households was calculated using the formula 1 2 2 2 e n z p p n z p p n where n calculated sample n households in the municipality z confidence level 95 196 p probability of the event 50 e sample error 5 as a result we constructed table 2 in parallel we prepared a questionnaire that was applied in december 2012 with 50 families of elementary school students in elementary school marechal floriano peixoto in the district named floriano belonging to the city of maringa considering the results obtained it suffered a series of adjustments that were made in the research team meetings between july and october 2013 the questionnaire was applied in 10 municipalities we conducted 639 interviews in the urban area covering 1735 people and 78 in a rural area that comprised 215 people amounting to 717 questionnaires and 1813 respondents the data collected were systematized into a database in an excel spreadsheet the results are shown below results and discussion this section was divided into two parts a demographic and social aspects of the interviewed families of elected municipalities in each river basin and b rural and environmental aspects we point out that it was not always possible to separate these contents as for example in rural areas they were closely related demographic and social aspects according to ibge the area of the municipalities studied in the three basins is 476098 km² of which most are located in paranapanema 4 and the lowest is in paranapanema 3 the population is composed of 717970 inhabitants mostly living in the basin pirapó the municipalities are highly urbanized and the smallest degree of urbanization observed is in paranapanema 4 and higher degree in pirapó basin this situation appears to be stronger than the paraná average which is 853 in all basins the female population is larger than the male and this situation is sharper in the pirapó river basin as shown in table 3 spite of this relative homogeneity of the data the distribution of variables was unequal between municipalities of the basins as shown in the same table 3 as can be observed there is a municipality in each basin which has the largest share of total and urban population the municipality that stands out in the basin paranapanema 3 is cambé in paranapanema 4 is paranavaí and in the pirapó basin is maringá pointing to the fact that environmental problems arise or are accentuated from some municipalities which concentrate not only the population but also the industries and farms a reflection of increased job and development opportunities in the region there are differences not only between basins as well as within each basin in the paranapanema 3 miraselva has 768 of the urban population while cambé has 961 in the basin paranapanema 4 the degree of urbanization varies from 813 to 953 in the pirapó basin this variation is smaller ranging between 924 and 982 when comparing the average number of inhabitants per household with those found in the field research presented in table 4 the average is 28 people per household in paraná and in the region of study such average is 27 people per household however the differences are accentuated regarding the urban data we have the following information in table 4 as can be observed 639 families were interviewed of these 712 owned their own house and 283 rented their houses the analysis by basins reveals that the percentage of households with own house range a in the paranapanema 3 is 790 b in the paranapanema 4 is 638 and c in pirapó is 711 the families numbered 1725 inhabitants of whom 525 were in paranapanema 3 paranapanema 4 concentrated 433 people and 767 inhabitants were in pirapó in addition 56 of respondents are illiterate and the highest percentage is in paranapanema 3 further 265 had incomplete primary education and the highest percentage is in paranapanema 4 and 176 had completed elementary school ranging 226 in the paranapanema 4 the complete and incomplete secondary education corresponds to 339 and pirapó is the highest percentage the respondents that had finished the graduation correspond to 147 and the largest percentage is located in paranapanema 3 this latter result is surprising because in pirapó lies the city of maringá an educational hub as it concentrates 8 colleges and a state university which should be reflected in the results another aspect that stands out is that the largest number of people with complete or incomplete higher education in the basin is concentrated in maringa which shows the concentrating characteristic of the municipality the average number of persons per household is presented in table 5 in a comparison between ibge cidades with the field research the field research shows that both the paranapanema 3 as the pirapó follow values of the ibge to the average and urban sector and are quite different for the rural sector thus are significantly higher this situation may indicate a process of population retention or return to their rural areas which needs to be further explored in future population surveys in the case of paranapanema 4 data collected are presented quite different the average and the urban sector are below and to the rural sector presents similar which may indicate a process of expulsion migration which also deserves further investigation it was also verified by the data collected that the average population per household is higher in rural areas than in the urban sector in all of the municipalities surveyed in pirapó and paranapanema 4 in paranapanema 3 the exception is bela vista do paraíso these data are similar to the consensus that there is a greater number of children per inhabitant in the rural sector regarding poverty we chose to use the latest data of the number of families who register and receive the bolsa família 1 because can only be on the federal government program those who are poor or live in extreme poverty we alert that these data differ from those found in the 2010 census as a result it is presented the table 6 this table shows the total number of families and people of the municipalities surveyed the number of registered families which receive up to r 7000 and those who earned between r 7000 and r 14000 so as the number of beneficiaries the average payment and the number of people surveyed who receive the bolsa família or other government support in the field research with the exception of alto paraná in all municipalities we interviewed people who receive bolsa família according to the data of table 6 the number of poor families and individuals and extreme poverty is alarming furthermore the beneficiaries of bolsa família are concentrated in the urban sector because only in cambé and miraselva were registered beneficiaries in the rural sector according to the ministry of social development and fight against hunger in all municipalities of the basins there are percentages approaching 50 of households in the municipality as beneficiaries of the income transfer program of the federal 1 the bolsa família program is a program of direct income transfer conducted by brazils federal government that benefits families in poverty and extreme poverty across the country when analyzing the number of registered persons and beneficiaries in the table 6 it is not possible to identify a direct relationship ie not necessarily the larger the number of poor people more benefits apparently the number of registrations has greater weight but this needs to be researched more thoroughly because the information to identify if all who are in extreme poverty have been benefited by the program is not available another point that stands out is that some municipalities that have higher percentages of registered families with income up to r 7000 per capita in which although there is high rate of extreme poverty among registered families these municipalities are not always receiving higher amount of beneficiaries or benefits there are also coincident cases of major beneficiaries such as cambé alto paraná paranavaí but also maringa which has lower rate compared with the other the poverty rate in paranapanema 3 represents 62 of total households in the basin and by all indications public policies contribute very little to the generation of jobs and income with regard to access to welfare all households in which interviews were conducted have electricity in both the rural and the urban sector there is piped water supplies in all of the urban and rural households however the source of this resource is differentiated in the urban sector the majority of families uses the public water supply however the use of wells was verified as follows paranapanema 3 cambé1 family and miraselva6 families paranapanema 4 alto paraná1 family and terra rica1 family pirapó colorado2 families and maringá2 families in the rural sector all households have piped water drawn from wells except in paranapanema 3 the municipalities of cambé and miraselva in the basin of pirapó both arapongas and colorado beyond the well also use river water the situation of the interviewed families that do not have sewer is worrying as shown in table 7 as can be observed in the rural sector not all families are served by sewage treatment and as seen above all draw water from wells which present risks to both human health and for the environment including water resources it is noteworthy that all basins and municipalities are above average provided by ipardes which is to paranapanema 3 with 372 of families with treatment paranapanema 4 is 350 and in the basin of pirapó is 425 exceptions however are worrisome because there are municipalities with families with more than 40 nonattendance as terra rica and paranacity the situation is alarming in miraselva because all families interviewed claimed not to have sewage treatment q q q q q q q q r q q paranapanema 3 b the situation in the rural sector and the environment the conditions of possession of the house and educational level are presented in table 8 the table shows that from the 78 families interviewed most of them have their own property 7 were tenants and two were sharecroppers and one was settler in the pirapó river basin all families have their own property we found other conditions in all obs pp own property ar leaseholder pc sharecroppers as settler analf iliterate inc incomplete com complete f primary school m high school s higher education source field research municipalities of paranapanema 3 in the basin of paranapanema 4 only terra rica has recorded the presence of tenants and sharecroppers in alto paraná only one settler was interviewed the respondent families aggregate 215 people 79 of whom were in paranapanema 3 81 in the paranapanema 4 and in the pirapó 55 people out of this total 16 are illiterate and the highest percentage is in paranapanema 3 further 265 had incomplete primary education and the highest percentage is in paranapanema 4 we found 274 of the respondents with complete primary education while the highest percentage is in paranapanema 4 the complete and incomplete secondary education corresponds to 284 and and in the pirapó is the highest percentage the complete and incomplete higher education corresponds to 55 while the highest percentage is located in paranapanema 4 once again this last result is surprising because in the pirapó lies the city of maringá an educational hub another aspect that draws attention is that in maringa there is no presence of people with complete or incomplete higher education in the rural case we find more people with the completed elementary school and lower values for education levels of high school and higher education the practices of the rural sector are result and dependent on the history of the region characterized by the green revolution and the introduction of heavy machinery and equipment high technology and intensive livestock farming introduced in regions with highly vulnerable land as a result the practices found by the field research are presented in table 9 it is noteworthy that notill farming is associated to not soil tillage permanent coverage with organic material and crop rotation the integrated management in its turn though admitting the use of chemical and biological raw materials is also associated with crop rotation thus when analyzing the table 9 we can infer the following in the paranapanema 3 most families conducts notill farming using transgenic seeds and chemical fertilizers makes crop rotation and does not perform integrated management however some aspects draw attention all the respondents in cambé reported using chemical fertilizer which influenced the percentage of the basin transgenic seed is predominant in all the studied families the notill farming predominates in bela vista do paraíso and cambé in bela vista do paraíso and cambé there were slashandburn farming practices2 there is some coherence in practices because those families who perform notill farming usually perform crop rotation too and partly perform integrated management with the exception of cambé thus cambé seems to be the most problematic municipality because all respondents stated that they only perform chemical fertilization although most do not perform notill farming or crop rotation do not use organic fertilizer and dont perform integrated management in the basin paranapanema 4 predominates organic fertilization farmers do not use genetically modified seeds the technique of notill farming as well as crop rotation are made in a smaller proportion however they do not perform the integrated management paranavaí stands out for presenting 100 of notill farming 100 of organic fertilizers use and 100 of integrated management although only 50 claimed to perform crop rotation in the pirapó basin notill farming predominates as well as crop rotation organic fertilization and integrated management however both in colorado and in paranacity the percentage of those who perform notill farming and integrated management is greater than those who declare to make crop rotation furthermore in arapongas respondents use chemical and organic fertilization one of the toughest questions to be answered was regarding the use of transgenic seeds 3 whose highest incidence occurred in the paranapanema 3 and the lowest frequency in the pirapó regarding the pig farming whose wastes are highly contaminating we present the table 10 there is a greater presence of pigsties in the paranapanema 3 and pirapó with the exception of paranavaí maringá and arapongas whose facilities match or approximate of the number of families who perform pig farming it is clear that the families who declare to perform any kind of swine production is greater than those who claim to have pigsties because of these respondents in the three river basins sell and or create for their own consumption which can impact the environment although the nutrients present in the feces and urine of these animals have encouraged their use as organic fertilization this procedure also present hazards of environmental contamination resulting from its storage form distribution and use furthermore hormones 3 there is still much controversy surrounding the spread of genetically modified food the defenders argue that transgenic aggregate greater nutritional value and even eliminate some undesirable characteristics generate crops more resistant to the cold drought and pest attacks and diseases increasing productivity the opposites to introduce of transgenic in food argue that there is still much ignorance about the effects of genetic manipulation which may represent a serious risk to human health and to the environment meanwhile government agencies and consumer protection organizations advocate labeling of all foods that contain a genetically modified ingredient in its composition to facilitate the identification of such products and guarantee consumers the power to decide whether to consume them or not table 9 practices in the rural sector in percentage by selected municipalities in the river basins 2013 and antibiotics can be eliminated with the feces and urine of animals being incorporated into the soil municipalities of among other practices analyzed are those relating to the households and the production as shown in table 11 as seen in the table the river basin paranapanema 3 concentrates the most troubled municipalities because the majority does not separate waste does not perform the recovery of riparian vegetation and has the highest incidence of not having septic tank this frame contrasts with the other municipalities of the basins in which all respondents have septic tanks with the exception of colorado where only 50 have this structure the biggest problem in all municipalities is the nonrecovery of riparian vegetation in all basins and no separation of waste on this last issue is the identification of street cleaning by the public sector as shown in table 12 as seen in the table 12 the situations are different but present trends in the paranapanema 3 the vast majority claims to have weekly cleaning however in bela vista do paraíso and cambé cleaning is biweekly and monthly crossing the data of table 11 with table 12 only 1 respondent claims not to have public collect although most of the households didn´t separate the recyclable materials in the paranapanema 4 the majority declares that cleaning is biweekly and most of the respondents in terra rica have argued that cleaning occurs weekly the situation is most critical in pirapó because all respondents reported the lack of public cleaning with the exceptions of arapongas and colorado in all municipalities there is no collect of construction debris and rubble or debris from trees in these municipalities when comparing the tables 11 and12 we see a curious situation because while most claims separate waste also claims that there is no garbage collection by the public sector with the exception of one family in arapongas and another one in colorado this situation deserves further clarification these situations which were described point to the problems generated by waste of the establishments which may be impacting the environment including rivers another aspect that was investigated was the view of environmental problems and again the basins have different characteristics among the various problems studied treated the native vegetation in the pirapó river basin the area of native vegetation coverage increased in percentage in the period 20082011 in the same period the paranapanema 3 reduced its coverage area by 33 and paranapanema 4 declined sharply its area of native vegetation coverage according ipardes as a result of field research the view of the respondents with regard to rainfall the floods erosion pollution of rivers among others ie the outlined imbalances are presented in table 13 there was no record of flooding and water logging in rural households of respondents as well as water rationing with the exception of one family in paranacity and another one in terra rica we chose to present the data by frequency and percentage clarifying that there are environmental issues that were systematized in an aggregate form such as soil erosion and compaction and clearing of the banks of rivers and siltation of rivers in the table 13 thus the first observation to be made with respect to the data collected in rural households is the low percentage of responses including the maringás respondent that do not answered these questions although he had answered the others there are some explanations for this they were unable to have the dimension of the problem they do not want to answer they do not want to point out the problem by not having the notion of the consequences of their answer they do not know how to respond this is an aspect to be better researched although it is believed to be the alternative a that best explains this situation with respect to soil erosion and soil compaction in all municipalities surveyed there was the record of the respondents with the exception of arapongas deforestation and siltation of rivers is also registered with the exception of cambé improper disposal of urban and hospital waste is also noted with the exception of paranavaí and arapongas furthermore among those who answered the question occurred higher frequency on the polluted rivers however while respondents from the three basins pointing the problem often did not know or did not indicate the source as the pesticides as always environmental issues always create resistance in the responses regarding the use of rivers we present the table 14 according to the data presented in the table with the exception of maringa and paranavai in which respondents use the rivers for any activity it is observed that the vast majority of rural households do not use the rivers those who use do for recreation and fishing and irrigation located predominantly in paranapanema 3 and pirapó this low frequency in the use of rivers for recreation and or productive activity is interesting because in part may explain some distance from the developed practices and environmental impacts conclusions the region has no problems in terms of water quantity because the availability is always greater than the demand although access to this water in some municipalities demands investments in expansion the distribution system since there are no quantitative problems the issues listed assume qualitative nature the rivers and their tributaries receive originating from domestic industrial and rural discharges pollutant loads although there is increasing actions for their treatment particularly in pirapó in this basin there are high percentages of wastewater that in rural areas which do not receive any treatment in the urban sector the percentage of treatment tend to increase the socioeconomic conditions of the interviewed families in the selected municipalities are differentiated and the best condition is in the pirapó river basin due to its history marked by a hub city since the colonization and severe process of implementing the green revolution the conclusion is that there are a number of factors that reinforce or were reinforced by soil type and therefore interfere with the demand of water resources what can be concluded with data collected is that many environmental problems or are not perceived and or does not make the relationship between the practices and impacts particularly on water resources we can mention the issue of waste while only 11 households respondents stated that there are problems in the disposal of waste at the same time 31 families stated that they do not sort rubbish another example is that although 24 families indicate the problem of deforestation and silting of rivers only 9 families makes the recovery of riparian forests pollution of rivers was noted particularly in the river basin paranapanema 3 for two families while 10 families had no septic tank 20 of the 29 families have pig farming and only 11 have pigsties during the interviews there was much resistance to answer questions relating to the environment and its impacts municipalities

scarcity of water in the world virtually has two sources the quality and the quantity made available for populations in the area covered by this study the selected municipalities from the river basins 3 e 4 of the paranapanema river and from the basin of the pirapó river availability is always greater than the demand and the environmental problems are more often linked to the quality than to the quantity of water to check the socioeconomic aspects and the daily practices involving water resources and environmental problems we selected a representative sample of families from 10 studied municipalities the main conclusions point to the existence of key municipalities regarded as foci of pollution i e the municipalities do not contribute in equal measure to the pollution of rivers from their regions and some stand out in economic activities and inherited cultural practices however respondents did not always relate the environmental impacts with their routine and productive activities thus although the new legal environment imposes new practices there are still cultural heritages which require more incisive and continuous public interventions

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introduction almost all neonatal deaths in industrialised countries occur in neonatal intensive care units 1 2 with an important number originating from endoflife decisions made by clinicians and parents for whom these choices are often the most difficult of their life 3 4 nicu parents are at risk of adverse outcomes such as posttraumatic stress disorder and depression 3 5 6 despite lasting impacts the majority of bereaved parents eventually find some healing and many report posttraumatic growth 7 8 many interventions have been attempted to improve the wellbeing of families in the nicu such as involving veteran parents 9 in our definition resource parents are parents who previously experienced the hospitalisation of their child in nicu and use that strengths and limitations of this study ► this is the first study to our knowledge to investigate the views of both healthcare providers and bereaved parents on their engagement in different types of initiatives in paediatrics ► almost all stakeholders involved in the activities participated in the study ► one experienced resource parent was involved as coinvestigator in the design of the study the conception of tools data analysis as well as writing and dissemination activities ► this was originally an internal quality control and satisfaction clinical study that raised so much interest that the authors decided to publish the most transferable results ► limitations of this study include the representation of one site and one paediatric service only as well as the small number of parents the latter being partially compensated by the variety and duration of their experiences as resource parents open access unique perspective to improve care 10 11 12 because they are often considered part of a vulnerable population bereaved parents are often excluded from this type of collaboration for ethical and practical reasons mainly potential risks to their wellbeing 10 13 14 yet their perspectives and opinions are recognised as important and are increasingly sought 15 16 17 18 19 since 2011 we have teamed up with more than 30 resource parentssome of which are bereaved parentsas part of many different initiatives 10 12 20 we wished to expand our programme and recruit more bereaved parents but wanted to ensure that we would do so in a responsible fashion after almost a decade of experience we have done a rigorous in depth review of our programme the goals of this study were to describe the variety of activities in which bereaved resource parents participate describe the perspectives of bereaved parents and the clinicians who work with them and propose practical recommendations for those who wish to take part in such initiatives this research is part of a quality improvement clinical programme this broader project uses multiple and mixed methods approaches for evaluation measurement of impacts unmet needs analysis and satisfaction surveys the results are used for evidencebased orientation and decisions on support programmes for patients 21 22 the specific results presented in this article are strictly about the participation of bereaved resource parents and come from a study that was done in preparation of new activities to support the decision regarding whether or not to recruit and involve them in the development and animation of a new peertopeer workshop programme methods setting and participants the paf team was created in 2011 to recruit integrate and coordinate resource parents to optimise neonatal initiatives in saintejustine university health center a motherchild tertiary care universityaffiliated hospital the nicu has 70 beds and admits on average 1100 neonates a year with about 50 to 60 annual deaths resource parents were recruited among former parents either because they came forward to participate or were suggested by providers bereaved resource parents were recruited a minimum of 2 years after their childs death and were offered compensation to participate for complex initiatives they received specific detailed training and preparation for example when involved in peertopeer support they followed the same training as other volunteers and received additional support on the other hand for many simple initiatives such as giving their opinion on a parentparticipant consent form they did not require specific training more details on the recruitment of resource parents and their gradual integration and training are available in our previous publications 10 12 data collection qualitative field documentation all the field notes correspondence and reports pertaining to activities performed by bereaved resource parents since 2011 were reviewed and sorted by the principal investigator the initiatives were categorised by the analysts as either research clinical or teaching and they were classified further as taking place in hospital setting or not and as involving or not direct interactions with hospitalised families or providers for example a bereaved resource parent who has cotaught a palliative care course three times would be analysed as having participated in one teaching initiative and in a total of three activities taking place at the hospital and in interaction with providers only mixed questionnaires from january to april 2017 an online questionnaire was distributed to all resource parents bereaved or not who had been involved in neonatal initiatives requesting feedback on their experience who recruited and worked with them the questionnaire included closed questions on their preferences regarding past and future activities and open questions that invited them to describe in their own words their motivations their positive and negative experiences their opinion on compensation and their views on the impacts of their participation for the purpose of this study we limited our analysis to the answers of the bereaved resource parents a different online questionnaire was sent to the 17 providers who collaborated with bereaved resource parents they were asked closeended questions to categorise their experience with resource parents as well as openended question on their opinions regarding the positive and negative aspects of their collaborations and the impact of the parents participation in their activities data analysis we used descriptive statistics for quantitative data from our compilation on activities and participation and from quantitative items in the questionnaire qualitative data from the openended questions in the questionnaire were analysed using a descriptive and inductive content analysis with nvivo 1141 software package 23 24 25 26 a descriptive approach was used to develop and define emerging themes and subthemes by a team of four investigators all qualitative content was double coded in an independent fashion reliability and stability of the coding process was assessed systematically and discrepancies were resolved through discussion between investigators to on may 10 2024 by guest protected by copyright bmj open first published as 101136bmjopen2019034817 on 6 september 2020 downloaded from patient and public involvement statement the study was conducted with an experienced resource parent acting as coauthor she was involved in all aspects of the study and for its entire duration from design to tools development data analysis writing and dissemination plan ethical considerations this project was done in the context of an internal programme evaluation study the research ethics committee of the chu saintejustine research center believed it did not require an ethical review and expressed no objection to the publication of the study as it was done to inform the preparation of a quality improvement clinical study involving bereaved parents participants provided informed consent at the beginning of the online questionnaire once they had read the introduction which explained the study and informed them that the data created would be coded and that their identity would not be shared results at the time of the survey eight bereaved resource parents had been collaborating with providers for at least 2 years their demographic profile and details about their experience in the nicu are summarised in table 1 the providers included nine neonatologists two nurses two fellows and three consultant nurses description of activities the compilation of our field documentation shows that since 2011 bereaved resource parents were involved in a total of 465 activities categorised in 17 types of initiatives in three broader categories research education and clinical care or administration all bereaved resource parents collaborated to optimise clinical care and six were also involved in research and education they had various degree of participation from a minimum of one activity in one initiative to a maximum of 167 activities in 17 different types of initiatives over the period not all these partnership activities required them to be physically present in the hospital or to be in direct contact with parents or patients for example they could review information given to parents from home other activities were more complex and required contact with bereaved families for example matched buddies for new bereaved parents most research activities occurred outside of the hospital setting for example reviewing consent forms or research protocols educational activities often required coming to the hospital and being in contact with students and trainees for coteaching testimonials feedback and evaluation during medical simulation sessions classes or casebased learning although most of the activities were related to palliative care and bereavement four bereaved resource parents also participated in activities that were not associated with these topics such as being involved in a quality control committee to improve clinical care one father specifically stated that he did not want to be involved in projects pertaining to death as illustrated in this quote from the correspondence notes i want to improve the care babies and parents get give back focus on the positive life give what i can give but i dont want to talk about death and things related to that open access bereaved parents perspectives in the parents questionnaire most bereaved resource parents expressed that they wanted to becontinue being in contact with providers students and bereaved families only three parents wanted to participate in activities where they would be in direct contact with parents of a sick baby and two reported not wanting to be in contact with the clinical environment the correspondence notes include this representative quote taken from a fathers message i want to continue helping but i dont want to go in that unit again smell the hand wash hear the bells motivations experience and perceived impacts in the questionnaire parents were asked about the circumstances of their child or childrens death and their answers reflect both different and similar experiences four parents gave factual data only twin boy died from necrotising enterocolitis at 2 weeks three parents added more details and recounted the decision to withdraw lifesustaining interventions including this couple who show a lot of coherence when describing their experience in their own words her lungs were very sick and she was not breathing on her own the doctors suggested we remove the breathing tube because the damage was very important she had several complications during her stay her condition did not allow her to continue her battle so we ended it we noted that this couple shared the same story but had very contrasted preferences regarding the types of activities they were interested in when asked about their positive and negative experiences as well as their perceived impacts of their participation all parents had positive comments after identifying specific themes in the initial coding of the answers to these three questions it became obvious that they all related to two general overarching themes helping others and helping themselves the general themes overall parental responses illustrate that they believed their contribution and thus the help it brought originated from their desire to share the legacy of their childs life as well as their experience as parents although we aimed to keep the analysis at a very descriptive level a more comprehensive analysis revealed this notion of legacy as a central theme which we introduced in the title this also strongly resonated with the parents to whom we presented the preliminary results of this analysis through their engagement they wishedand often felt some kind of responsibility tokeep the memory of their child alive and to make sense of their journey by putting their experience and knowledge to good use terms used in the majority of their answers to openended questions include for example hope to give a voice to parents in my situation give meaning to the experience we went through doing this in the memory of my child giving back since we had the chance to meet wonderful people through our ordeal my child enabled this made it possible share with families who went through the same difficult situations give me some kind of control that i did not have during my childs hospitalisation and so on only one parent reported a negative experience a mother who was invited with others to give her opinion on the new unit to ensure it was safe for patients and optimal for familyintegrated care in this context she participated in a unit simulation playing the role of the mother at the bedside of a manikin baby although she was not involved in a mock simulation of a distressful intensive intervention there were more intense scenarios in the ward and the general ambience of the unit with the bells and staff brought back painful memories in the following days in the satisfaction questionnaire completed a few weeks after the activity this mother shared her thoughts on her negative experience i found it difficult during simulations it somehow made me relive parts of the experience of my babys death i really wanted to participate i would go so far as to say that i felt the need to however my reactions are a little difficult to predict even for me i do not know how much it will benefit me to immerse myself too deeply in my memories… one thing is certain i will continue helping as much as i can while making sure to preserve my mental health when it comes to simulations it should be noted that notes about another mother who participated in the same activity show a high level of risks during the simulation although she was informed about the scenarios and did not expect any problems this very experienced resource parent became very emotional remembering intense moments shared with her childrens father in nicu more than 10 years prior she talked about it after the activity and following some debriefing she decided to go on with the other planned lighter scenarios training support and feedback all bereaved resource parents reported in the questionnaire that they received training and preparation from the providers who invited them to participate four parents thought we could improve their experience by suggesting the following steps describe precisely the objectives and timeline of their involvement describe everybodys role before and if needed during the activity and identify one specific provider or researcher they could contact if necessary before during or after the activity most bereaved resource parents reported receiving support during their participation and open access appreciated it all wanted to receive feedback about their participation and followup regarding the projects they were involved in they want to know why involving a parent helped how they could improve and always be informed about the research results remuneration and compensation when asked about compensation and remuneration bereaved resource parents answered it depended on the nature of the activity and tasks for short and simple activities they did not want compensation nor remuneration for activities that required more time and effort three reported wanting to be compensated and remunerated and three reported compensation and remuneration should only occur if they had to travel for example to the hospital or a conference three parents answered that they would prefer to give back all or some of the money to the familypartnership programme three also expressed some discomfort with the question and this subject for example one mother wrote i participate for the cause not for the money and one father expressed uncertainty about the subject i never thought i would be paid well who wouldnt want to be i also know there is not much money in the research world… and it is a pleasure to help providers perspectives all clinicians and researchers reported that teaming up with bereaved resource parents had positive impacts the main themes invoked in their answers were mostly centred on the parental perspective and feedback which lead to a better understanding of the needs of families for example a neonatologist researcher gave concrete details about what parents can sometimes see and do better than providers and researchers they can optimise a research protocol consent forms they also see some simple solutions in the health system and how to improve the unit through simple solutions that are not ► we hope we have helped other families who mourn improving the system ► i think i can also provide not just a parents view but a nonmedical view to improve things isnt it bizarre that providers teach each other how to communicate with parents how to be sensitive with parents and parents are not involved in this they see their world through statistics and prognosis we see it also with our heart with love for example we do not want only to know that our child has a high percentage of death we want to know how this will change our life how we will be able to face this what this means in the practical sense for our family we can change the system a bit giving back ► i find it important to give because we had the chance to meet wonderful people through this ordeal ► improve services and give back to the hospital and the team general theme helping self making sense meaning making ► participating in these activities gives sense to all the experiences we had no matter how difficult it was i would even say that it fills and answers a need ► it helps me make sense of the nicu stay to also have something good about all this experience… apart from my kids i mean memorylegacy ► i want to do this in memory of my son ► this research project is a legacy from my childs life she enabled this she made it possible and she made life better for other families empowerment ► i like feeling useful ► collaborating in research projects that had to do with what my daughter had it is some kind of control that i did not have during the hospitalisation repairingreinvesting the relationship with providers ► she was great and gave me hope that not all physicians treated fragile babies the way my daughter was treated…i also actually participated because she told me i knew more about parents than she did that we could both make things better ► i love seeing the nurses and doctors again open access always obvious to the clinicians a nurse reflected on the depth of parents contributions and feedback they give us a better understanding of the needs of families how to develop meaningful relationships another neonatologist described how this type of collaboration can improve team work it is an enriching experience that brings a different and necessary point of view it also allows multidisciplinary discussions to be more focussed on the patients and families there is also more respect among members of the clinical team when parents are present none reported negative impacts on the involvement of bereaved resource parents but two reported challenges such as the limited availability of resource parents and the lack of tools and guidelines on these new forms of collaboration discussion parent and patient stakeholders are essential actors that can help us improve our practices in clinical care medical education and research 7 19 28 29 on the other hand bereaved parents are rarely recruited for these kinds of initiatives because they are considered a vulnerable population to our knowledge we are the first to report the practical aspects of integration of bereaved resource parents in many types of activities parents who experienced the death of their child in nicu are all unique some are young firsttime parents while others are already parents who had a baby hospitalised in the nicu before many parents experienced a multiple birth and the death of one twin or triplet not long after birth there is no other speciality in paediatrics where parents regularly experience the death of a child and the need to come back to the same intensive hospital unit to care for their other child 30 31 it is therefore crucial to take the time to talk to parents on recruiting to understand their unique story and how they feel about their involvement in the different types of activities some activities are simpler and more common than others such as those that do not involve coming to the hospital or meeting nicu parents as a general guide we designed a pyramid of complexity to categorise the activities according to their complexity and their potential risks for parents at the base of the pyramid are the simple lowrisk and more common activities most bereaved parents can easily do and should begin with not all of them will want to climb the pyramid and get involved in more complex initiatives indeed bereaved resource parents have different preferences regarding the type of activities they participate in and their degree of involvement 10 12 some only engaged in initiatives outside the hospital possibly for timedistance constraints or because they did not wish to come back to the hospital some may also wish to participate in activities that are not related to palliative care and focus on improvements instead of their loss for example four bereaved parents who lost their child because of complications of prematuritysuch as necrotising enterocolitis andor infectionparticipated in quality improvements projects aimed at preventing these complications open access these partnerships were described as positive by all bereaved resource parents and providers who teamed up with them parents reported they wanted to help others and improve care by participating they also gave meaning to their loss which probably contributed to their healing process 7 8 providers also reported these stakeholders enriched projects by bringing their complementary and unique perspective harm was reported by one participant who experienced unexpected flashbacks during a simulation with mock codes posttraumatic stress symptoms are common for parents who experienced the nicu 6 in our experience medical simulations where parents play the role of nicu parents are highrisk situations as shown in the pyramid of complexity where this type of activity is found at the top of the pyramid 12 as the integration of stakeholdersplaying their roleseems to be increasing in medical simulations our experience shows the existence of risks for patient or parent participants bereaved resource parents should be informed about these risks and made aware that they can interrupt their participation whenever they want to the parents willingness to participate should not be the only factor to take into consideration as it remains the providers or researchers responsibility to control carefully what more fragile parents should and should not be exposed to for example viewing a video of a mock code with the sound of the alarms may help them decide if this is an activity they want to do in all cases it is imperative to know the family story and remember that all parents are unique adding the perspective of clinicians to the parents point of views was helpful as it brought more depth to the results and anchored the recommendations we wish to share in both the parents and providers opinions we have developed several practice points that may be helpful for teams who wish to embark on such initiatives with bereaved stakeholders in paediatrics because of knowledge gaps in this field they should be regarded as practical suggestions that need to be evaluated and adapted to each specific project and they could be useful for comparative analysis between organisations and countries as well as for the development of more formal guidelines this study has several limitations it is limited to a single centre and did not include any outcome measures such as clinical outcomes we also have to keep in mind that only some bereaved parents will want to get involved in such initiatives for this reason this represents the perspectives of some bereaved parents those who engage in these activities although stakeholders participation in healthcare is increasingly recommended practical knowledge about their participation is rarely published bereaved parents are rarely recruited because they are considered a vulnerable population not all bereaved parents want to become resource parents but by knowing their story and understanding their perspectives it is possible to integrate them in our teams to improve clinical care teaching box 1 practical recommendations for teams who wish to incorporate bereaved parents in their research teaching or clinical activities coordination ► create a multidisciplinary team consisting of one or two bereaved resource parents at least one physician one nurse and at least one individual with an administrative role recruitment and orientation ► recruit and work with non bereaved stakeholders first integrating them in simple and then complex activities ► bereaved resource parents should generally be recruited at least 1 year after the death of their child ► ask bereaved resource parents about their motivations their goals and interests are they able to share their story ► make sure they know that for some tasks they do not have to come to the hospital andor meet neonatal intensive care unit parents ► recruit and work with parents of discordant twins or triplets when starting to work with bereaved resource parents ► it is preferable to gradually integrate bereaved parents making them start with simple tasks this will decrease the risks to them and other parents training and preparation ► give details about the project goals steps duration and what is expected from them in a practical fashion ► inform everyone involved in the projects about bereaved resource parents roles use the name of their deceased child they should be informed and sometimes reminded that bereaved resource parents are not members of the hospital staff nor actors ► make sure parents are prepared for their activity for example a bereaved parent who wishes to share his experience with a class of medical students could be asked to write about his experience then speak about it with his family and the teacher of the class to better prepare ► greet parents when they first come to the hospital visit the nicu with them the first time some parents may then decide they do not wish to engage in activities in the nicu or with nicu parents supervisionsupport ► make sure bereaved resource parents have a contact person they can easily reach if they need help or information ► monitor how the project is going ask them for feedback and adapt activities or tasks if needed feedback and followup ► offer support after the activity especially if it was intense ► share information with them about results and impacts of their implication ► share all publications and presentations they may have contributed to include them as coauthors in abstracts and articles if they satisfy authorship ► ask them about their views on the activity their satisfaction and their recommendations compensationremuneration ► always offer compensation ► adapt incentives to the context and requirements of each activity inform parents some resource parents want compensation and others not offer a way they can waive their compensation or give it back open access and research this type of collaboration is rich and gives bereaved parents an opportunity to do something positive for others and contributes to their healing process for most of them this is in a way their tribute to their childs life and legacy data availability statement data and additional information will be available upon team who made this study possible eliane charbonneau melissa savaria fanny labelle josée prince thuy mai luu and steve turmel our sincere gratitude goes to all the resource parents and patients who teamed up and continue to work with us they teach us how to improve neonatology make our care better and are a constant source of inspiration we thank keith barrington for his careful review and help for this article contributors cjb cocreated the concept and design of this work leaded the procedures for data acquisition and analysis made a substantial contribution to data interpretation and drafted the original article sd cocreated the concept and design of this work made a substantial contribution to data acquisition and analysis and drafted sections gm made a substantial contribution to the design of the work and to data acquisition and analysis and help select appropriate citations mr made a substantial contribution to the design of the work and to data acquisition and analysis aj cocreated the concept and design of this work made a substantial contribution to the design of the work and to data analysis and interpretation and drafted the original article all authors revised the article critically for important intellectual content approved the version to be published and have participated sufficiently to be accountable for all aspects of the work competing interests none declared patient consent for publication not required ethics approval this project was approved by the research ethics committee of the chu saintejustine research center as a quality improvement clinical study participants provided written informed consent at the beginning of the online questionnaire provenance and peer review not commissioned externally peer reviewed

to cite bourque cj dahan s mantha g et al my childs legacy a mixed methods study of bereaved parents and providers opinions about collaboration with nicu teams in quality improvement initiatives bmj open 202010e034817

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introduction the planets climate has constantly been changing over geological time with significant fluctuations of global average temperatures it is caused by releasing greenhouse gases primarily carbon dioxide into the atmosphere through human activities such as burning fossil fuels deforestation and agriculture these gases trap heat from the sun in the earths atmosphere causing the planet to warm at an unprecedented rate climate change involves not only rising temperatures but also extreme weather events rising sea levels shifting wildlife populations and habitats and a range of other impacts the geographical location land characteristics multiplicity of rivers and the monsoon climate render bangladesh highly vulnerable to natural hazards the coastal morphology of bangladesh influences the impact of natural hazards on the area climate change has a wide range of effects on the natural and human systems including sea level rise more extreme weather events such as heat waves droughts floods changes in precipitation patterns ocean acidification and harm to biodiversity these impacts can in turn have significant consequences on human health infrastructure food security and economic activity the impacts of climate change are not evenly distributed and that marginalized and vulnerable communities are often the most affected this study analyzes the impact of climate change on the fishing and the firming community of patharghata district and their local adaptation strategies patharghata is a coastal upazila in the bay of bengal located in the southwestern part of bangladesh patharghata and its surrounding areas are highly vulnerable to the impacts of climate change this study emphasizes on the role of power relations social inequality government policies and activities and ngos activities in determining who is most affected by climate change and who has the resources and ability to adapt this approach also stresses the need to consider the role of historical and cultural factors mainly religion in shaping the people perception of climate change and impacts of climate change methodology patharghata upazila is a rural area in the barguna district of bangladesh with a population of approximately 150000 people it is bounded by mathbaria and bamna upazilas on the north bay of bengal on the south barguna sadar and the bishkhali river on the east sarankhola doi 1048165sajssh20234304 upazila and the balaswar river in the west it has a reserved mangrove forest named haringhata between the bay of bengal and patharghata locality which works as a natural shield in any flood and cyclone that comes from the bay of bengal the study participants are the local inhabitants of that area the local people are mostly farmers and fishers many of them have migrated to different cities already but are excluded from the study some govt stakeholders and ngo workers were also interviewed for a detailed explanation due to time and resources limitation 40 participants have been selected for an indepth study the sample was selected by purposive random sampling from those living there and directly or indirectly connected to fishing and farming the study is conducted using a qualitative approach to provide an indepth analysis of the local adaptation strategies to climate change the data is collected by semistructured interview key informal interview focus group discussion and observation finally several specialists in t h e related field are interviewed in kiis method to gather supportive information about how the govt and ngos work to help people adapt to climate change the data has been analyzed using thematic analysis to identify the key themes and patterns that emerged from the data theoretical framework in this study the effect of climate change on fishing and the firming community and their local adaptation strategies are analyzed with paul robbinss concepts of political ecology paradigm paul robbins in his political ecology a critical introduction examines the ways in which power and politics influence the way people understand and respond to environmental problems and he focuses on how these factors shape the production and distribution of environmental knowledge he introduces the concept of environmentality that refers to the ways in which individuals and societies become environmentally aware conscious and responsible and how this awareness shapes their behavior and actions findings bangladesh is predominantly an agricultural country with twothirds of the population engaged doi 1048165sajssh20234304 in farming or agrobased industrial activity in the study area the main ways of livelihood are farming fishing and fishing business among the total population 3103 population is connected with farming and the same portion of people is also connected with fishing so the overall impact of climate change on agricultural production and fisheries in this study area would be widespread and devastating for the countrys economy every year a lot of people get bankrupt due to these natural disasters fishers get lose their fishing nets and boats fish farmers lose their fish due to rising water levels and farmers get to lose their crops for floods cyclones and heavy rainfall salinity intrusion causes a great loss to the farmers especially the land outside of the embankment is not arable because of salinity and in time of the flash flood the saline water gets into the arable land inside the embankment so it has an impact in the long run because it doesnt ruin the contemporary crops only it also spoils the fertility of that land for some coming years another problem of salinity is the scarcity of fresh irrigation water due to salinity intrusion the water of ponds and canals gets saline and if the salinity of arable lands comes to an end by the blessing of rain the water of ponds and canals doesnt get clean that early so it makes the scarcity of arable fresh irrigation water during the time of the rainy season the sky remains cloudy most of the time and frequent cyclones norwester has to be faced by the people the biggest problem is there is no weather forecasting signal for norwester so they have to rely upon their local knowledge and experience of knowing when the cyclone would hit lots of fishermen get lost and die in the rainy season while fishing in the sea basically they go into the deep sea to catch fish normally there is no available signal so they hardly get any weather forecast when they experience indicators of disaster according to their experience they start heading to the coastline after coming oneor twohours distance they get signals on mobile phones and are able to know the weather news if it seems like a very powerful cyclone they come back to the seashore or they keep fishing in the deep sea sometimes they cant predict the disaster in time or they dont get enough time to come back which costs both their lives and wealth local prediction system in the local area of patharghata people call all kinds of disasters related to water and wind like flood flash flood cyclone storm is boinna this word came from the bengali word bonna the local prediction system is a way of predicting coming disasters without hearing the weather forecast there we have found some indicators by which the local people predict the weather but these indicators vary from person to person depending on their knowledge and occupation the mostly used predictors are ▪ type of cloud ▪ color of cloud ▪ wind pace ▪ wind direction ▪ temperature ▪ billowing sea situation ▪ sound of waves ▪ water level ▪ getting more fishes ▪ activities of certain pests and insect especially older people can predict the weather currently they predict the weather by seeing the cloud and its color besides this they rely on wind pace and direction if the wind comes from the south or norwest side then they think there would be a disaster they also rely on the temperature if the temperature increases suddenly unlike other days they think of it as an indicator the prediction system of the sailor is kind of different they rely on the situation of the sea the sounds of waves the quantity of fish coming into their net etc when there is a probability of a cyclone the sea becomes turbulent and the sound of waves changes normally waves come from one direction but before cyclones and storms waves come from all directions the fisherman starts getting more fish fishes come up to the coastline from the deep sea some people say there is another indicator which is the reaction of a particular pest locally called gairra pok normally this kind of pest is the inhabitant of the jungle but before a major disaster it comes to the locality and bites people beliefs and rituals centered climate change according to clifford geertz beliefs work as a key component of cultural systems and by examining the beliefs and values that underlie cultural practices anthropologists could gain insight into the motivations and meanings behind human behavior belief systems play an important role in shaping the way people think feel and behave and they provide a framework for making sense of the world and navigating personal and collective experiences they can influence individuals decisions actions and interactions with others and they can shape the larger social political and cultural systems in which they are embedded the people of the fishing and firming community of patharghata district have different belief systems and practice some rituals depending on their belief system most of the old people of the patharghata district believe that there is no climate change rather this socalled climate change is a curse from the allah they believe that the modern people of the current world dont act according to gods will and they dont practice religious life which makes god dissatisfied so god gets angry and takes revenge on people through different calamities depending on this belief system they practice some rituals every year and also before and in the middle of disasters when the fishermen become ready to go for fishing they arrange milad a group praying system in this milad one or more religious leaders from the mosque are invited they recite some ritual verses and at last they pray to god they ask god not to give any problems to them in the sea so that they can come back genteelly and to give them more fish in this prayer system people participate actively with the worship leader and give consent to what the hujur asks to god besides this people also urge personally what is in their mind to god in that same prayer the important thing is only male persons of the community participate in this prayer during the drought they also arrange milad for rain they pray for the rain to god in the time of cyclones they recite different religious verses to make the wind less powerful sometimes they recite the ajan loudly to make the cyclone less powerful they believe that the cyclone is something related to the devil some say that the devil comes from the doi 1048165sajssh20234304 sea and destroys everything in the form of wind so they believe if they recite the religious verses the devil would go away some people also believe that lightning is the weapon of god which he uses to destroy satan there also work some belief mechanisms in staying at home rather than not going to cyclone shelters as the muslims belief system nothing happens without gods permission so if god wants to save them none can do any harm and another belief is if they leave the house empty satan will enter the house so to destroy satan god would also destroy their houses so they prefer to stay at home for these reasons response to natural calamities the fishing and farming community of patharghata district takes different kinds of precautions to mitigate the losses of disasters their responses are categorized into two types long term responses and quick responses long term responses to do this they follow a number of local strategies to save their houses from the cyclones they stretch their house with strong rope or metal wire it keeps the house on the basement small cyclones can be protected by this in the time of flood and flash floods their houses go under water so to keep their basement higher than the water level they build their houses on high this strategy is mostly followed by the people who live outside of the embankment because flood is a regular event at the outside of this embankment even if it doesnt need to hit a flood it could happen by a normal tide in the time of spring tide besides this people use polythene to cover their basements to save them from the tide because the tidewater and rainy water both make the soil of the basement melt and finally it gets washed by the water people who are financially in a better position build their houses on the brick paving basement so they dont have to take these measures there is one more strategy for those who are in between these two groups financially they infix some pillars in the ground and fix their wooden house with them so that the wind cannot move house they plant a lot of wood plant around their houses especially at the south side so that they can protect the houses from the wind coming from the sea these trees saved a lot of life in major floods and cyclones doi 1048165sajssh20234304 the water outside of the embankment is saline water and after major floods the water inside also becomes saline so in terms of using water they have to rely on rainy water pumps or filters but the pump and psf are in long distance so they ultimately use rainy water they harvest rainy water and preserve it in plastic drums pots and other available things when the rainy water finishes they use pond water by dipping alum in it quick responses in the study area peoples responses to disasters are diverse all of them dont follow the same strategies taking responses starts with the prediction and weather forecast for medium to severe cyclones and floods different ngos especially the red crescent and govt agents try to make people aware rapidly of taking proper steps and if the disaster seems severe they try to take people to the govt cyclone shelter before the disaster starts at first people bring every necessary thing inside their house some store dry food for the coming disaster some inform that they store dry food in their basement by digging it so that the flood cant sweep away the food if the water rises to that level if they recognize the water level is rising they bring their domestic animals into their house too most of them dont go to the cyclone shelter before the disaster starts without experiencing its effectiveness only they start to go to cyclone shelter when it seems lifetaking to them most of the time it becomes too late to go to the cyclone shelter because its almost three kilometers from the community so when they fail to go to a cyclone shelter or dont want to go there they take shelter in a big house in their neighborhood which seems safe to them going to a cyclone shelter has a different mechanism related to economic and social class in this area people who belong to a higher social class and financially develop dont go to cyclone shelters for some reason first of all they dont want to leave their wealth behind normally they have lots of things like cash gold clothing furniture and other valuable things so its impossible to go to a cyclone shelter with all these stuffs on the other hand they dont want to leave this least they could be robbed so better they stay at their home with all these belongings another factor doi 1048165sajssh20234304 is this kind of people dont want to stay with marginal people in cyclone shelters theyre not used to this kind of marginal living and there are some prestige issues in the contrary poor people dont have this problem they dont have that much wealth so its easy to carry their belongings with them moreover they dont have an issue with living among the commons they also take shelter in their neighbors house in case they dont have the opportunity to go to cyclone shelter or simply they dont want to go their neighbors provide a place to sleep and food to eat for that certain time recovery process at the first phase immediately after the disaster they wait for govt and ngos response to the disaster they provide them food water and other mustneeded things they also got helped by rich neighborhoods and political personalities but their main struggle began after that because these kinds of support come as onetime support to save their lives but after that they have to build their houses again and manage their way of livelihood to maintain a regular life for this they take loan from the ngos and collect wood around them the source of wood they can make house is the haringhata forest but this forest is reserved by the govt and the forest officers dont let them collect wood from there but people said that those who are politically empowered or able to give some bribe could collect wood from the forest though its illegal sometimes the fishing boats and nets are floated away by the flood so they lose their work both as an owner of that fishing boat or just as a laborer of that boat besides this fishing activities remain closed because of rough weather at that time the people who worked as fishing men in others boats start searching for alternative work such as day labor but most of the time they change their style and type of fishing as the boat and net are gone they start fishing another type of fish where there is no need for a boat or that kind of net after every powerful cyclone some of the families loss everything they are living depending on and migrate to another place for a fresh start role of gob and ngos according to the ministry of disaster management and relief program administration to address chronic poverty and vulnerability the government of doi 1048165sajssh20234304 bangladesh is implementing a large number of social safety net programs these programs address poverty and vulnerability from a broad perspective through education health nutrition employment disaster response programs etc vulnerable groups particularly the elderly women children and disabled persons are given priority in the delivery of safety net support programs provide benefits in the form of food cash transfers or a combination of the two and are administered through government agencies and elected local governments ngos of bangladesh also play an important role in the adaptation and mitigation of climate change hazards most of the ngo activities in the coastal districts of bangladesh aim to contribute to poverty alleviation and community development but they tend to limit their activities to some specialized areas for example some mainly address womens issues others are involved in the financial credit program and others in social mobilization activities however it seems pretty good that the gob and ngos have been implementing many programs for marginal and floodaffected people but there have some critical issues regarding their way of implementation and the transparency of their activities which are focused on later in this chapter peoples perception and experience of gob services have shown that the selection process is heavily politicized and prone to corruption members of union parishads often suggest names of people who support and vote for them and demand bribes from poor people to get a vgd or vgf card this results in a biased selection process where relatives and political supporters of the chairman have a higher chance of receiving government support there is also evidence of misappropriation of relief with responsible people of union parishads taking a portion of the aid plenty of implementation of this kind of ssn program in this way is not working as per the gob target of removing poverty through sustainable development people who are really in a vulnerable situation arent got helped that much by these programs sometimes they have to pay a bribe to get this free relief which creates wounds on the die of vulnerable people food for work is a renowned govt safety net program where people can work in maintain and develop rural infrastructure including renovation programs during postdisaster periods and the normal yearly cycle usually involving manual labor for food grain but in recent times the local people have limited scope to get involved in these projects under the coastal embankment improvement project1 the embankment of the patharghata coastline was reconstructed by a chinese company named chwe china in this project they use a lot of machineries which reduces the scope of manual labor and the rest manual work is done by the labor imported from the northern part of the country for their low wage rate like this one the local people are losing their scope to work on development projects in exchange for food grain or payment in the case of ngos the local peoples experience has shown that while the ngos do provide immediate relief after major disasters and have some social activities the main issue lies with the microcredit system the highinterest rate of 1220 on credit makes the already vulnerable people more vulnerable as they have to pay a fixed portion of money with interest every week in a repayment mortgage system there have also been reports of harsh behavior by ngo workers if the loan takers fail to pay back the installment and they may even seize their belongings the respondents have also stated that the ngos focus on creating a community of loan takers and executing projects among them with little help provided to people outside of that community this is likely an attempt to create interest in the microcredit system and expand its market discussion the impact of climate change on the agricultural and fishing communities in the study area of patharghata in bangladesh is severe in this study the whole adaptation strategies are analyzed in the government of bangladesh and nongovernment organizations are implementing a large number of social safety net programs to address chronic poverty and vulnerability in the country the programs aim to provide benefits in the form of food cash transfers or a combination of the two to vulnerable groups particularly the elderly women children and disabled persons however the implementation of these programs has been marred by several critical issues such as corruption and political influence in the selection of eligible candidates from a cultural and political ecology perspective the impact of climate change on agriculture and fisheries in bangladesh is deeply intertwined with cultural and political factors the cultural practices and knowledge of local communities play a crucial role in their ability to adapt and mitigate the impact of climate change similarly the political and economic systems in place also shape the ability of communities to respond to climate change for example the local prediction system used by the people in the patharghata district to predict coming disasters is a cultural practice that has developed over generations it is based on local knowledge and experience of the weather patterns in the region this knowledge is invaluable in helping communities prepare for and respond to disasters but it is not always recognized or valued by external factors such as government agencies or international organizations doi 1048165sajssh20234304 furthermore the ability of local communities to adapt and mitigate the impact of climate change is deeply tied to political and economic factors the lack of access to resources and infrastructure such as pumps or filters for saline water can exacerbate the impact of climate change on agriculture and fisheries in addition the economic systems that prioritize profit over the wellbeing of local communities can exacerbate the impact of climate change on vulnerable populations conclusion climate change is a complex and multidimensional issue that affects different regions and communities in different ways in the case of patharghata the impact of climate change on agriculture and fisheries is not only determined by environmental factors but also shaped by cultural and political factors however the impact of climate change on agriculture and fisheries in patharghata is also shaped by political and economic factors like access to resources land tenure and market opportunities these factors often perpetuate vulnerability and exacerbate the impact of climate change on local communities addressing these structural issues requires a holistic approach that involves working with local communities government agencies and other stakeholders to build resilience and promote sustainable development acknowledging and valuing local knowledge and cultural practices as well as addressing the political and economic systems that perpetuate vulnerability can help build resilience and mitigate the impact of climate change on local communities

the geographical location land characteristics the multiplicity of rivers and the monsoon climate render bangladesh highly vulnerable to natural hazards kabir hossen 2019 the general economic situation and cultural way of life of bangladeshs coastal residents have been impacted by climate change the risk of natural disasters such as cyclones storms floods and salinity are the greatest in bangladeshs coastal regions chowdhury 2007 in order to comprehend how the natural disasters brought on by climate change affect peoples lives the study has taken into account the fishing and farming communities of patharghata a coastal upazila of the barguna region both qualitative and quantitative mixmethod approaches were used to reach the studys objectives the firsthand data is collected using case study kii fgd semistructured interview structured interview and observation this study has found some local strategies followed by the people to predict and adapt the natural calamities the govt of bangladesh and different ngos and ingos are working to mitigate the climate change challenges the study demonstrates that these activities of government and ngos have some weaknesses so they sometimes fail to make positive changes at the root level the local people have their own social political and religious belief system and worldview which significantly impacts disaster response to achieve the sustainable development goal of this area it needs to apply bottomup policy formulation synchronizing their local social context

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background despite the global focus on physical activity and health and a booming fitness industry there is a lack of people with disabilities in fitness centres 12 this is a considerable problem as about 15 of the worlds population is estimated to live with some form of disability 3 and this group has a higher prevalence of illness and lifestyle diseases related to inactivity 4 as well as reduced healthrelated benefits and decreased physical function psychological and social health can be impacted due to inactivity as this can enhance feelings of isolation stigmatisation and lack of social relations 5 fitness centre training appeals to a broad audience of people with disabilities because of relatively easy access flexible hours and no requirements of specific physical skill or physical fitness level 6 however they are perceived as a particularly exclusive space by people with disabilities 7 using a critical disability studies lens and contesting conditions of ableism and disablism in society 8 numerous complex and interrelated phenomena illuminate why people with disabilities are excluded and underrepresented in fitness centres 9 ableism frames images policy and discourses as if all people are nondisabled 10 excluding any representation of a different physical form 11 ableism values selfsufficiency autonomy and independence leading to the exclusion of many people who do not align to a culturally created imagery of ableness 8 ableism is proposed as a regulator within sport and exercise settings including fitness centres as they are often spaces that value one particular muscular fully functional aesthetic physical form leading to the exclusion of people with disabilities in these spaces 12 this leaves people with disabilities feeling intimidated unwelcome excluded and oppressed in this setting 13 disablism which refers to the social oppression people with disabilities experience from the physical environment and relationships with others 1415 can be another barrier to inclusion in fitness centres it arises in two different forms indirect and direct psychoemotional disablism both are keenly apparent within fitness centres indirect psychoemotional disablism relates to structural barriers that exclude people with disabilities from physical spaces and project messages that this community is not welcome and does not belong 16 fitness centres send these exclusory messages through lack of physical access inaccessible changing facilities unsuitable equipment and lack of space to transfer to equipment 2 17 18 19 direct psychoemotional disablism refers to the negative interactions people with disabilities have with others such as negative or invalidating responses being stared at having jokes made about them or dealing with callous remarks or comments which can result in feelings of anger otherness lacking selfworth and feeling excluded 20 both ableism and disablism are substantial barriers in fitness centres in uk 1321 over the last 2 decades research has focused on identification of barriers and facilitators of disability inclusion in fitness settings this dearth of research shows that over this time little has changed as the same structural attitudinal and relational issues such as no access ableist and disablist interaction are continually reported 127131722 as a result scholars have called for academics to move beyond these types of exploratory studies as at this point findings are merely repetitive and descriptive as the inclusion of people with disabilities has changed so little adopting this approach 23 instead scholars must take the leap to develop strategies to address inclusion issues rather than merely describe them 22 in this research we move towards developing a strategy to improve inclusion in fitness centres and a country that has yet to be contextualised within the greater global disability inclusion movement disability research is strongly represented in welfare states in scandinavia however denmark is lacking behind with fewer research environments than both norway and sweden 24 thus denmark requires particular attention for improving and promoting disability inclusion in denmark as in other countries people with disabilities have lower levels of education and fewer people are in the labour market 2526 this makes leisure time and associated activities an opportune place for people with and without disabilities to meet 27 as such fitness centres may be a meaningful place where disability prejudice can be brokendown unfortunately leisure time sporting activities in denmark are segregated into traditional sport and parasport which does not align to inclusion as such creating an inclusive fitness centre could be the first step to meet on equal terms and reduce prejudice as there is little work on disability inclusion in denmark there is an exciting opportunity not only to promote inclusive sport and exercise but also to create a space that is truly inclusive by addressing dis ableist attitudes to bring disability inclusion to attention the campaign fitness for allfitness for people with physical disabilities was initiated establishing three new pilot inclusive fitness centres across denmark this programme sought to rethink nonprofit clubbased fitness centres and create an equitable space for both people with and without disabilities as peers an inclusive exercise space may not only provide a space for people with disabilities to access equitable fitness opportunities but also educate nondisabled people about disability and reduce ableist prejudice further results from this research could begin the important dialogue of informing the design of a fully inclusive fitness centre that will satisfy both groups and inform other fitness centres in inclusive practice thus the purpose of this paper was to improve inclusion in fitness centres by first identifying the ableist attitudes we will inevitably encounter from nondisabled members this underscored our aim of identifying ableist barriers to inclusion wherein we could anticipate the potential barriers attitudes and perceptions that may hinder inclusion and address these before members with and without disabilities use this exercise space the aim was shaped by two key questions what is the ideal fitness space from the perception of nondisabled fitness users and how might their disableist attitudes negate inclusion in three future pilot inclusive fitness centres across denmark methods we adopted a qualitative cross sectional design whereby we sought to develop an indepth detailed data set of danish nondisabled persons perceptions of an inclusive fitness centre the steering committee of the project fitness for all fitness for people with physical disabilities selected the three specific centres for intervention after receiving applications from potential nonprofit and clubbased fitness centres to be a part of the campaign the chosen nonprofit clubbased fitness centres are located in three different municipalities in denmark one was located in a village awaiting an extension and establishment of a fitness centre another was a small fitness centre awaiting a new and bigger building within an already established sports club in a minor city and l the third was a newly established fitness club awaiting a building were under reconstruction located in a suburb to a big city a focus group interview was conducted at each location with a group of nondisabled adults the interview project was scientifically approved by the university of southern denmark research and innovation organisation on behalf of the danish data protection agency journal number 2015570008 the coreq checklist for qualitative interviews and focus groups 28 was used for reporting sampling and participants employeesvolunteer workers at the three selected fitness centres acted as gatekeepers to participants and were partly responsible for recruiting the participants for the focus groups they were asked to compile a list of potential fitness users of the coming inclusive fitness centres with information about gender age and fitness centreexperience the list was used to secure maximal variation of the participants included in the study this enabled a wide and indepth range of experiences and demographics to be collected that would allow for comprehensive accounts of nondisabled persons perceptions of inclusive fitness centres the inclusion criteria for the participants defined as potential members were adults who were users of the already established fitness centres andor future users of the upcoming three inclusive fitness centres participants were excluded if they had physical or cognitive disabilities or a severe visual or hearing disability or were unable to speak and understand danish participants previous experience and contact with people with physical disabilities were not taken into consideration in the sampling process participants were recruited through a notice in the local fitness centre or through relevant groups on a social media platform supplemented with snowball recruitment the gatekeepers used snowball recruitment in their network to compile the list of potential users further we used snowball recruitment when contacting the persons on the list if we lacked participants of a specific gender or age especially when recruiting the younger participants in total 18 people participated in the interviews the three focus groups comprised fivetoseven people each and participants were contacted by telephone by the first author to orally confirm their interest in participation double check the eligibility and to secure maximal variation within groups in terms of gender age and fitness centre experience fitness centreexperience was selfreported and the information was validated through the information from the interviews further the participants could ask questions and obtain more detailed information about the practical arrangements of the interview and the relation to the fitness for allcampaign written data collection data were collected using a focus group at each fitness centre focus groups were used as they facilitate the creation of new knowledge in areas that are underresearched bring forth spontaneous dynamic dialogue between people participants have a higher degree of control over discussions and people may be more willing to discuss things in depth as part of a group rather than one on one 29 a semistructured guide with openended questions was developed for this study to ensure both width and depth in the focus groups to increase internal validity two pilot interviews were conducted with 2 and 3 participants respectively all were current fitness centre users in a similar nonprofit clubbased fitness centre setting but at another location only small adjustments were performed by adding extra cues to the interview guide and rephrasing a few questions to facilitate participant specific examples of their experiences the guide was developed with three overall themes the physical surroundings and accessibility activities and usability and atmosphere in the fitness centre broad openended questions were composed for each of the themes focusing on the participants experiences and perceptions both positive and negative examples of questions included what are your experiences with fitness centres what is good accessibility to you where do you experience problems how do you use the fitness centre how do we make a successful inclusive fitness centre for both people with and without physical disabilities pros and cons all three themes were discussed in each interview but the order differed and as the topics are linked together the conversation naturally jumped from one topic to another further all subthemes were mentioned within each of the interviews the focus groups were conducted by the first author acting as moderator at the three different locations which was a meeting room either in relation to the coming fitness centres in the local sports club or in the city hall the interviewer has a background as a trained physiotherapist msc in health science and has personal experience with both nonprofit sport clubs and commercial fitness centres therefore she was familiar with the jargon in the interviews but had no associations with the 3 fitness centres and no local knowledge the interviews were conducted as a part of a phdstudy only the first author and the participants were present during the interviews the duration of each interview was 98112 min which led to a total of 5 h and 10 min data material from all three focus group interviews the interviews were conducted in march and april 2018 field notes was made after each interview to get capture new reflections after each interview data analysis the audio recorded interviews were transcribed in a slightly modified verbatim mode as proposed by malterud 30 that is focusing on the content of the interviews and carefully making smaller adjustments from spoken language to written language eg by erasing repetitions and empty words and adding punctuation the first author performed the transcriptions with a descriptive and explorative analytical approach the data analysis was thematic with a crosscase approach and data driven the analysis was performed in 4 steps following the systematic text condensation method by malterud 31 the four steps were total impressionfrom chaos to themes identifying and sorting meaning unitsfrom themes to codes condensationfrom code to meaning and synthesizingfrom condensation to descriptions and concepts four authors were involved in the analysis focusing on the participant´s perceptions on fitness centres the nonprofit club format and the new inclusive concept the coding was performed in nvivo 12 software an initial coding process was performed by two researchers to ensure structure and content of the analysis the first author performed the coding and the overall analysis was performed with many different meaning units on a detailed level from the beginning and subsequently grouped together in code groups and subgroups two authors discussed the code groups and subgroups and discussed the analytical categories results according to the analytical categories the results was divided into two subsections first an account of how the participants describe their ideal fitness centre and secondly perceptions of sharing an inclusive fitness centre with participants with physical disabilities interview no 1 2 and 3 refer to the three different locations for interview the ideal fitness centre room for comfort and diversity basic expectations for a nonprofit clubbased fitness centre the participants had certain expectations for the upcoming inclusive danish nonprofit fitness centre locations with easy access both by car bicycle or public transportation were highlighted as very important if the location was considered inconvenient they would not use it further participants requested a bright welcoming and wellmaintained clean environment to make the exercise setting attractive and comfortable susanne explained i think it is important with light how it falls and the illumination colours on the walls and not in the linoleumsmunicipalityway and no smelly rubber … so when you go in you think this is a nice place to be i like to be here because something is calling for me the participants stressed the discomfort of the stench of sweat and rubber and the intimidation of posters and other media on the walls with proteincommercials and extreme examples of fit men and women in general the participants drew upon past experiences of a traditional commercial fitness centre marielouise talked about one of her experiences when i started exercising i thought the easiest thing was to start in my local commercial fitness centre right across the street i opened the door and there it was the smell of sweat the loud music going on duff duff duff and the very high stresslevel so i thought this is not what im looking for … later when i became a more experienced fitness centre user i went back to try again but i am not going in there its a nogo regarding the use of space the participants underlined the importance of the right training equipment and room for socialising they also asked for flexibility they expected long opening hours with key tags so members could come and go as preferred the price level for membership and how to get value for money was very much debated among the participants they sought a balance of price levels between very cheap prices in volunteer sports clubs and more expensive in commercial fitness clubs participants generally agreed price levels of 100150 dkk per month would be reasonable maya stressed if it costs 35 euro a month and if i only come once every two weeks i must admit that i am too stingy for it user exercise knowledge and skills are required the participants all agreed that basic user competences were required to exercise in a fitness centre and stated that if someone did not know what to do and why then they would never enter or be a regular user therefore in order to feel comfortable the participants strongly recommend that an introduction session would be very important eg oneonone sessions or small group introductions david talked about his practical limbo i would sit on such a machine and say uh yes what next ive been practicing handball and soccer and like to run for a ball but jumping on a treadmill… ive never tried it so i think i would fall off participants also found it very important to have someone to consult with regarding how to use the fitness equipment composeadjust exercise programs and someone to lead classes and maintain the equipment they were aware of potentially heavy employee costs so participants suggested volunteer instructors should be available on specific hours or collaboration with educated professionals or students within sports science or physiotherapy marielouise told how it was done in her nonprofit fitness centre the volunteer staff have to be users of the fitness centre because they are often there anyway and know exactly how all the machines work so they can assist others … being a volunteer is only something you do if you gain something out of it it could be free instructor courses fitness clothes paid membership and a dinner once a year with all the other volunteer staff rules and behaviour in fitness the participants were very engaged regarding how to run codes of practice ie etiquette and rules regarding how users should behave and what is allowed in the centre several examples were brought up about annoying behaviour such as inconvenient use of equipment and mobile phones inappropriate attire failing to cleanup or forgetting to wipe off the fitness machines after use charlotte illustrated i get so annoyed if people sit on a machine or bench without exercising then i say so do you use it as an armchair or what in general participants wanted to confront other members in a polite suitable or humoristic way but found it hard to do as an ordinary member and believed it was easier to do for the volunteer staff with more authority issues regarding other users who puffed and groaned aloud sweated smelled or became noisy when using the equipment was considered harder to regulate birger gave an example of an uncomfortable situation some time ago a woman used to come and work out in the fitness centre and not many liked her because she smelled the other users knew when she used to come and exercise and they simply stayed away or came an hour later the atmosphere fitting in with social relations the participants kept returning to talk about atmosphere or the right spirit in the fitness centre as a key aspect when deciding if they would actually use the fitness centre or not they stated the importance of felling that they fit in sylvester explicated many times when you come into such a fitness centre you feel so overlooked because you have such a feeling that it is a crowded bunch and the users come in such super smart clothes and everything so it must be a place that is nice to come and where you feel at home the feeling of belonging and fitting in was perceived to be possible if there were greetings when seeing others sharing the space with peers in terms of similar age appearance and preferences for specific training types in particular participants discussed intimidation of not being able to live up to super fit body norms with big muscles or skinny appearance which made them feel uncomfortable out of place and not welcome contrary to many commercial fitness centres they wanted a place without bodyshaming with room for normal overweight persons tommy summed up this new fitness centre should be for everybody fitness for allit has to address the local people so as you say there should not be any bodyshaming it should be a place for mr and mrs denmark or mrs name of the town social relations were also very important for participants they noted enjoyment in meeting people they knew but also making new acquaintances often new relations began with small talk progressed to a cup of coffee and later developed into friendships in general participants found other users friendly and helpful tommy gave examples after all most people are kind and sweet if you ask sorry can you please tell me how to do this or if they can see that it is completely hopeless what you are doing then most people can also come and say shouldnt i just show you how to do this or shouldnt i just lend you a hand generally participants expressed the need for good social relations for longterm commitment to exercise being part of a team who exercised regularly had fun and met in the cafeteria afterwards were noted as very important although some preferred to exercise on their own the majority preferred training in smaller groups of 25 persons matched by age fitness type and fitness level the participants underlined the importance of social relations and being part of a club based on experiences from other sports clubs they had been members of earlier in life josefine gave an example if it is a club then there should also be a common room where you can sit down and drink sodas and meet people and have the opportunity to talk otherwise its not a club ideal inclusive fitness centres reflections on sharing a fitness space with people with disabilities the degree of disability all participants responded very positively towards establishing new inclusive fitness centres for both fitness users with and without disabilities several participants made clear that people with disabilities were more than welcome to join however there were also inherent ableist perceptions and statements made such as others may choose a different fitness centre because of the presence of people with disabilities and the further inclusion of people with disabilities should not happen at the expense of those people without disabilities who were already using the fitness centre specifically the participants were focused on the severity of a members disability ie whether that person required a carer could exercise independently or something in between ib was straightforward but also showed some already inherently ableist perceptions of members with a disability you could be crude and say that when we say disability we do not really mean the multidisabled who need help with everything right it is the ones whoyou can sayin many cases are selfsufficient possibly supported by a carer adaption of settings the participants quickly address the requirements for physically inclusive adjustments such as lifts extra space for wheelchairs and zones with special fitness machines suitable for both people with and without disabilities they also discussed the need for extra cleaning when dirty wheelchairs enter a centre where only indoor shoes are allowed several of the participants stated the importance of securing the feeling of a volunteer fitness centre with no resemblance to hospitals rehabilitation centres or other medicalised buildings charlotte reflected on the sense of belonging i may be naive but i think we can easily make a disabilityfriendly centre where people can get around and where things are placed so that it fits when sitting in a wheelchair but still so that we others can be there without feeling were in a hospital room social codex for inclusive centres participants discussed separated or integrated training classes but struggled on how to put this into practice tommy summed up i think it is harder to adjust so they can participate in our classes than for us to participate in disabled classes because of the big difference we run do pushups and squats etc it would be hard to remove all these things i think it would be easier to adjust classes especially for them and then we could also participate there another issue was when people with disabilities should use the fitness centre some of the participants assumed that people with disabilities would use the fitness centre in daytime and therefore not take up the more desirable times after normal working hours from 4 to 8 pm a sense of community was important for the participants and they said that they wanted people with disabilities to be part of that as well they valued diversity and that everyone should feel welcome regardless of age background or social class but at the same time participants thought it much easier to be tolerant and inclusive towards people with physical disabilities in contrast to people with cognitive issues or mental disabilities making it difficult to follow the codex for normal interpersonal behaviour birger explained i dont know if it is wrong to call it for a social disabilityhandicap but if you do not have boundaries like most other people you could bother other users in the fitness centre that would be a problem being part of a voluntarybased community it is important to help each other and create a culture where all people take care of the place and clear up after oneself participants valued this kind of atmosphere where members helped each other during exercise this also involved helping people with disabilities but only to a certain extent as participants did not want to be obligated to help or be delayed in their own exercises maya reflected i dont mind sharing the fitness centre with disabled people but on the other hand i would be annoyed if i went to exercise and ended up behind a wheelchair user who takes forever to transfer between the fitness machines it is not nice to say i know but i would be annoyed interaction with users with disabilities finally several participants stated that they had some fear of interacting with people with disabilities because they were afraid to do something wrong or be misinterpreted they wanted everybody to feel comfortable but felt insecure regarding how to behave so that they did not unintentionally offend josefine elaborated either you have reluctance to deal with people with disabilities or you want to help but they dont need your help and react with disappointment if you ask it is problematic should you ask or shouldnt you do you look at them or should you not when you yourself are nondisabled and they are disabled you need to take these problems into account so everybody feels comfortable and you dont get snapped at and refuse to engage or talk to this disabled person again participants believed that no one should be offended disappointed insulted or snapped at so that people with disabilities had the experience of dignity and pride in general the participants were very engaged in how to do things right be respectful and treat people with disabilities as everyone else ib summed up it sounds like a cliché but you have to respect them as they are i cant explain it in any other way some participants felt that they lacked social competences on how to do interact in practice because of their limited relations with people with disabilities in daily life henning shared his thoughts on how to handle specific situations i would just say you just give me a sign if you feel in need of help then you have not directly asked and they do not have to say no then they know that if they have a need for help they can get it the above section highlights that participants may have good intentions regarding sharing a space with members with disabilities but it is apparent through many comments that there are inherent ableist perceptions and biases held by nondisabled members these perceptions shed a light on the various disabling encounters that must be addressed during the conception of an inclusive fitness centre to avoid the pitfalls of early research discussion participants expressed opinions about the right settings for nonprofit clubbased fitness centres with room for comfort inclusion and diversity and how the ideal inclusive fitness centres should be to include people with disabilities but ableist perceptions were apparent throughout in this section by means of four discussion points we discuss how these expectations and suggestions may be operationalised with reference to existing knowledge on inclusive fitness centres and potential pitfalls regarding ableism and how this must be considered when designing and inclusive fitness space nonprofit fitness centres compared with commercial fitness centres participants had certain expectations and ideas about the ideal fitness centre based on their experiences with commercial fitness centres and nonprofit fitness centres in general and in line with existing knowledge participants stated several important issues when choosing a fitness centre such as locations with easy access 32 33 34 clean and wellmaintained settings with a variety of uptodate equipment 3536 and a centre not too crowded 37 noisy or smelly 38 when participants evaluated the settings it all came down to how the space affected them how it made them feel these findings underline that people have different preferences 3940 and this can explain the booming fitness industry whereby the centres become more and more niche orientated our findings further highlight the importance of creating a welcoming and comfortable space the participants preferred lowcost memberships as previously reported 3541 and quickly calculated the price per expected visit when arguing expense on the other hand they also preferred equipment with high standards found in commercial centres so this is a tradeoff to be aware off room for socialising was much in demand in nonprofit fitness clubs in contrast with commercial centres where places to meet before and after almost are nonexistent good social relations and a sense of community were highlighted in several studies 42 43 44 but for the current participants it differed because they prioritised social relations beyond training studies of regular fitness centre users in commercial centres also stressed friendship both inside and outside the fitness centre 45 we found however that room for socialising and focus on social relations may attract a specific kind of user to the nonprofit fitness centres instead of commercial fitness centres motivating atmosphere the atmosphere in a fitness centre was very important for the participants and they kept returning to this topic stressing an atmosphere and welcome and invite motivated their use in that sense a good atmosphere is prioritised over functionality which is notable as a good atmosphere has not been widely described as motivating in previous studies focusing on nondisabled people generally studies concluded motivation related to improving body appearance and performance reducing health issues or improving mental wellbeing 39 46 47 48 49 50 in only three studies the atmosphere was associated with feelings of being comfortable valued and welcomed 344251 to further create a motivating atmosphere participants highlighted the importance of fitting in and belonging regardless of age bodily appearance clothes or type of training preferences which could be facilitated through verbal and nonverbal interactions with members and staff indeed staff members play key role in creating a good atmosphere 5253 which may be the reason why participants requested rules for behaviour and staff to enforce them to avoid stigma and enhance pleasant experiences for everybody regarding ensuring welcome and invitation participants were concerned about newcomers lack of knowledge and confidence entering a fitness centre for beginners fitness equipment can be complicated so guidance is needed on both what to do and how to do it right these issues have not been well established previously but is described in relation to older adults 4350 lack of skill and knowledge may be considered a barrier that needs further consideration if all new members with limited or no experience should be included in fitness centres as it is not only related to age staff and other fitness centre members can play a key role helping and introducing newcomers to the space trainings and equipment to ensure a welcoming inviting atmosphere interactions with people with disabilitieslack of experience participants believed they were welcoming of people with disabilities in fitness centres and expressed a more positive attitude compared to other countries for example only three quarters of participants in a survey from the uk were open to taking part in sport or active recreation with people with disabilities 54 the current participants were overtly openminded but also foresaw many potential barriers for inclusion on a more interactive level especially when including persons with intellectual disabilities due to a lack of social codex which is supported by previous studies 5556 this is further supported in our specific work in denmark as early analysis of focus groups from persons with disabilities points to similar findings for example in a quote from one of the interviews maria described problems when interactions between persons with and without disabilities go wrong many things regarding people with disabilities are kind of shushed down and you should not ask as a nondisabled person but it results in nondisabled people not knowing they are not mean they just dont know better they dont know how to do or how not to do in situations you are not familiar with and then it gets awkward and you might say things that are taken in differently than they were meant i think it goes both ways this example is provided for context and an indepth focus on people with physical disabilities is forthcoming while the participants in this study in general had a positive attitude they expressed a distinct absence of interactions with people with disabilities they simply lacked experiences from their daily life with this group of people this might be due to the national sport organisation where leisure time sports activities are split in traditional sport and parasport which does not favour inclusion if attitudes however predict behaviour then inclusive fitness centres have a good starting point supported by a global movement with more positive attitudes to people with disabilities 57 intergroup contact theory 58 describes how direct contact between groups work in changing attitudes and reducing prejudice this theory has been used in disability inclusive efforts previously including within schools 59 university 60 and the workplace 61 and may have considerable impact within a fitness centre however this is the case only assuming that positive attitudes towards people with disabilities is not just a consequence of politically correctness but reflecting their actual attitude yet while participants perceived they had positive attitudes to people with physical disabilities in general they struggled with defining and exemplifying the group of people with physical disabilities they found it difficult not to stigmatise when talking about the others and us normals unfortunately this common way to portray people with disabilities as other and not an integral part of the normal world may be a barrier for social inclusion 57 the nondisabled participants tried to omit these expressions but they lack concepts and terminology to express themselves otherwise highlighting unconscious ableist attitudes ableism what is normal the participants welcomed inclusive fitness centres but did not pay much attention to how fitness centres could be inclusive except for mentioning the obvious the need for accessible environment and adaptive fitness equipment but this is only one element of inclusion and will primarily be solved by the fitness centre and not by the participants themselves the participants were not aware of their own implicit bias and role in exclusion regarding different ableist aspects of prejudice and ignorance which can be a vital barrier for inclusion as it can lead to direct psychoemotional disablism for example within the context of this study participants expressed the importance of helping others to create a positive atmosphere but stated that persons with a disability requiring regular assistance may become annoying further participants discussed the importance of supporting people with disabilities but were concerned about time resources and staff being taken away at the expense of nondisabled users these ableist examples may negate an inclusive effort and result in persons with disabilities experiencing direct psychoemotional disablism the issue about direct psychoemotional disablism is further supported by preliminary analysis from our focus groups with participants with disabilities about their perspectives for inclusive fitness centres one quotation from caroline underlined her experiences of ableism from nondisabled persons maybe it is also the fear of actually living up to some of the prejudices about persons with disabilities you feel that nondisabled people are looking at you and if you ask for help you feel the look even stronger in the literature direct psychoemotional disablism is both related to other fitness centre users staff members and management 1362 this narrow perspective is what anderson et al describe as an ableistenvironment being exclusive towards people with disabilities 63 the nondisabled participants in this study are not surprisingly viewing inclusive fitness centres through the lens of their perspective and they mention several situations where they imagine irritation with people with disabilities chouinard would characterise this as ableism of ideas practices institutions and social relations that presume ablebodiedness and by doing so construct persons with disabilities as marginalized oppressed and largely invisible others 64 this is stigma that should be avoided but might be difficult to counter unless the perspective of both fitness users with and without disabilities are represented and included when establishing and running the new inclusive fitness centres in that way normal is not defined by the nondisabled group of people with an ableist perspective but as the variety of both people with and without disabilities using the fitness centres limitations and future directions to improve naturalistic generalisability we strove for maximal variation within the group of adult nondisabled potential participants in the upcoming inclusive fitness centres which we successfully achieved in terms of gender age and fitness centre experience the participants were geographically recruited in 3 different parts of denmark and are anticipated to be representative for all of denmark however they are not representative for commercial fitness centre users which is arguably a space with heightened ableism that excludes persons with disabilities 13 this is a market that continues to see growth thus if ableism is not challenged in this space as well exclusion of people with disabilities may become even more of an accepted norm research focusing on inclusive efforts to resist ableism and disablism in other fitness spaces such as commercial centres are essential in order to stop the continued acceptance and normality of ableist practices in the fitness domain this article focused on the perspective of the nondisabled fitness users of the coming inclusive fitness centres but of course the perspective from fitness users with physical disabilities were very important as well their perspective will be presented in an upcoming publication based on three comparable focus group interviews studies show that the perspective of fitness users with disabilities is underrepresented in the scientific literature 65 however barriers for people with disabilities is reported when wanting to participate in gymbased exercising eg lack of accessibility lack of social support oppressive attitudes within gyms 765 and further instructorsstaff have a key role in promoting inclusiveness or the opposite 6667 in fitness centres less has been written about the overt and unconscious ableism that must also be addressed to craft inclusive fitness spaces while we did focus on ableism as a lens in our work more much be done to explore the foundations influences and strategies to dismantle ableism not only in the fitness domain but wider society a further limitation of the study is that the fitness for all initiative may only be applicable in denmark and similar cultures as disability is so socially culturally and politically influenced we encourage other countries to address the ableism attitudes and sociocultural influences that shape attitudes and discrimination of people with disabilities within their own specific cultures and share ideas for interventions to create more inclusive fitness spaces in this way we can create a global inclusive movement such that there is better understandings and support of disability culture and potential contributions and collaborations that may be made across countries conclusion this is one of the first papers to explore the perceptions of inclusive fitness centres within denmark thereby adding essential knowledge to the literature this papers aim was shaped by two key questions to identify the ideal fitness space from the perception of nondisabled users and to explore their disableist attitudes related to the future inclusive fitness centres first of all participants pinpointed the importance of a place with a good atmospherea place that made them feel welcome and gave them a feeling of belonging the participants mirrored themselves in relation to other users and aspects like body ideals gender age exercise preferences and furthermore social relations were found important when they consider whether they fit in or not therefore it is important that fitness centres not only focus on location and advanced fitness equipment but also how to create the right atmosphere participants welcomed people with disabilities and wanted them to feel included in the fitness community but they predicted challenges for the future inclusive fitness centres and expressed unconscious prejudices this underlines that accessibility is not the only barrier for inclusion since social skills ableism ignorance and preconceptions can be important barriers too inclusive fitness centres must address this so the definition of normal is not only defined by the nondisabled group with an unconscious ableist perspective this could be adjusted eg by having staff members who are good role models to uphold policies and rules by having both fitness users with and without disabilities joining the fitness centre and even have fitness users with disabilities as a part of the staff to make a greater impact we need however to research the perceptions of people with disabilities regarding inclusive fitness centres and this will be presented in a forthcoming publication abbreviations ifc the inclusive fitness coalition ifi the inclusive fitness initiative stc systematic text condensation additional file 1 authors contributions bjk and jt conceived the project hn bjk and jt designed the study hn conducted the interviews hn lfs evr and jt analysed the data hn evr and jt drafted the full manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background representation of people with disabilities in fitness centres is lacking despite initiatives to promote inclusion mainly in the uk and usa success creating these inclusive spaces is mixed and few were crafted taking into account attitudes and biases of nondisabled comembers inclusive fitness centres have not gained much attention in denmark and the campaign fitness for all fitness for people with physical disabilities was initiated the aim of this study was shaped by two key questions 1 what is the ideal fitness space from the perception of nondisabled fitness users and 2 how might their disableist attitudes negate inclusion in three future pilot inclusive fitness centres across denmark method three focus groups involving 57 total n 18 adult nondisabled participants were conducted aged ranged between 19 and 75 years both men and women were involved with fitness centre experiences ranging from 0 to 20 years interviews were transcribed and analysed using malteruds fourstep method of systematic text condensation results of most importance was a pleasant atmosphere which should make them feel welcome and comfortable good social relations within the space were also highly valued participants welcomed people with physical disabilities but predicted many challenges with an inclusive fitness centre and expressed unconscious ableist attitudesthe current study adds essential knowledge regarding how nondisabled people perceive the ideal inclusive fitness centre a welcoming and inviting atmosphere is essential whereas social skills ableism ignorance and preconceptions are important barriers that may hinder inclusion of participants with disabilities in inclusive fitness centres

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introduction the quest for more integrated care has become a prominent policy theme in highincome country health care systems over the past decade it is considered as a means to provide more patientfocused coordinated care and a more efficient health care system in contexts where people living longer with longterm multiple conditions have emerged as among the main cost drivers in lowand middleincome countries perennial debates about how vertical health programmes impede coordinated health service delivery have led to divergent views on the processes and benefits of better integration of services a vertical programme tends to provide the solution of a given health problem by means of singlepurpose machinery by contrast a horizontal approach favours more holistic ways of dealing with health problems by investing in strengthening existing health services over the long term over time interest in more horizontally integrated care has grown spurred by the aspiration to provide better continuity of care for patients affected by conditions that are increasingly seen as chronic and often occurring in combination such as hiv and tuberculosis or tb and diabetes an additional more recent push in lmics has been a global commitment to ensure that countries and external funders alike optimize constrained resources in all countries the rationale for more integrated care shares the common goals of improving quality and continuity while reducing costs often through an enhanced role for primary and communitybased care over specialized and hospitalbased models despite such similar rationales two very distinct and separate strands of research on integration of care have developed in hics and lmics this paper starts to map the similarities and differences between these bodies of knowledge and the contexts in which they were generated in order to come to a richer understanding of each and in so doing explore whether lessons for policy and practice can be learned across these diverse settings integration form approaches and scope across countries highincome countries integrated care takes many different forms and remains challenging to define a review published in 2009 found no fewer than 175 definitions and concepts of integration although they had many elements in common one definition potentially useful across many settings is integration as a tailormade combination of structures processes and techniques to fit the needs of the people and populations across the continuum of care it focuses on the patient not only as a beneficiary but also as an integrator of hisher own services it spells out the need to deliver the right care at the right time or in the vocabulary of the recent english national voices definition the capacity to address needs in response to a set of i statements setting out what users want from their care however this definition may mean that integrated care becomes entirely personor contextspecific as it responds to patients needs through highly tailored services and clinical pathways this raises challenges for both defining and evaluating integrated care models in any sort of generalizable way there are several ways to make more specific the definition of service integration in hics the first is to define the population of interest for instance integrated care can target a whole population a defined population across a range of diseases or a group affected by one or multiple conditions the second is to assess how strongly elements of service delivery are coordinated aligned or integrated this can relate to staff information systems governance and policies culture and leadership and financial management among conceptual frameworks that have been used in hics to describe and evaluate integrated care the one defined by valentijn et al has proved valuable in distinguishing the different ingredients of integration listed above that are needed at different levels in the health care system it sets out clearly the multifaceted and complex challenges of bringing about care integration lowand lowermiddleincome countries the debate between proponents of vertical and horizontal approaches to health care delivery in lmics can be traced back to 1960s when the merits of interventions focused on specific highpriority services vs a more holistic approaches to primary health care were first contrasted this culminated in the 1978 almaata declaration on comprehensive primary health care which became the defining objective for horizontal integrated service delivery for a generation beset by the challenges of implementing this holistic agenda in resourceconstrained settings however the proponents of vertical service delivery responded by promoting the concept of selective primary health care as a more feasible and therefore potentially more effective approach to improving care especially in the shorter term as experiences were documented thinking became more nuanced and took on a systems lens using the language of continuity between levels of care rather than an assumption that the primary health care level alone could provide a comprehensive integrated package of care following these debates who was defining integrated service delivery as the management and delivery of health services so that clients receive a continuum of preventive and curative services according to their needs over time and across different levels of the health system in a systematic review of integration in lmics from 2006 briggs and garner identified three types of integration in the first the integrator is generally a communicable disease programme often funded by external agencies the second provides an integrated service to replace previously separate services and facilities testing and treatment within family planning services rather than at separate infectious disease clinics or providing family planning services at a maternal and child health centre rather than at a separate family planning clinic the third covers the development of packages which integrate services for a specific population programme that aims to provide enhanced childcare services vs routine child health care these models of integration in lowincome settings generally focus on health care and seldom attempt to integrate with nonhealth services most exceptions to this are in the fields of hiv and genderbased violence in which wider sociostructural drivers are more frequently recognized and interventions have included a range of supports to empower women adolescent reproductive health programmes have also recognized the need to partner with ministries of education and youth and sports to provide more holistic care beyond the health sector to address poor adolescent reproductive health outcomes such projects have encompassed clinicbased care alongside schoolbased debate and teaching on sexual and reproductive health womens rights and the role of health services some have sought to engage young people especially boys in taking greater responsibility for their actions including in relationships and families scope of integration across income settings in general compared with hic integration approaches those in lmics have been narrower in scope and arguably less ambitious integration in lmics has tended to focus on integrating specific clusters of health services for specific populations at the service delivery levelfrequently in response to external donor priorities and accountability requirements the focus in hics is often on managing multiple morbidities across a wider patient subpopulation or includes attempts to coordinate a wider range of services including those outside the health care system table 1 compares the target populations expectations of integration and examples of care between income settings as shown in table 1 the focus of integrated care varies depending on context as noted earlier the target populations are different and the expectations of integration in lmics are particularly about improving funding and efficiency in order to improve access to and uptake of services while in hics the emphasis is more on improving quality and patient experience and reducing dependence on perceived more costly hospital and residential care this reflects the different starting points of systems at the two different income settings in terms of prior investment current capacity and population needs thus the models of care also have a different emphasis in lmics they are targeted at investing further in and redesigning priority services while in hics the care models are aimed at changing the way the system works as opposed to how individual services interact although the scope of integrated models of care vary across settings the burden of diseases and health conditions that used to be thought of as western is increasing rapidly in lmics creating a double burden of noncommunicable diseases alongside traditional communicable infectious diseases in addition a rapidly growing challenge for lmic health care systems are patients with multiple morbidity while services have typically been organized around a specific infectious disease does the impact and process of integration differ across settings impact of integration there is scant evidence on the outcomes of integrated care in lmics in a review published in 2006 briggs and garner found only five published studies of adequate quality they concluded that there was some evidence of an increase in service utilization and better health outcomes associated with a range of integration initiatives however the review noted that no conclusions could be drawn on the cost aspects of integration it also highlighted that the studies only focused on the supply side and did not give consideration to the demand side with little account taken in these interventions of patients views and experiences similarly a review conducted by the global fund showed that the provison of integrated services increased uptake and coverage of several health interventions and had positive effects on some but not all health outcomes in particular there were positive effects when screening programmes were provided with routine services since these led to subsequent increases in the uptake of treatment for underserved populations however the provision of a wider platform of health services such as immunization and hiv services showed mixed results in terms of service uptake the global fund review also found some evidence of efficiency gains in the case where an increase in uptake of integrated community case management services led to a reduction in unit costs of treatment this would generally involve investing in activities to create demand for integrated services in the intended population to ensure and sustain high utilization of those integrated services in highincome countries integrated models of care have been promoted as a means to build a more effective and efficient healthcare system that is more patientcentred and thereby better meets the needs of the populations served there is some evidence that integrated care produces better patient experience however compared with usual care schemes it seldom seems to lead to improved health outcomes evidence of cost effectiveness is generally scarce and contradictory for example although some reduction in delayed hospital discharge has been identified no integrated care scheme seems to have demonstrated a sustained reduction in hospital use such as emergency admissions it has been argued that this might be due to schemes often focusing on too small proportion of the patient population who are very costly per patient but who are small in number as a result even if the care of such people were transformed this would not improve efficiency systemwide in this respect such a narrow targeted approach has much in common with the specific programmebased integration of care more commonly found in lmics process of integration if evidence on outcomes and costs of integrated care is mixed or missing there is plenty of evidence on the processes of integration in particular the perceived barriers and facilitators to implementation of integration the nature of these seems to be remarkably similar and consistent across settings as shown in table 3 although there are differences in emphasis in hics enabling strategies focus on integration of governance structures and finances as well as a strong focus on better patient experience this also means that challenges faced by hics in realizing integrated care can be significant in lmics as tackling systemic issues necessitates strong political support and large investments in lmics the core enabling strategies are dominated by improving leadership and motivation of staff at different levels of the system to enable structural deficits to be overcome few systemic reforms to support further integration have been implemented in lowincome countries beyond pilot schemes with the exception of health extension workers in ethiopia overall the challenges between settings are rather similar albeit to different degrees with fragmentation and competition between services for resources exacerbated by specialized programmes and workforces common to both sets of countries integration across different agencies and sectors seems particularly difficult notably in lmics where funding comes from many different sources rather than being the subdivisions of a single or small number of largely public sources discussion can useful lessons be learned across income settings we have seen that integrated care has taken somewhat different forms and approaches in highvs lowmiddleincome health care systems in lmics the focus has been more on developing specific clusters of services communicable disease programmes or services for specific patient groups while integration in hics has been more about better management of a broader group of people with multiple morbidities andor with complex health needs together with a focus on altering the wider system components that support coordination see table 2 these approaches have been driven by different emphases in terms of goals and expectations of paramount concern for lmics has been to use integration to improve the uptake of priority services with a view to gradually achieving universal health care coverage while concomitantly increasing efficiency in hics the focus has been more on changing patterns of use with a view to decreasing the overall cost to the system it has also involved a stronger focus on individual patient experience and an emphasis on improving quality of care however in both highand lowincome settings the implementation of these initiatives tend to uncover unmet need thereby pushing costs upwards even if some savings can be made elsewhere overall there remains a tension between the objectives of improving patient experience and cost reduction these appear to conflict at least in the short term table 2 conceptual framework of integrated care adapted from valentijn et al the resulting models of care reflect the different ways in which this tension is played out integrated models of care in lmics tend to be more narrowly focused on health services at the point of delivery while hics tend to invest in systemic enablers such as governance financing planning and information systems while also developing crosssectoral collaborative models of frontline work such as multidisciplinary team working joint contracting pooled funding and coproduction with patients a big question for researchers and practitioners is whether there are lessons that can be learned from hic integration initiatives that might enable greater continuity of patientcentred care in lmics beyond the specific packages currently targeted for integration in particular do hics have anything to offer in terms of their experience with care planning and service delivery the lack of patient focus in integrated care schemes in lmics contrasts with the strong emphasis on improving experience and higher patient engagement in the development of more integrated care pathways in hics this includes new ways of measuring users experiences of care it seems likely that lmics could benefit from giving the patient perspective greater weight when seeking to increase uptake and equity of service delivery although there would be challenges because the understanding of and demand for integrated better or even simply different services is often limited in lmics the recent world health assemblys call for strengthening integrated peoplecentred health services provides further impetus to this suggestion a more critical question is perhaps whether or not it is feasible for resource constrained health systems both in lowand highincome settings to move from a narrow focus on particular target services populations and diseases towards systems that seek to integrate functions more widely at every level currently this is proving particularly challenging as so many health care programmes in lmics remain vertically funded and managed as a result the supporting systems such as information finance contracting and training also tend to be separate often spurred by external funding agencies with the burden of disease becoming more complex and comorbidities increasing rapidly lmics need to focus more on integrating systems as well as services the experience of hics could be very valuable in this regard in turn it is possible that hics can also learn from lmic experiences in particular of improving communication and coordination between sectors and agencies even when formal bridging structures do not exist for example as mayhew et al illustrate in this supplement front line staff in lmics with motivation and support are able to take the initiative to make connections without having to wait erens et al leggat and leatt mangiaterra maruthappu et al van der klauw et al curry and ham ham et al watt et al kings fund and hung et al for wider system change another area of learning for hics which tend to have an extremely specialized health care workforce is to explore how lmics have been able to extend specialized health care workers skills to provide more holistic services through interprofessional education and collaborative practice including in some cases by formally taskshifting finally populationwide prevention and health promotion interventions are often directly integrated with treatment programmes in lmics when contrasted with separate prevention health promotion and individual treatment programmes that predominate in hics conclusions this commentary has made clearer how integrated care models differ across hics and lmics in scope models of care and expectations there is still insufficient convincing evidence that integration has a significant impact on improving health outcomes or cost effectiveness in any setting this is partly due to the very wide range and heterogeneity of integrated schemes their complexity and the difficulties of rigorously evaluating these schemes however there are potential lessons from one type of setting to another that are worth exploring further this commentary seeks to spark wider debate about what lessons couldand should be drawn between income settings while being cognisant ofbut not constrained bythe contextual differences through pooling and discussing insights across settings we can maximize our understanding of how and why health systems and their staff are better able to provide holistic patientcentred care ultimately leading to better health outcomes this is consistent with the recent who strategy to promote peoplecentred integrated care however introducing and scaling up integrated care will need to be undertaken carefully through piloting and evaluation of potentially promising integrated care schemes especially in highly resourceconstrained settings evidence of the benefits of various forms of integrated care remains insufficient to support rapid scaleup among key research questions that need to be addressed by countries and international organizations alike are how patientcentred are integrated care schemes what is their costeffectiveness over the medium term and what are their effects on the wider local health system these are challenging but important questions if the global community wants to continue supporting more integration of care this will need commitment both politically and financially finally it will be critical for researchers from currently very separate parts of health services and systems research to start a dialogue on how to share methods and substantive knowledge to evaluate integrated care comparatively in a wider range of settings and thus provide better evidence to policymakers conflict of interest statement none declared

over the past decade discussion of integrated care has become more widespread and prominent in both highand lowincome health care systems lmics the trend reflects the mismatch between an increasing burden of chronic disease and local health care systems which are still largely focused on hospitalbased treatment of individual clinical episodes and also the longstanding proliferation of vertical donorfunded diseasespecific programmes in lmics which have disrupted horizontal or integrated care integration is a challenging concept to define in part because of its multiple dimensions and varied scope from integrated clinical care for individual patients to broader systems integrationor linkageinvolving a wide range of interconnected services eg social services and health care in this commentary we compare integrated care in highand lowerincome countries although contexts may differ significantly between these settings there are many common features of how integration has been understood and common challenges in its implementation we discuss the different approaches to scope of and impacts of integration including barriers and facilitators to the processes of implementation with the burden of disease becoming more alike across settings we consider what gains there could be from comparative learning between these settings which have constituted two separate strands of research until now

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introduction public opinion is a thematic replication of social truth in a particular age it is a summary of the attitudes of the group beliefs emotions and expectations public opinion revolves around the presence development and transformation of an intermediate social event in a particular social space the openness of the internet and virtual aspects of communication propel it to a new height with the increase in technology and the fast spread of information technology it the number of people creating speeches on the internet has greatly increased for instance cyber abuse happens very often the effect of online public opinion on culture is growing and managing it is becoming increasingly challenging the internet eras pressing concern is how to execute actual organization and authority of the public opinion network public opinion examination by precisely understanding the evolution of its dissemination and decreasing its harmful effects as a result a big number of academics have employed advanced approaches such as machine learning big data and artificial intelligence ai among these methods big data has received important attention recently particularly in terms of guiding network public opinion big data is the general term of information that can be aggregated and analyzed using research tools such as the internet in the framework of big data the social contradictions are complicated different values collide with each other and the spread of information is accelerating it makes the information on the network complex and the attention of the traffic high in addition the undercurrent behind the internet serves as a window to show the dynamics of social group thoughts it is estimated that a considerable part of the workforce will use the mechanism of group emotional mutual assistance dissemination and social network coupling to disseminate and aggregate ideas and value orientation it can be said that the degree of attention paid to the information flow of the network can indirectly affect the normal functioning of the economy and society in recent years there has been a high degree of attention among students on hot topics as the main element of the incident students generally lack social experience and media literacy they can easily be misled by inflammatory information in severe cases they can lead to serious conflicts within academia and increase the handling of public opinion incidents in colleges and universities robert heath pointed out that avoiding a crisis or quelling a crisis in its early stages is the greatest opportunity cost the analysis of the big data network public opinion is now a hot topic for the present organizations because of the exponential growth of the internet the number of global internet consumers is rising quickly many outstanding online social networks exist including some successful social sites of networking and microblogging with huge microblogging messages being produced daily how to knock these enormous quantities of data examination and propagation to attain sustainable track complex information and public opinion patterns top trending decisions has now become an essential approach and challenge the conventional way of analyzing public opinion founded on data statistics is not appropriate conventional public opinion tracking techniques relied on highpriced workstations in the face of enormous amounts of data it is frequently demonstrated as great cost poor expandability single point interaction failure and so on when combined with the traditional database it is difficult to batch process millions of data records we demonstrate how to implement public opinion hot issue finding and monitoring for this developing an effective online early warning public opinion tool can serve as a fundamental safeguard for data mining reporting analysis research judgment and evaluation the management of online public opinion in colleges as well as in universities will help accurately control the complex network in the public opinion environment the growth of a college online publicopinion timely warning system is critical each college student can comprehend the heart of the problem and create a reasoned decision by directing college students online thought and public opinion however in the contemporary perspective of big data vast network information poses fresh problems to the college online public opinion earlywarning tool in terms of the scale of data processing and fast public opinion feedback to solve the problems of establishing a collegiate online public opinion early warning scheme in the context of big data it is essential to formulate clear indications of early warning quality judgment and quantitative early warning creating an early warning system utilizes rating pointers the opinion information is gathered by the association technique which is based online as well as offline sources the efficient screen prior to data analysis is opinion information after screening the data are analyzed using the online public opinion analysis component lastly the paper summarizes the rationale composition as well as trend analysis founded on indicators of early warning uncertain factors are minimized in order to ensure positive and healthy online public opinion as a result this article constructs a scientific and efficient mechanism for networked public opinion organizations founded on big data technology and proposes that colleges and universities optimize a strategy for networked public opinion management other contributions of this research paper are listed follows 1 investigate the characteristics of colleges and universities network public opinion in the age of big data 2 to construct an early warning mechanism for network public opinion in colleges as well as in universities 3 to analyze the mechanism of university public opinion database finally conduct an investigation and design optimized networked public opinion management strategies in colleges as well as in universities the rest of this paper is set as follows sect 2 discusses related works by other scholars sect 3 discusses the role of big data in the guidance of network public opinion in colleges and universities sect 4 discusses optimized strategies for networked public opinion management in colleges and universities and sect 5 windsup our paper related work it is easy to see that social public opinion has evolved through various phases based on the present publicopinion examination of the related literature it includes simple public opinion mining for huge data environments the relation between present hot topics government decrees and social public opinion mining are analyzed in simple social publicopinion analysis to get the original data analysis simple social public opinion analysis is primarily conducted using a questionnaire survey in this context the authors of laurenson used a sampling poll to investigate new zealanders attitudes toward alcohol legislation the authors of abadie used data from the gallup world opinion survey to investigate the link between attacks of terrorists and public opinion the advent of facebook microblogging twitter as well as other social media platforms and services has accompanied network public opinion studies because of the openness of the network a huge amount of data is created daily additionally the rise of multimedia has resulted in several formats of data including text video images audio and so on there are numerous network public opinion analysis tools based on the study of the features of huge data network public opinion public opinion analysis was conducted on weblog data mining regarding the social network analysis of the relationship network public opinion monitoring assessment and governance are interdisciplinary embracing computer science supervision sociology interaction psychology and other regulation and have stimulated the interest of academics in these disciplines native researchers have studied chinas national situation from a variety of viewpoints in recent years it includes monitoring and analyzing network public opinion analyzing and responding to situations and warning systems of crises the researchers concluded elements such as network public opinion formation subject delivery characteristics subject evolution emotional evolution group effects influence analysis climate simulation analysis and modeling for monitoring and assessment in terms of case study researchers looked into the vulnerability analysis index system and applied it to a precise area finally the reaction supervision control and significant areas of study included guide strategy a method of reacting and model of governance as well as models and methodologies used in forecasting and anticipating crisis events inhouse research also includes company management in terms of university education policy decisions group activities food security and the application of research activities the authors investigated the effect of the networks public opinion on the structure and quantity of the play in ma and chan in addition to the above little research has been done on the technical sides of public opinion assessment using large data networks in light of these considerations we investigate the role of big data in the guidance of network public opinion in colleges as well as in universities it improves the efficiency and motivation of students forming opinions in colleges and universities 3 role of big data in the guidance of network public opinion in colleges and universities in this section we explain the role of big data in supervisory network opinion in universities and colleges to discuss our proposed model we first describe the characteristics of colleges and universities utilizing big data and then we build an early warning mechanism for network public opinion in colleges and universities finally we describe our optimized networked public opinion management strategies in universities as well as in colleges analysis of the characteristics of colleges and universities network public opinion in the era of big data many college and university students use social media to direct their feelings and opinions as a group with active thoughts in their daily lives public opinion has risen as a result of the widespread use of social media teachers will benefit from analyzing public opinion on social media to better understand their students perspectives and provide theoretical education advice this dissertation employs big data to guide network public opinion in colleges and universities to effectively investigate public opinion the characteristics of colleges and universities network public opinion in the age of big data can be explained in fig 1 the suddenness of the incident suddenness is a significant feature of online public opinion in universities as well as in colleges in general there will be some controllable signs at the start of public opinion most of them will be ignored by the managers therefore when information is quickly gathered and stimulated it will explode quickly making all parties involved at present students can use weibo wechat qq tieba douyin and various video websites to access they can receive and publish information and form huge traffic by reposting comments and other functions this leads to the bursting of public opinion and is forced to disperse the public opinion control of university directors dispersal of public opinion the diffusion of public opinion online in colleges and universities has accelerated in the age of big data the rise of emerging media has helped disseminate public opinion in colleges and universities coupled with the open nature of the internet network users can distribute information more freely and easily this not only facilitates communication between individuals but also speeds up the spread of public opinion online group cohesion group cohesion is the total amount of all the factors that cause group members to remain in or be drawn from the group group cohesion can be thought of as the cultural glue that holds the group members with each other numerous individuals assume that teamwork with a strong group cohesion feature can perform much better in terms of achieving work objectives even so users should be aware that the study on this assertion is mixed group cohesion is caused by the interaction of several factors and not by a single cause whereas group cohesion can have an impact on group achievement teamwork can also generate or boost group cohesion individuals in highly integrated groups on the other hand may be encouraged to do more this may or may not be under the organizations performance goals of rational thinking and effective filtering of information about the problem but will be prompted to influence and blindly follow the crowd broadcast content the broadcast content is more diverse and rich in the big data age students are involved in a wider range of opinions and emotional expressions and they continue to accumulate the structure of data and information will gradually become more complicated causing a snowball effect in addition the event spread also increases the multiplier it will continue to deepen the impact which in turn will provoke public opinion on the internet building of an early warning mechanism for network public opinion in colleges and universities the early warning method for college and university network public opinion is referred to respect the consistency commonality and directional characteristics of college and university network public opinion establishing an appropriate monitoring mechanism to collect and analyze public opinion summarizing the rationale composition and trend analyses of college and university network public opinion and rationalizing management policy with the existing organization as per legislation of the college and university network public opinion people are guided to make a scientific rational judgment and reaction when they are aware of any upcoming cultural progress college network public opinion frequently occurs in a location where public opinion is concentrated and flows freely the creation of a university network public opinion early warning mechanism should include widespread organizations and public features of colleges and universities network public opinion in big data the suddenness of the incident the diffusion of public opinion online in colleges and universities group cohesion broadcast content fig 1 features of colleges and universities network public opinion in the age of big data media on campus aside from the aforementioned college and university public opinion early warning mechanisms refer to the use of big data to do a good job in surveillance prevention early warning analysis and treatment of public opinion in colleges as well as in universities based on information gathering to understand and properly handle potential situations and to adjust response strategies in real time dynamic monitoring technique of public opinion in colleges and universities the most serious connection in the procedure of dealing with public opinion in colleges and universities is whether the relevant management departments can monitor the emergence of public opinion online efficiently and accurately this involves the use of a relatively mature dynamic surveillance mechanism the operation of the dynamic surveillance mechanism involves specific requirements in terms of computer processing technology and surveillance means at the same time it should be staffed with professionals capable of analyzing and controlling network data monitoring achieve perfect collaboration between personnel and technology conduct research and judgments based on dynamic monitoring results and perform realtime report reminders via preliminary judgments to summarize data for further measurements in the three stages of online public opinion development the timely development of public opinion is difficult to detect and observe with the naked eye the data do not reach a certain peak and is easily ignored by surveillance also there are many platforms to monitor but the data are scattered the monitoring phase must be careful and avoid problems according to fig 2 the monitoring subsystem covers systems such as weibo realtime forums douyin kuaishou tieba and official accounts and reports everything based on the actual situation so that action can be taken in a timely college and university public opinion database summary mechanism the aggregation mechanism mainly comprises the collection and integration of information the aggregation mechanism solves the task of aggregating information and begins to bring into play the subjective initiative of managers in the threelevel transmission system of schoolcollege staff after centralized feedback from the monitoring mechanism it is integrated and processed by management staff and current dynamics are included in the database data for archiving and then viewed from time to time the information is updated over time which is convenient for the next step of the analysis figure 3 shows the overall mechanism of college and university public opinion database summary the database summary mechanism of college and university opinion consists of four systems surveillance system surveillance is the monitoring of behavior information or influence in simple words it is the practice of closely observing an individual or a group our surveillance system monitors public opinion with the help of weibo wechat forum and news platforms this system gives collected public opinion to the pooling system pooling system it is a systematic procedure for gathering and incorporating opinions from a group of participants the pooling system collects information from the surveillance system for integration analysis system it is the process of studying a method to identify its aims and objectives and to develop systems and procedures that can achieve them effectively it consists of a decision information base information mining and expert analysis of public opinion disposal system it is the final system which consists of case assignment hierarchical monitoring and disposal plan the role of big data in network public opinion within the colleges and universities 10857 analysis mechanism of university public opinion database academic public opinion database analysis mechanism refers to the systematic analysis of information in the database first quantitative analysis is used to form a model and use data analysis software to process the data to increase the fairness and correctness of the efficiency of network public opinion analysis following quantitative analysis the expert module for standardized analysis is integrated numerous different data must be identified and analyzed to determine the way and tendency of public opinion development furthermore to refine and optimize the information summarized in the database as well as to solicit public opinion for administration be dynamic and make fair judgments to serve as a reference for decisionmaking the analysis mechanism of the college and university public opinion database can be explained in fig 4 early warning mechanism for the crisis of public opinion in colleges and universities in colleges and universities the public opinion early warning mechanism refers to determining the level of early warning of public opinion based on quantitative and qualitative results of the analysis mechanism it monitors the plans that should be provided based on different levels of early warning depending on the administrative regulations of the relevant institutions in the country and the factors of international practice of the tendency to explode public opinion the warning levels are divided into general warning warning light and moderate in addition there are five categories of early warning alert severe early warning hazardous severe early warning and extremely dangerous mechanism for eliminating public opinion in colleges and universities as for the mechanism for handling public opinion in colleges and universities it is essential to approach based on the dynamic and timely monitoring of public opinion and information feedback first colleges and universities should fully embrace their position as a constructive guide in the mainstream media during public opinion incidents by conducting hierarchical processing and realtime monitoring of numerous platforms following that they should implement highprecision public opinion propaganda using big data technology and publish the incidents origin efficiently and accurately to avoid incident fission second colleges and universities should do a great job of integrating information in the process based on big data technology by breaking down platform barriers they should be able to communicate with government media and network supervision departments furthermore by performing well in public opinion development research and judgment they should be able to perform the mechanisms predictive function finally form a multiangle public opinion management plan that allows for rapid response and effective management of specific events in public opinion figure 5 explains the intensity of supervision and guidance of college students online public opinion figure 6 explains the comparisons among our selected public opinion technologies such as supervision analysis prediction guidance and others according to this figure public opinion prediction technology has the highest ratio as compared to the rest optimized strategies for networked public opinion management in colleges and universities to fill in the gaps in a timely manner big data is a doubleedged sword therefore colleges and universities need to make good use of big data to optimize public opinion processing strategies figure 7 explains the overall process of optimized strategies for networked public opinion organizations in colleges as well as in universities as per the diagram above the network public opinion system collects opinions from college and university students this system sends these opinions to the public opinion examination engine which then assigns them to the public opinion examination model similarly this system stores these opinions in the database server where theyre being supplied to an index server through a bidirectional process following that an early warning mechanism is created through monitoring analysis and intervention 41 cultivate a highlevel network public opinion work leadership mechanism to make big data network public opinion organization professional in the period of big data the heart of the management and control of public opinion oversight in colleges and universities lies in the work leadership mechanism colleges and universities should strengthen and improve organizational guarantees and cultivate specialist teams for alerting various leading departments and institutions of the school as a result from the perspective of universities the school office the party office the propaganda department the student office and college counselors student information officers and so on can form the network public opinion leader and executor system to achieve rapid discovery understanding and resolution the team of public opinion networks must work hard to improve its overall quality and promote the professionalization of public opinion processing in colleges and universities the second goal is to improve the work systems structure manage campus networks effectively and standardize the use of campus networks simultaneously increase the building and oversight of the public opinion work system such as establishing a daily monitoring work system an information spokesperson system and ensuring that public opinion is correctly addressed through a professional systems mechanism improve the multilevel network public opinion model to make big data network public opinion management more precise the big data network public opinion monitoring must highlight the accuracy characteristics to improve the multilevel network public opinion model we first ensure full data acquisition it is possible to create a multiinone network public opinion structure model by improving the parameters of the network public opinion research and judgment model and using big data technology to capture the results using different combinations with varying degrees of freedom establish linear relationships and fragment associations and construct the high dynamic operating mechanism of public opinion in the school network simultaneously it is necessary to avoid the mechanical system of the network monitoring the public opinion of the network in the college and university network monitoring system it is essential to focus on building fig 5 the intensity of supervision and guidance of college students online public opinion the role of big data in network public opinion within the colleges and universities the artificial intelligence and big data model to eliminate the complexity and dilemma of formatting the public opinion monitoring data of the network 43 build a new media matrix guided by online public opinion to make big data online public opinion management more efficient firstly the official fresh media platforms of colleges and universities should form an organic whole that is closely associated with various types levels and subplatforms resonate with the same frequency and form a synergy the official account which has become the major avenue for authoritative school promotion should do a good job of interpreting school policies and marketing the image the schools functional departments colleges and student club accounts must provide specialized and advanced information based on their own needs so that teachers and students can grasp the situation at the same time it can build a big database collaboratively distributed public opinion cloud platform and use the fastcomputing power of big data to deliver crossplatform resourcesharing data analysis results making it multidisciplinary creative and integrated for processing and analysis to network public opinion in colleges and universities in this way public opinion data can obtain internal and external collaboration open links between resources and promote effective monitoring of public opinion conclusions with the fast growth of online social media a true media stage has progressively attained everybody can generate web content and rapidly distribute it over connected social networks huge data have posed a significant challenge to public opinion control big data has the potential to transform online public opinion management the paper data availability enquiries about data availability should be directed to the authors fig 7 optimized strategies for networked public opinion management in colleges and universities the role of big data in network public opinion within the colleges and universities 10861 conflict of interest the authors have not disclosed any competing interests 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 orglicensesby40 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the online public opinion of colleges and universities which utilizes social opinion is a type of college students individualism that exists on campus and is a societal hot concern with the advancement of internet skills and uses public perception of the network has changed significantly in terms of data quantity sophistication and production speed the current public opinion assessment and monitoring system is hard to adapt to the variations occurring in this situation it must be created under the guise of big data investigation furthermore with the use of social opinion by colleges and universities the problem of online public opinion is becoming more serious the academic community has also been very interested in the colleges early warning research on online public opinion this manuscript examines the role of big data in guiding network public opinion in colleges as well as in universities it is based on the analysis of the current state of college online public opinion our proposed model builds multilevel and comprehensive guidance metrics for new media through dynamic monitoring it will help colleges and universities prevent early warning processing and analysis of online public opinion besides it will promote the professionalism of online public opinion management in colleges and universities accurately and effectively

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introduction in 1997 glazer boldly stated that we are all multiculturalists now whether we want it or not what this statement highlights is a perceived move away from monoculture towards what was later referred to as multiculturalism or superdiversity being located in the united states glazer was primarily preoccupied with structural discrimination and injustice against african american people paradoxically while embracing and encouraging multicultural education he also singled out islam as a potentially rebellious element within western societies because of muslims lack of commitment to liberal values what emerges here is an interesting tension between the endorsement of multiculturalism on the one hand and the singling out of muslims as cultural others potentially threatening multiculturalism on the other it is the endurance of this tension between western liberal values and imagined muslim others that we seek to investigate in this paper by taking sweden as a case in point specifically we hone in on the educational initiative civic orientation for newly arrived migrants and we investigate whether co constitutes an example of culturally relevant education the co initiative is part of the broader establishment programme for newly arrived migrants the establishment programme is open for those have turned 20 but not 66 and recently received a residency permit as refugee a person in need of protection or if you are related to a refugee or someone in need of protection it includes language classes co and support to enter the labour market through practical courses and internships granted co is not unique to sweden but is in line with a larger trend in the global north where migrants are expected to learn about the country of arrivals laws norms and culture at the same time as they seek to enter the labour market in sweden co is organized by the municipalities and regional administrations it is offered in the participants bauermilanivon brömssen spehar 114 mother tongue or another language which the migrant has good command of and the courses are led by society communicators who themselves have a background of migrating to sweden we believe that co is particularly relevant for the remit of this special issue on culture on the move because as we will see in more detail below the inquiry that led to the introduction of this initiative strongly emphasizes 1 dialogue and reflection 2 active participation of migrants and 3 the importance of drawing on their previous knowledge and experience accordingly co seems to be built at least in policy documents on a principle akin to what ladsonbillings has called culturally relevant pedagogy by focusing on minoritized students knowledge strengths and active involvement culturally relevant pedagogy aims to help students to accept and affirm their cultural identity while developing critical perspectives that challenge inequities to ensure that they can achieve academically … demonstrate cultural competence and … both understand and critique the existing social order however previous research has demonstrated how educational initiatives directed at migrants in sweden are built on the view that migrants especially newly arrived ones diverge from swedish society through odd behaviours or unusual food practices in contrast what counts as swedish is seen as modern developed and normal as a result through these courses migrants are expected to change in three areas they are expected to change vocation basic values värdegrund and language thus a focus on values also has a long history within adult education directed at migrants in sweden in the swedish context the concept värdegrund that is basic values or value foundations is often used to describe principles which are at the core of a group a corporation an educational initiative or even society at wide however the semantics of values is complex not least because swedish has two words for it värden and värderingar the two words have slightly different connotations as can be gauged by looking up their definitions in the swedish dictionary while värden indicates values as a measure of utility size or desirability värderingar is more about subjective perceptions against this backdrop we investigate how values are discursively constructed in relation to co and how they relate to culturally relevant education the paper is informed by the following research questions 1 how is co presented and constructed in policy documents with regard to values 2 what are the broader media discourses about co and its relation to values 3 how do these discursive constructions of values trickle down and get interpreted and rearticulated by those involved in organizing co 4 how are they discursively negotiated in the classroom in order to answer these questions we analyse discourses about values on multiple levels a macro level of policy and media a meso organizational level of policy implementation and a micro level of classroom interaction furthermore as we focus on values as a discursive construction we follow what fairclough called intertextual links the metaphor here is meant to suggest a chain in which discursive constructions hook into each other forming a discursive chain put differently individual utterances and uses of values are not idiosyncratic but are linked to each other thus making up the whole discursive construction in the following we first outline the theoretical framework and the methodology employed in this paper we then start off with an analysis of policy documents to illustrate how co was portrayed and legally defined thereafter we analyse swedish media discourses about co over a 20year period with the help of corpus assisted critical discourse analysis this allows us to map the media context within which co policy was interpreted and implemented subsequently we analyse 14 individual interviews with people who interpreted and implemented co policy in sweden lastly we show how these discourses and discursive constructions were negotiated in the classroom theoretical concepts methodology and data since the article aims to explore how discourses and discursive constructions occur get reinterpreted and get rearticulated on multiple levels we believe that the douglas fir groups conceptualization of the multifaceted nature of learning and teaching can be particularly useful to capture the dynamic interplay between different scales macro meso and micro while the scholars behind the douglas fir group were primarily concerned with second language acquisition their model can also be a valuable heuristic for understanding how language as social interaction operates on multiple interconnected layers figure 1 the multifaceted nature of language learning and teaching by language as social interaction we mean how specific ways of using language become routinized over time thereby constructing social meaning this is what we refer to as discourse which can also be defined as ways of representing aspects of the world discourses are not neutral rather they shape and reflect the way in which issues are thought about and engaged with moreover discourses function as systems of rules which make it possible for certain statements but not others to occur at particular times places and institutional locations while discourse are systemic their specific textual materializations are what we refer to as discursive constructions in order to operationalize the douglas fir groups model we draw on the discourse ethnographic approach suggested by krzyzanowski which integrates anthropological and criticalanalytic perspectives through on the one hand extensive fieldwork and ethnography in institutional spaces and on the other hand the critical analysis of discourses of actors in our case this has meant taking a multimethod approach which combines qualitative and educare 117 quantitative techniques while we outline the methodological steps in more detail below suffice it to say at this juncture that we employ qualitative methods to analyse policy documents about co interviews with co organizers and fieldnotes collected during participantobservations of six co courses over a period of six months in 2020 we also use quantitative methodologies to analyse a large corpus of media texts about co in what follows we first present how we constructed and analysed the media corpus we then go on to present the policy documents interview data and ethnographic fieldwork the corpus we constructed for this paper consists of 1257 articles totalling 1381485 words published between 2002 and 2021 this timespan was chosen as it covers the period leading up to the introduction of co as well the period during which we conducted classroom observations and interviews the articles were published in the national local and specialist press and were collected with the help of the swedish media database the articles were found with the help of the search term civic orientation because of the corpuss breadth of coverage it can be seen as representative of the swedish media landscape all articles were downloaded as txt files and compiled according to the year they were published and the type of press after compiling the corpus we used the software lancsbox to generate word frequency lists for each year and media type these lists were then copied into microsoft excel where function words such as prepositions conjunctions and words relating to copyright and the swedish media database were removed for a word to be deemed relevant for the specific year and included in the frequency list it had to occur ≥10 times frequency lists are commonly used in corpus linguistics and in corpusassisted critical discourse analysis to identify patterns of language use across time frequency thus speaks to the aboutness of a text or a corpus after the frequency lists were created a few indicative patterns emerged such as absolute frequency of specific words across media types or increasedecrease of occurrences of words over time however frequency lists do not say much about where and how these words are used in context therefore we searched for collocations that is words that cooccur in a nonrandom way across the texts in our corpus identifying the collocations of a particular word can provide a helpful sketch of the meaningfunction of the word within the particular discourse accordingly collocations can be used to identify semantic prosodies that is the consistent aura of meaning that a word accumulates over time for example if illegal and immigrant are often paired as collocates we may be primed to think of one concept even when the one is not present to identify such collocates we used mi3 score rather than showing absolute frequency the mi3 score shows how likely the collocations are to appear together across the corpus it thus identifies words that are more likely to appear together in a statistically significant way the statistical value was capped at ≥12 and the frequency at ≥5 meaning the collocate had to appear at least five times and with a collocational strength that is higher than or equal to 12 following the identification of these collocates we then looked at their concordances that is how collocates cooccurred in a particular cotext that is the text that surrounds the collocates looking at specific contexts of usage was a useful way of finding outliers such as in the case of specific words that have a high frequency score simply because they feature in the name of a new law that was introduced in a particular year interestingly one of the most recurrent words across the media was values as we mentioned earlier there are two words in swedish that can correspond to values in english namely värden and värderingar in the media corpus the latter was far more frequent so it was our main focus however the distinction between the two will be further fleshed out and exemplified below in order to fully understand the macro level of ideological structures of co we also collected three policy documents that have been instrumental to the implementation and organization of this educational initiative 1 the inquiry commissioned by the government to propose the format content and organization of co 2 the law that governs what the provision shall contain and how it is meant to be organized and 3 a special inquiry commissioned to investigate how to expand the courses as well as how to put an increased emphasis on teaching values and norms these were all systematically read in terms of both how they related to culturally relevant pedagogy and how they discussed and constructed values in order to delve into the meso level of co discourse we conducted 14 semistructured interviews in the winter of 20192020 the interviewees were selected on the basis of their position as organizers or implementers of the co policy when it was first legislated in sweden in 2010 therefore these individuals responses offered us an opportunity to understand how discourses and discursive constructions are negotiated and rearticulated at the mesolevel by those who have to respond to macrolevel political discourses importantly from a critical discourse analytical perspective our questions mainly concerned the organization of co in the interviewees municipalities however we also recognize that co organizers work within a broader context as it will become clearer below the interviews took place at the time when the swedish government decided that co should have a stronger focus on norms and values in the light of this it is not surprising that one of our interview questions concerned values and that the participants themselves were keen to talk about the increased attention to norms and values in the courses as a result of policy change finally in the spring of 2020 we followed six different co courses in three large municipalities in sweden the classroom observations started off in person but were moved online due to the onset of the covid19 pandemic three of these courses were taught in arabic and three in english those of us who attended the courses spoke arabic and english respectively so we had no need for interpreters fieldnotes were taken by hand and we took the position as participant observers meaning that we did not interfere with the class but spoke when asked to and actively participated in the breaks we conceptualized the classroom as being part of the micro level as this is where the discourse is articulated face to face to sum up this paper is based on an investigation of the construction and function of values in co on different interconnected levels our investigation follows deans perspective on governmentality an analysis of government then is concerned with the means of calculation both qualitative and quantitative the type of governing authority or agency the forms of knowledge techniques and other means employed the entity to be governed and how it is conceived the ends sought and the outcomes and consequences in practice such a multilevel perspective entails fleshing out 1 how values are discursively constructed and justified in policy documents about co 2 how they are circulated through media discourses and interpreted and rearticulated by those in charge with organizing co and lastly 3 how these discursive constructions are relayed or contested in the classroom policy document analysis one of swedens four constitutional laws the form of government states that the individuals personal economic and cultural welfare emphasis added shall be foundational goals for the public sector the notion of cultural welfare being foundational for all state actors and programmes is of interest here cultural welfare through public structures does not just refer to swedish citizens wellbeing but also includes anyone regardless of their legal status in the country an example of such a concern with everyones wellbeing can also be found in the report from the parliamentary inquiry that led to the establishment of co the section that focuses on dialogue and reflection states that co provides greater possibilities to utilize the experiences and competences that participants bring into the teaching situation the experience is that dialogue properly executed is a way to treat participants with the respect they have an obvious right to as civic orientation involves values and norms such an argument echoes both freires wellknown insistence on the pedagogical importance of dialogue and ladsonbillings emphasis on education as designed not merely to fit the school culture to the students culture but also to use student culture as a basis for helping students understand themselves and others structure social interactions and conceptualize knowledge while not directly referring to either freire or ladsonbillings the policy document echoes their pedagogical principles it portrays migrants participating in co as resource holders and agents in their own rights with the potential to create engagement and mutual reflection and the ability to discuss and come to a mutual understanding of values and norms that co should be built on this reflective and interactional approach is also mentioned in another section of the same policy document which deals with social codes for example codes present in the workspace the role of religion in sweden or the celebration of traditions such elements ought to bör be present in civic orientation in part based on the idea that such knowledge can be a useful tool for facilitating the encounter between people with different cultural backgrounds this indicates how cultural markers in swedish society are discursively constructed not so much as something migrants need to learn or adapt to but as starting points for dialogue and reflection educare 121 which will then enhance the mutual understanding of differences and facilitate the encounter between co participants and others in swedish society nevertheless there is a glimpse of a fracture in the discourse constructing co as a form of culturally responsible pedagogy while such knowledge critical reflection and dialogue may indeed be empowering in theory the preposition between performs interesting ideological work in this context as it indicates a mutuality in the encounter however the only people who are expected to attend co courses and actively engage in these dialogues and reflections are the migrants and the communicators thus the underlying logic in the policy concerning co is to prepare migrants for encounters with what is assumed as an otherwise homogeneous and undifferentiated swedish population rather than offering a space for different cultures to engage in dialogue with each other on equal terms the importance of values is also evident in the legal document regulating the co courses which states that the purpose of co is to give a foundational understanding of swedish society and a basis for continued knowledge acquisition the document also specifies that participants will gain knowledge of 1 human rights and the foundational democratic values 2 the individuals rights and obligations generally 3 how society is organized and 4 practical everyday life since dialogue and reflection are also mentioned in this legal document it might sound quite unbalanced that only migrants are supposed to be changing and opening themselves up to further change by participating in co while we certainly agree that human rights and democracy must be valued and respected we take some critical distance from the twofold discursive construction of swedishness as always already embodying these values visàvis newly arrived migrants as not and therefore in need of education about them the metaphor conveyed by the adjective foundational is particularly interesting here as it conveys the image of a base upon which the rest of oneself and by extension the wider imagined community of sweden is built as outlined in the introduction in the swedish context the concept värdegrund which means basic values or value foundation is often used to describe principles which are at the core of a group a corporation an educational initiate or even society at wide in the legislation about co basic values are never defined with precision but are simply presented through the word cluster human rights and foundational democratic values bauermilanivon brömssen spehar 122 when discussing these foundational values the parliamentary report that led to the introduction of co states that the courses need to be pragmatic and that t he place of departure is to explain and give tools for the newly arrived to function in everyday life by being in dialogue about these values the participants are expected to take them up and to use them as tools to function in society the report also gives pedagogical indications by stating that discussions about values should not be based on surveys that map cultural patterns of behaviour rather they should be linked to swedens constitution and constitutional values however a different picture about the meaning of values emerges in the report from a following inquiry about co published in 2018 according to which co shall aim at the participants getting to know swedish values emphasis added but the material taught shall be characterized by universal values as they are expressed in for example human rights this statement shows a clear change in rhetoric whereby values are no longer referred to as constitutional or foundational but are overtly tied to the ethnicnational qualifier swedish by as shown in the map below sweden is presented as an outlier even to the rest of the global north the position in the top righthand corner furthermore spatially constructs sweden as what in social semiotics is described as the ideal and the new accordingly the spatial position on the map conveys the idea that sweden with its allegedly most advanced and progressive values in the world is an ideal which other countries should imitate or strive for the usage of this survey in co was justified in the report because it meets the basic requirements of an objective and credible assessment needless to say the wvs has been critiqued for the biased cultural assumptions upon which it is based a glaring visual example of such a bias can be seen in the caption in the bottomleft corner muslim countries in italic which ties back to the tension outlined in the introduction of this paper here the visual singling out of these countries is the manifestation of a strategic othering of muslims and islam all of these countries are located in the bottom left square of the map categorized as traditional and holding values focused on survival rather than selfexpression whereas the position in the top right corner indexes sweden as new and ideal being located in the bottom left corner indexes the opposite that is old and real in her analysis of knowledge production and the wvs lundgren argues that the map represents a problematic correlation the more economically developed a country is the more developed values it has in practice this means that the global north has in writing the success story of some the map simultaneously presents a story of failure for others mostly muslim but also formerly colonized countries showing them as less developed both in terms of economy and values importantly discursively constructing values as both more developed or more mature implies a directionality according to which those who do not currently hold the same ideas can change they can develop or grow into holding them what is important to stress here is how the analysed policy documents highlight an underlying contradiction namely that swedish values are simultaneously presented as objective and universal and as particular this contradiction is fleshed out in the remainder of our analysis media analysis as previously mentioned this paper is concerned with how discursive constructions form intertextual chains and how they are articulated on various levels focusing on not only how such constructions are similar or different but also how they are embedded in the same macro context in particular the previous section revealed how the conceptualization of values seems to have shifted from viewing values as democratic and foundational to viewing them as national the question that remains to be investigated is how values are presented in media representations of co and whether such representations are also characterized by such a shift of meaning before doing so however we need to first return to the distinction between the two words for values in sweden namely värden as more objective measures of utility and värderingar as subjective perceptions there is a stark difference in the frequency of the two words across the corpus while värden there is also a difference both in the use and collocational patterns of the two words table 1 provides a collocate list for värden with function words such as the conjugation word and removed further down table 2 provides a similar list for värderingar showing the difference in collocates 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 2 0 2 0 2 0 2 1 värden värderingar as can be seen in the table there are no statistically significant collocates in the specialist press the two top collocates in both the national press and the local press are welfare state and everyday life which is not surprising as they together with värden are part of the title of one of the reports that lay ground to the introduction of co furthermore the strongest collocates in the national press are equality central and foundational which support the swedish dictionarys definition of värden being more about measures of utility as for the local press we see a high frequency of words emphasizing interpretation and understanding while swedish occurs as one of the top collocates here such a result is due to the data in this particular case being skewed by a local politician having published the same opinion piece in multiple local newspapers in 2010 in which he warns of the danger of arguing that there is no such thing as swedish values to map out how the use of värden and värderingar changed over time it is crucial to examine the cotext in which the words occurs in 2009 then minister for integration and gender equality nyamko sabuni argued that the government was introducing the establishment programme as reforms to facilitate newly arrived migrants entry into the labour market and society… for us it is important that the establishment process also provides civic information both how society educare 127 works and what values värden make up the cement that binds society together fundamental human rights childrens rights and gender equality this is such important information that it is part of the swedish educational system and because of that i think that it is important that newly arrived also get to take part of it through civic orientation here values is named as one of two topics that should be included in the establishment process in sweden the other one being how society works as in the collocate list above the word values is used to describe human rights childrens rights and gender equality as the cement that binds society together constructing it as integral to what defines swedish society accordingly these values are presented as connected and mutually dependent in relation to what makes up society while the ethnicnational qualifier swedish does not appear in sabunis pronouncement a specific yet somewhat vague set of ideas is subtly tied to one particular context society here the linking of gender equality to sweden inherently presents this notion as extrinsic to other societies this could be taken as example of what van dijk has called denials a discursive strategy through which those in power engage in boundary work yet make statements that construct their own group as inclusive thus affirming the superiority of the self värderingar in contrast to värden the word värderingar appears in the frequency lists in all types of media it is first used in the years 20092011 as part of the justification for introducing the socalled establishment programme of which civic orientation is part these justifications make an effort to explicitly state that these värderingar are not exclusively swedish values but rather foundational values such as equality or human rights however the word does not appear again until 2016 when it peaked it was still one of the 50 most frequent words in the specialist press in 2020 and in the national press in 2021 below is a collocation list for värderingar the collocates swedish our norms and foundational occur across all three types of press swedish is the strongest collocate in both the national press and the specialist press and the second strongest in local press the notions of swedish and the possessive plural our are of special interest in this paper as they signal a boundary of what comprises us the pronoun our is one of those little words with big meanings words that make up the nation in everyday life thus the strong collocational link between our and swedish in relation to values gives the impression of an imagined homogenous national community sharing a particular set of beliefs however a closer look at the list of collocates reveals interesting contradictory semantic prosodies on the one hand values are argued to be foundational for all and on the other hand they stand out as ours and swedish therefore the word values itself becomes an important discursive marker of a boundary namely the collocation of our with values demarcates and enforces the boundary between the nation and those who are part of it and those who are not an example of such reasoning can be seen in an opinion piece arguing that values vary between cultures authored by a local politician representing the conservative christian democrats in the stockholm city council the biggest challenge of integration concerns transmitting standing up for and spreading those values värderingar on which our society rests that is the values themselves are an important part of what makes up an imagined us and there is also a clear delineation between us and them the argument in this opinion piece goes as follows if the biggest challenge of integration concerns values on which our society rests these values are under threat thus values are constructed as subject to threat from the other that is the migrant or in this case the newly arrived there is a shift from the earlier quote in which sabuni articulated values as the cement which binds society together and therefore as a necessary part of civic orientation to the piece published seven years later in which values were constructed as the most crucial and biggest challenge to integration by following these intertextual links we also see an increasing convergence between society and a distinct set of values values upon which our society rests or our values which is viewed as integral to integration the next section shows how such societal values morphed into swedish values in media discourse swedish values the phrase swedish values first appeared across all three types of media in the corpus in november of 2009 following the liberal partys congress where nyamko sabuni gave a speech touching on the topic of values in what was then proposed as citizenship courses which later became civic orientation in that context the reporting on the ministers speech highlighted how such courses would focus on foundational values rather than swedish values swedish values appears again with the introduction of civic orientation programmes in 2010 yet again in reports that these programmes will not deal with swedish values but foundational values as frequency of the expression swedish values and foundational values in the graph there is a spike in the expression swedish values in 2016 this reflects the media response to the increase of asylum seekers in sweden during 2015 which led to pathbreaking decisions on the regulation of refugee immigration to sweden as well as a reorientation of the political discourse on migration these decisions included making it harder to obtain residency and reducing rights for noncitizens living in the country relevant in the context of this paper is the simultaneous emergence of specifically swedish values in the media discourse response just as residency rights were particularized so were those values that were previously constructed as universal and foundational although part of a longer trend the nationalization of values in co contradicts what has previously been argued for civic integration as a whole namely that it represents a convergence around liberal values rather than national values instead the policy and discourse nationalize those very same liberal values the link between values and swedishness was strongly emphasized in a 2016 oped in the national newspaper svenska dagbladet by then party leader of the centrerightwing moderate party anna kinberg batra for sweden to be a society where each and every one has the freedom to shape their own life we need to continue to protect swedish values such as industriousness diligence and togetherness unlike sabuni and the local politician mentioned in sections 41 and 42 above kinberg batra explicitly uses the expression swedish values here again the pronoun we functions as a demarcating agent establishing and iterating an us visàvis a them although there is no explicit mention of who they are swedish values are said to be in need of protection from an assumed other importantly in a context where värden was previously used svenska värderingar is now used instead to talk about comparable topics it is the subjectification or perhaps more aptly in this context nationalization of values that we argue is emblematic of the discursive shift that has taken place in sweden rather than universal foundational values politicians and media practitioners instead articulate swedish values in opposition to those values that migrants are assumed to hold in addition kinberg batras statement shows the construction of the imagined other as outside of both the universal and the particular an anomaly which represents the antithesis of the self in another speech roughly a year later kinberg batra made it clear that whilst we increase opportunities for migrants we shall show that sweden is not a nostringsattached community we want to introduce a duty to integrate with demands on following swedish values partaking in civic orientation and learning swedish here she positions herself as someone who will offer opportunities as a tolerant understanding leader while at the same time constructing the undifferentiated group migrants as not adhering to swedish values if interpreted in good faith the statement can be said to offer a bridge to becoming part of the community or sweden however the imagined community of migrants is still constructed as antithetical to sweden through a lack of specific values and language much research both in sweden and elsewhere has established that learning a language is not just about acquiring syntax grammar or phonetics but also about being a particular speaker one who is most often constructed as white and from the global north meso level analysis of organizers having outlined the macrodiscursive context through an analysis of values in the co policies and media representations of this initiative we now consider how these discourses and discursive constructions have been interpreted and rearticulated on the meso level by co organizers what all the interviewees have in common is the fact that they were responsible for the interpretation and implementation of co in three large municipalities when this new provision was introduced in 2010 therefore the interviews give an insight into how those in charge of running the programme interpreted the elements in the policy that can be taken as culturally relevant pedagogy according to the aforementioned policy documents co should be taught in the mother tongue or another language which the participant has good command of the following reasoning was given it is of the utmost importance that civic orientation is provided early on in the establishment process and this in turn means that most of the participants do not have good enough command of swedish to achieve the required level of understanding we consider this another element of culturally relevant pedagogy because co is envisioned as a platform which should harness linguistic knowledge and skills already available to the students however the interviews revealed that the rationale underpinning the use of the mother tongue is that communicators can be positive role models for the participants by showing that people who speak their language are already part of swedish society as one of the organizers we interviewed expressed it you meet a person from your own country maybe … who has a large eh network here who knows the system by presenting people who speak their language and are educare 133 deemed part of swedish society migrants are presented with something they should also aspire to become nonetheless finding people who are able or willing to teach is especially hard for languages that are less commonly spoken in sweden the organizers said that this is mainly due to municipalities being unable to provide permanent contracts for communicators who may only be needed to teach one course every few months or even once a year however in some locations this was seen as less of a problem because of a relatively eh stable language basis språkunderlag while referring to a large number of speakers of a certain language is not necessarily a normative assessment the construction of that group needs to be examined closer what does it mean to be part of a group of speakers of certain languages one of our interviewees described their feeling of relief when the arabic speaking communicators they had met did not express any strange values because they were well acquainted with differences between what it is like when you come entirely … as newly arrived here and concerning values surrounding well women men children interestingly the interviewee articulated the close connection between a certain group of speakers and the values associated with that group according to the organizers logic the communicators have undergone the process of leaving behind strange values and now hold good values concerning equality when describing the recruitment process for the communicators another organizer said that they listen to them test their language written eh there is a presentation in arabic so the mother tongue and english plus there are also questions about values to see if this communicator is mature or immature they talk about democracy domestic violence and we talk about eh this with se… homosexuality eh child rearing and see if the person has a certain level of maturity here the values held by prospective communicators are tied to maturity since the communicators are meant to represent sweden maturity functions as a proxy used to discuss swedishness and swedish values interestingly the specific values named are democracy and gender equality therefore in this articulation the assumption is that holding certain values also means having a certain level of maturity to be able to represent sweden and swedishness this in turn echoes a general assumption of swedishness being the unmarked normal strikingly but perhaps not surprisingly the interview discussion about values also revolved around the wvs some of the organizers explicitly expressed negative views regarding the usage of the map in the classroom because they claimed it homogenizes too much and does not leave room for people from different parts of the world to be different in their view co should not be based on the assumption that simply because some migrants speak the same language they also share the same culture religion or values they then questioned why the world had been divided up into nations in the first place but they quickly added that their stance might come off like a teenage rebellion because of their critical questioning of the map however they emphasized the importance of maintaining some critical distance because otherwise one might fall for these simple explanations one organizer was not as explicitly critical of the map instead the organizer was critical of how the secretary general of the wvs bi puranen had presented the survey at a conference they had attended namely the assumption that everyone shall be moulded in a certain way nonetheless the organizer still voiced bi puranens idea that there is such a thing as swedish values that migrants need to learn it will all be fine because we will all … all of us will get swedish values sooner or later in this process other organizers held positive views of the wvs one of them said that the wvs is useful as an aid to talk about norms and values in relation to swedish legislation they believed that it could be a good starting point to discuss what it means that we are one of the worlds most secular countries one of the worlds most gender equal countries these comments show a blurring of the lines between sweden as state and legislation and sweden as a nation and population this further complicates the discursive construction of swedish values as reflecting progressive legislation on the one hand and values held by swedes on the other another organizer was unequivocally supportive of the usage of the wvs and said yes but of course at the start of the course you need to show the world values map and have it as a kind of starting point throughout they believed it was a good representation especially because it made it very clear that you are not the ones that are different and it is not your home countries it is us sweden that is weird and crazy importantly when showing sweden as an outlier the wvs indexes the country as most developed on the map consequently the migrants in co might indeed be told that sweden is abnormal but they are simultaneously taught that this abnormality is a form of superiority it is still the best country in the world educare 135 the next section shows how this perspectivization of sweden and swedish values is discussed in the classrooms both through the wvs map and through pronouncements about gender equality as inherently swedish micro level discourses in the classroom the wvs was not explicitly brought up or used in all of the courses we followed but its perspectives and conclusions were discursively present throughout the courses in one of the courses where the cultural map was used the participants were asked to locate sweden and then switzerland what does that mean a student says it means that sweden is more secular than switzerland are your countries somewhere here the communicator points to the bottom left corner where the traditional and survival oriented countries are located one participant says she is from uganda another from nigeria they are both in that corner in this interaction sweden is first contrasted with another country in the global north switzerland to point out that it is positioned in the very top left corner thereafter the participants are shown how the location of sweden is diametrically opposite to their countries of origin by using the map the communicator visualizes the distance between swedish values and the supposed values of the participants countries thus the map functions as a reminder to migrants of the difference between sweden and the rest of the world crucially this is not just a matter of cultural difference but also carries moral implications because sweden is constructed as ultimately more developed and better on the cultural map the contrast between swedish values and those of the participants countries is evident and is frequently emphasized in the courses for instance in one course a communicator emphasized the benefits of swedish values in contrast to the participants culture and values which in most cases he described as in need of change while their traditions and culture were articulated as rules that they need to adhere to swedish cultural values were presented as flexible and dependent on the individuals own desires taken together we see in these statements how nonswedish values are portrayed almost as cages in which the participants are trapped as a solution participants are presented with opportunities to escape these cultural prisons and be free by instead embracing swedish values another form of contrasting swedish and nonswedish values in the courses concerned tolerance in another course a communicator explained that people are supposed to live and practice their religions and traditions but at the same time accept the other in other words migrants taking part in co are assumed yet again to be less tolerant this discursive move is reminiscent of what has also been observed in france where ethnocultural minorities are more or less suspect of nonloyalty to common values therefore migrants in sweden are also told that y ou never have the right to judge others or treat them based on their sexual religious or even political beliefs this is classified as discrimination in sweden and requires penalty the pronouns you and them are of interest here as they further construct the participant as the one who are doing the judging and not adhering to swedish values in contrast to culturally relevant pedagogy and co policy documents that highlight participants as agents and focus on dialogue and reflection the teaching emphasizes what the participants are believed to be doing wrong and therefore that they are in need of being educated throughout the courses we observed equality in relation to gender and sexuality was presented as constituting the main difference between the participants and sweden in one of the courses the participants were presented with a timeline of different events that have impacted and thus reflect swedish values while the events in question have indeed taken place they are a good example of how laws can be utilized to convey swedish values as objective facts and as a string of unavoidable events the choice of events affirms the idea of gender equality as the inevitable outcome of swedish history at the end of that class the communicator went back to the list of events and commented that it is the most important slide perhaps its the evolution of the swedish welfare state and it is very important by selecting these events co presents a story wherein gender equality not only comes to represent swedish values but is also part and parcel of the evolution of the welfare state taken in context with our previous analysis of how the participants are positioned as being from places that hold values diametrically opposite to values in sweden such representation of gender equality presents the participants with a choice they either hold on to their less developed values or leave them behind and become gender equal swedes conclusion in this article we have sought to investigate whether and if so how co is an example of culturally relevant pedagogy to do so we used a multilevel mixedmethod discourse analytical approach to look specifically at values as a discursive sign following its discursive chains and intertextual links by adopting the framework outlined by the douglas fir group our analysis has illustrated the complexity of education policy and practice showing how discourse and discursive constructions operate and connect on the macro meso and micro levels although the policy documents contain explicit statements about drawing on the newly arrived migrants knowledge and previous experience to encourage dialogue and reflection these statements need to be viewed and analysed in the macro discursive context in the media discourses we were able to show how democracy human rights and gender equality become increasingly nationalized turning into swedish values conversely the knowledge and experiences held by the participants are viewed and constructed as less developed and not mature and therefore in need of change accordingly through co the state seeks to use the participants knowledge and experiences in order to make them realize that they have been wrong and need to modify their behaviours therefore rather than being a form of empowering education co functions as an instrument that seeks to make prospective citizens fit into what is discursively articulated as a more mature and developed mould consequently it is fruitful to question what is actually meant by values as a whole by following the intertextual links we have shown how each individual link of values is slightly different what foundational values are cannot be established a priori but is the result of decisions and choices in policy documents foundational values are never explicitly defined but acquire meaning by association to human rights and democratic values these word clusters in turn become discursive common sense constructions such constructions are difficult to spot or even question as they are thought to be universally shared and therefore do not necessitate further definition however it is when implementing policy that the meanings of values come to surface and become more explicit in a macro discursive context where discussions about migration and integration policies are formulated in terms of the nation and swedishness concepts such as democracy human rights and gender equality are coopted into marking a boundary between the swedish self and the immigrant other thus instrumentalizing foundational values as part of what defines the nation is murky business as it risks particularizing such a shared foundation and simultaneously excluding those deemed not part of the nation this is diametrically opposed to the principles of culturally relevant pedagogy according to which we should be asking a different question and focusing on what knowledges and experiences those in the classroom already hold rather than on what we believe they do not throughout the data democratic and gender equality keep reappearing our analysis has shown how these discursive constructions as they move from macro to meso to micro level become less abstract in their articulation in practice we see how the wvs is used to position swedish values not only as the most extreme in the world but also as the best most developed and most mature crucially when viewed in the light of the macro media discourse democratic strongly collocates with sweden and swedish values in such a way that one only needs to see the one to think of the other unsurprisingly these articulations become most direct in the classroom where the participants are constructed as the antithesis of democratic and are taught what gender equality is we have seen multiple examples of articulations concerning choice and respect for individuals as being at the core of swedish society yet these are somehow contradictory to the rest of the discursive constructions due to the construction of swedish values as inevitable and better than any other values although we do not propose cultural relativism as a solution we argue that the homogenization of the rest of the world visàvis sweden makes a mutually constitutive and respectful dialogue impossible in practice educare 139 while the aims of co as expressed in policy documents seem closely related to culturally relevant pedagogy our analysis has shown that it is not the case in practice declaration of interests the authors declare no conflicts of interests

this article contributes to ongoing discussions on education for migrants as a form of integration policy and practice it does so by investigating whether the initiative civic orientation for newly arrived migrants in sweden constitutes an example of culturally relevant education drawing on a mixedmethod and multilevel analysis we hone in on values as a discursive construction in order to see how particular principles are linked to swedishness specifically we show how values are discursively constructed on multiple levels through 1 a qualitative analysis of policy documents instrumental to the implementation of civic orientation 2 a quantitative corpusassisted critical discourse analysis of media articles 3 individual interviews with 14 persons involved in organizing the civic orientation courses and 4 ethnographic classroom observations from six such courses our results show how on the one hand sweden is constructed as the most developed country in the world in terms of values and on the other hand migrants are portrayed as antithetical to such educare 113 an ideal imagination furthermore we show how a specific set of values human rights and democracychanges meaning from being universal to becoming particularized and nationalized as swedish

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introduction in the uk the provision of sexual and reproductive healthcare has historically been made available through the specialties of genitourinary medicine hiv medicine family planning and primary care while gum and hiv medicine practitioners historically focused on the acute needs of their patients in hospital settings fp emphasised prevention providing attendees with contraceptive strategies delivered by women for women within the community from these divergent roots sprung two very different professional and care cultures characterised by differing pay grades professional status and approaches to patient care since the early 1990s however calls for the integration of gum hiv medicine and fp have gained traction it has been argued that the distinction between attendees of fp services on the one hand and gum and hiv medicine attendees on the other is no longer best suited to address the converging sexual and reproductive healthcare needs of the population integration of services it is argued encourages comprehensive horizontal sexual and reproductive healthcare provision by acknowledging the closely related needs of attendees while improving costefficiency of care these rationales have driven policies promoting strategic healthcare change including the uks first ever national sexual health strategy better prevention better services better sexual health calling for the development of broad partnerships and collaboration in the provision of sexual and reproductive healthcare despite these changes there exists only a handful of published evaluations of attendee views and experiences of integration existing studies focus overwhelmingly on the onestop shop a model of service provision wherein a full range of services are brought together under one roof and care is provided by comprehensively trained practitioners studies have discussed a number of concerns that influence attendees preferences for or rejection of integrated services over standalone options including the location and accessibility of the clinic staff attitudes interpersonal relationships and the presence of other attendees competency of delivery and confidentiality and stigma summarising key concerns it is clear that stakeholders are worried about possible changes in the clinic environment staff attitudes and expertise and the presence of others in these new facilities yet given that integration of services involves consolidating all services within one facility it is surprising that none of the existing studies have placed a spatial lens on the question of the experience of such facilities this study addresses this gap by focusing on the link between organisational change clinic design and attendee experiences the following section introduces the spatial concepts used to explore and understand the experiences of attendees as they encountered and made their way through the clinic from therapeutic landscapes to affective landscapes therapeutic landscapes emerged as a concept to examine the way in which naturally occurring landscapes and spiritual retreats were linked to healing comprised of composite affective elements the physical social and symbolic therapeutic landscapes calls for consideration of the affect created by these interconnected environments from its origins as a concept applied to the natural world and spiritual spaces of healing therapeutic landscapes has been adopted as a means through which to examine experiences of psychiatric facilities hospital design complementary therapy and imagined spaces paediatric hospitals the family planning clinic and dementia care homes among others thus therapeutic landscapes has been used as a conceptual tool for examining experiences of a range of healthcare facilities in addition however the concept has also been influential for research into other spaces and settings as diverse as prisons care farming and nonhuman engagements with therapeutic place and entire cities what is evident in the literature is that landscapes have an affect on those experiencing them and that attending to these experiences through a spatial lens provides a unique understanding of the social world yet while therapeutic landscapes has proved a popular heuristic device to be applied to examinations of place experience the concept nevertheless veils somewhat the intangibility of affect and how we might approach understandings thereof this is where considerations of both affect and atmosphere in relation to place experience come in useful as a way of enhancing our understanding of peoples encounters with therapeutic landscapes affect might be understood as a prepersonal field of intensity and is positioned as the pure essential force which is then filtered through embodied social registers in order to be sensed and expressed affect is at times conflated with atmosphere as anderson notes in everyday speech and aesthetic discourse the word atmosphere is used interchangeably with mood feeling ambience tone and other ways of naming collective affects what atmosphere and affect share in common is a certain inaccessibility as existing outside of or beyond language yet somewhat paradoxically the word is used to relate to specific situations in common parlance for example applied to persons spaces and to nature we can recognise that on entering a room one can feel oneself enveloped by a friendly atmosphere or caught up in a tense atmosphere we can say of a person that she radiates an atmosphere so what is the difference between affect and atmosphere bissell suggests that the latter is the spatialisation of the former indeed atmosphere has a propensity a pull or a charge that might emerge in a particular space which might generate particular events and actions feelings and emotions bringing affect and atmosphere together bille bjerregaard and sorensen suggest the concept of affective atmospheres as a way of understanding the staging of design through the use of objects light and symbols yet the staging of affective atmospheres is subject to perception and experience and as such spaces are occupied and acted upon rather atmospheres are perpetually forming and deforming appearing and disappearing as bodies enter into relation with one another they are never finished static or at rest this paper make a number of contributions first it contributes to therapeutic landscapes by applying this theoretical lens to a new type of setting an integrated sexual and reproductive healthcare oss and in doing so addresses the enduring lack of attention awarded to spaces of sexual and reproductive healthcare provision in sociological literature second the inclusion of affect atmosphere and affective atmospheres to the theoretical approach offer a way of thinking about therapeutic landscapes that allows for consideration of the limitations of language in communicating experience of place finally this paper demonstrates the contributions that can be made by applying ethnographic research findings to debates around policy change and integrated service delivery in sexual and reproductive health an introduction to the clinic and its care pathways map of the clinic layout and directional flow of pathways top left entryway topright foyer bottomright main waiting room bottomleft atrium the walkin access route offers the opportunity to arrive at the facility unscheduled without an appointment the walkin runs from 830am 10am monday to friday although access into a peripheral foyer waiting area is available from 7am providing a discrete waiting area as well as shelter from the inclement weather each attendee to the walkin must pick up a numbered triage card on display in the foyer in order to be assessed by the triage nurse the cards specify the rules of access to the walkin which include noting that if an urgent walkin slot is not required the nurse will explain how best to get an appointment with a gp once inside the main waiting room those who have attended the walkin are called up one by one for triage their numbered card serving as a queuing system while also preserving anonymity in the public space of the waiting room once inside triage the healthcare practitioner asks each attendee to outline their reason for attending based upon what the attendee says the hcp will make one of three decisions providing that they can say no to a list of questions outlined on the reverse side of the triage card asymptomatic attendees will be placed on the notalk testing care pathway to be screened for four of the most common stis gonorrhoea chlamydia hiv and syphilis without having to undergo a consultation symptomatic attendees assessed as appropriate for an urgent walkin slot are placed onto the general clinic care pathway once triaged the attendee returns to the main waiting room in order to register with a member of the reception team located at one of three desks running up the righthand side of the space if the individual is allocated a place on the ntt pathway however they will be directed downstairs to a smaller waiting room without having to register those who are not provided with a space at the clinic on either care pathway are sent away unlike walkin attendees booked appointment holders phone a dedicated phone line at which point the operator will offer possible appointment dates it is not uncommon for there to be a wait of at least a month for the intrauterine contraception clinic where women are fitted with longacting reversible contraception including the intrauterine device or the lngius intrauterine system which releases levonorgestrel into the uterus booked appointment holders are required to present to a member of the reception team when they arrive before being directed straight into the clinical wing of the facility for their appointment methods this paper draws upon ethnographicallyinformed research designed to understand attendees experience of the clinic these methods described below were chosen to encourage active engagement in the real time practices and rhythms of the clinic and to equally prioritise the verbal communication between myself and the participants and the expression of affective response to the spaces of the clinic indeed the strength of combining interviews and observations is that there is the possibility of going beyond what is said by social actors allowing for both the subjective articulation of experience and observation of the otherwise unreported routine and subconscious human behaviours within their context in real time recruitment commenced at the walkin in january 2014 and finished when i sent out my last wave of postal invites for booked appointment holders in midnovember with fieldwork ending in december of the same year while the clinic offers a large number of services to a population with diverse needs the study in question focused on booked appointment holders to the iuc and those attending the walkin service this selection was informed by the principles of time people and context set out by hammersley and atkinsons with walkin and booked appointment holders presenting the opportunity to be at the facility at different times of day accompanying attendees with various needs and attending the facility for different reasons furthermore unscheduled walkins were included because the walkin is a popular access route into the facility but one from which a high number of complaints are generated women attending the iuc were chosen for their comparative potential not only when considering their means of accessing the facility but also in terms of their arrival time to the clinic which could range from first thing in the morning through to late afternoon and early evening over the course of the year of fieldwork i accompanied 16 walkin attendees and 13 booked appointment holders on their journey through the clinic sitting with them as they waited in various waiting spaces of the facility observing their consultations and then leaving the facility together to conduct the interview depending on the needs of the attendee the pathway that they were placed on these journeys lasted between 20 minutes and almost 4 hours taken together and when including time spent at the clinic waiting for participants significant time was spent conducting observations at the facility over the year of fieldwork in addition most of the interviews lasted an hour or more a note on engaging with walkin attendees while recruitment of the booked appointment holders used a familiar approach postal invitation packs recruiting from the walkin involved more creative thinking due to the unpredictability of the pathway and the practical obstacles this presented i designed an a4 information poster introducing myself and the study and attached this to the back of the laminate cards required for access to the walkin triage nurses acted as gatekeepers in the recruitment of walkin participants asking individuals if they wished to take part in the research despite fears that recruitment from the walkin would be ineffectual in such a transient and potentially sensitive setting this was not the case indeed on several occasions individuals waiting in the main waiting room approached me as i sat behind the reception desk to ask if they could take part this without having been asked by the triage nurse this receptiveness to the study was entirely unexpected and challenges assumptions about stigma shame and preferences for privacy that were anticipated by all involved in the project including the ethics panel clinicians frontline staff and myself during my time at the clinic i relied upon head notes to collect data this instead of visibly writing notes down i made this decision for two key reasons first i did not wish to make others around me who were not the focus of my study feel monitored second i wished to dedicate my time to the individual with whom i was with rather than compromising this by writing notes participants were generally talkative and when they were not we just waited along with everyone else around us preoccupied by our phones reading magazines or watching the silent television screens if my presence created some behavioural change among those with whom we were waiting it was not obvious to me of course the situation for the participating attendees was different as we were engaged in an ongoing interaction and as such their awareness of their role in the research would almost certainly have influenced their behaviour this said on the occasion that participants did speak of the impact of my presence on their experience it was positive linked to the idea of not being alone as indicated by a number of participants including danny who said well today because i was sitting with you i felt really comfortable it felt ok other times you feel a little bit tense because you are aware that other people are looking at you finally as a person who has used sexual health clinics and views these sites and the people who use them positively i never felt uncomfortable spending time at the clinic headnotes were developed into full fieldnotes at the end of each day which along with transcriptions helped shape my thinking while fieldwork was ongoing once i entered a period of intentioned analysis i familiarised myself with the textual materials i had generated i then began coding inductively and deductively using highlighter pens scissors glue and cards based on a priori interests of the research as well as new insights codes included anxiety knowledge of facility risk preconceptions social landscape stigma and responsibility this process gave me a clear visual representation of my findings however findings described below are limited and situated they represent the experiences that were shared with me by participants at a particular moment in their lives as bloch notes reflecting on ethnographic research the long conversation which the anthropologist observes has begun long before he came and continues on after they leave in this way the findings in this paper will only ever be snapshots of a much more complicated reality that remains beyond what is captured and retold herein finally the study received ethical approval from the universitys research ethics committee findings in this section i discuss the ways in which the component sorting spaces of the facility that is the foyer the main waiting room and the atrium worked to reinforce through the convergence of its affective landscapes the sense that sexual health services are different and deservedly lesser than other healthcare facilities or alleviate these fears through their affective impact arrival waiting in the holding pen the frontier spaces of the facility are comprised of the outer boarded walkway and adjacent entry sign the boundary wall the raised walkway the double set of heavy automatic glass doors and finally the foyer the foyer itself has few features other than a leaflet stand a wall mounted dispenser for laminated triage numbers and objects to encourage appropriate selfgovernance namely a large cctv wallmounted monitor and a notice stating the institutions zero tolerance approach to rude and inappropriate behaviour most notably not only is the foyer unfurnished without seating it has three sets of doors as a consequence of the featureless landscape the presence of doors and the lack of seating the foyers architectural design symbolises its purpose as a space for movement and temporality a space for those who are not yet arrived attendees commonly had to wait in the foyer an experience that was difficult for many accounts often conveyed feelings of discomfort social anxiety and uncertainty the foyer was referred to in a number of ways by participants including the holding pen the nonwaiting waiting room and that wee place the lack of seating was experienced as symbolically loaded penny a young medic who had visited the facility once before in order to get her iuc fitted was returning because she believed she had contracted genital herpes in pennys opinion while the foyer gave people an alternative to standing in the street looking like tramps it was nevertheless strange that there were no seats pennys reaction to the lack of chairs points to her sense that the foyer is a different kind of space and one that would not be acceptable in any other type of clinic pennys negative view of the foyer was not unique in fact all of the participants found it an unpleasant waiting area for reasons linked to the combined affect of its small size lack of seating and the forced social intimacy that resulted libby who was attending the clinic after living with painful symptoms of infection for several months explained it was kin…probably like intimidating like everyone was just it was just silent… noone was really speaking noone made eye contact or anything libby continued saying i just like walked in and there was like ten people just like all up against the wall sitting on the floor and i walked in behind a guy and he got a ticket so i was like ok i take it i have to have one of these so i got a ticket and then took a seat on the floor with everyone else laughing in libbys account she speaks of what hirscheuer in an ethnographic study of elevator rides calls the social constitution of an asocial space goffman describes what he calls civil inattention whereby one gives to another enough visual notice to demonstrate that one appreciates that the other is present while at the next moment withdrawing ones attention from him so as to express that he does not constitute a target of special curiosity or design hirscheuer applies this concept to the ethnographic study of an elevator ride to characterise how people act in tune with one another to create a space that is devoid of interaction it is this civil inattention that resulted in libby experiencing the foyer as intimidating and awkward with noone talking and people avoiding eye contact libby simply sat down using her phone as a prop until the main reception became accessible libbys response to the social space of the foyer is something that others spoke of a type of practicing of or way of being in the space this linking to bissells notion of the propensity of atmosphere already mentioned above in other words there is an affect that governs action among those within the place and generates emotions or feeling a disciplinary capacity of the atmosphere within the frontier stuart a middleaged gay man who feared he was going through seroconversion1 at the time that i met him said he still found the atmosphere in the foyer uneasy despite being familiar with the social landscape of the facility from previous visits aye in that wee place gesticulating towards the foyer thinking oh these people can you know they can see you and theyre like oh i know why youre here i know why youre here umm and thats a wee bit embarrassing for stuart the source of his embarrassment is that he feels everyone knows why he is there and that there is nowhere to hide so to speak a concern which echoes some of the gay men included in the study of the acceptability of integrated service provision by griffiths et al more often than not attendees to the clinic spoke of the foyer in negative terms it was experienced as a space of forced social intimacy an intimidating space an embarrassing space and a space that served to compound their sense of uncertainty and anxiety it signalled to them that this was a different type of healthcare facility this experience of social confinement among others exacerbated the anxieties attendees to the walkin often felt due to preconceptions of stigma attached to the service and the acute personal health concerns they were facing admission the main waiting room crossing the interior threshold from the foyer one enters the main waiting room this sorting space is painted in a light bright tone incorporating moments of colour in cool calm green and blue it is spacious compared to the foyer and the two triage rooms sit at the far end of the room the main waiting room acts as the threshold between the public and private spaces of the facility triage nurses and reception staff categorise individuals under organisational labels determining the care pathway each attendee will follow attendees appeared pleasantly surprised by the appearance of the space describing it with complimentary adjectives such as bright light and open roisin who had spent time in the foyer said i really liked the green décor of the nurses things um rooms you know its a nice big space theres a nice atmosphere to it for roisin the main waiting room was contrary to what she had expected having never been to a sexual health clinic before her only experience of such a facility was what she had seen on a reality tv show about a sexual health clinic in england in which the facility came across a bit grim the fact that she had also spent some 45 minutes sitting on the floor in the foyer had done little to change her expectation i dont know i guess you know its a grotty test you get to sit in a grotty place but it wasnt you know it was spacious and you know plenty of chairs so yeah its nice it was not only those who spent time in the foyer who found the aesthetic of the main waiting room unexpectedly pleasing pippa who was attending the facility via the booked appointment pathway also used the adjective grotty when talking about her expectations of the facility unlike roisin pippa had been to many different sexual and reproductive health care facilities in her lifetime including the now closed standalone fp service where she had attended for some fifteen years in fact it was pippas memory of the waiting room at the fp clinic that caused her to expect the new facility to be grotty as well its a lot more… clean and clinical in its appearance but thats not a bad thing you know there youd be sitting in the waiting room the waiting rooms were grotty whereas in there its clean its fresh it looks bright for roisin and pippa the appearance of the main waiting room at the facility its proportions use of colour cleanliness and fresh paint made a positive first impression of the facility that was unexpected thinking more specifically about the potential for the affective landscape to be therapeutic rather than simply aesthetically pleasing jules account of how the main waiting rooms aesthetic helped to calm her nerves is insightful recounting how she had arrived at the facility in quite a state due to her anxious anticipation around the pain involved in the process of getting her lngius fitted jules noted explicitly that she liked the colours in the main waiting room as well as the light for it helped me keep my mind off what was about to happen the case of jules demonstrates how the affective landscape of a space can have an effect on mood and emotion both negatively as was her response to the exterior of the facility and more positively in the waiting room for many their first impressions were positive a relief from the cramped conditions of the foyer or their preconceptions of a sexual health facility like the foyer before it however the main waiting room is socially heterogeneous the result of the social function of the space to differentiate categorise and spatially arrange attendees through interaction with gatekeepers how individual attendees interpreted and perceived those around them influenced their experiences waiting in this communal space harriet who attended the walkin because she did not wish to wait for a booked appointment found the integrated population of the main waiting room difficult for reasons that appear to be hinged upon concerns over being misclassified i dont want to be with the people for dropin i dont know why it matters but i want that sense of community harriet who also had found the heterogeneity of the foyer difficult spoke of a sense of community that was lacking as she waited in the main waiting room the community harriet felt she was missing was linked to her previous experiences of attending the standalone family planning service a place where she felt she belonged alongside other attendees whom she perceived as being the same as her at the walkin harriet found herself having to share the space with those that she constructed as other people for dropin of course those attending the dropin as harriet referred to them might well have been attending for reasons similar to herself but her perception was that there was a clear distinction between her and them perhaps her most explicit statement was that she worried about touching anything in the main waiting room a space she regarded as contaminated by the grubby fingers of others attending in this way harriet regarded the objects in the space such as the magazines and chairs as what douglas calls conductors of impurity while some attendees did not appear to feel themselves to be the recipients of other peoples judgement within the space danny felt that he was on the receiving end of scrutiny despite having attended on numerous occasions as part of his routine of selfcare as a young gay man danny still felt that it was a space wherein he might be stigmatised by others around him d you do look around and wonder oh theyre probably thinking what have i got or look whats he in for x so you feel a little bit like you might be d might be judged like uh stereotyped like theres another gay man who is constantly getting infections you know ive already got that stigmatism from being gay like so i get stigmatised like every single day and so to come here im expecting the same like even sitting in the waiting room everyones just looking at each other and its just kind of just awkward for danny the main waiting room was a space wherein he was selfconscious of the judgement of those around him dannys comment points to what griffiths et al found in their study of the acceptability of oss facilities among potential attendees including gay men whereby they note that fear of potential homophobia was raised as a reason for osss being viewed as undesirable these accounts of the social landscape of the waiting room make reference to the affective quality of the space which is never only something personal instead a product of a complex mix betweenlight sound bodies gestures 28 thus the main waiting room had both therapeutic and untherapeutic affective qualities crossing the threshold a space to breathe the atrium is quieter much larger and calmer than both the foyer and main waiting room located in the heart of the facility sounds from outside are more muffled the atrium has an aesthetic that belies its location within a specialist medical facility the exterior walls of the old victorian hospital remain exposed and are juxtaposed against the white modern architecture of the extension park style benches are placed in the grand hallway at the foot of the stairway here artwork often commissioned from the local art college are exhibited on the walls at the foot of the stairway the flyer racks that hold information on a number of issues such as hiv testing infections and safe relationships are the only reminder within this space of its location within a sexual and reproductive healthcare facility crucially and unlike the other sorting spaces on the journey the atrium is a space of movement rather than institutionally mediated stasis where the foyer missed an opportunity to address and assuage peoples anxieties about attending the clinic the atrium succeeded lifting attendees out of their preconceptions of a grotty sexual health centre distracting them from the practical function of population control and thus obscuring some of the anxieties around attending attendees found the atrium to be a welcome reprieve from the waiting spaces of the foyer and main waiting room rosa noticed the serenity of the space walking through that door and theres that very open space i mean it was just like oh wow kind of thing and it was all it was kind of more serene than i wouldve expected…um i suppose when i know this part of city name i know the old hospital when it was here you know how it was very much dark corridors and tunnels so i suppose i had that in my head so it was lovely harish attending because he had a rash all over his body and was concerned about it having had unprotected sex also made this point stating the whole building itself when you enter the entrance er looks like its a very small sort of like clinic buts actually not its quite a huge space cause most of it is all underground erm…and i really like the modern bit which is a newly built area on the ground over the course of my time conducting fieldwork i heard the atrium described to me in a number of ways maddie said it reminded her of a museum antonia said that she felt it looked like an art gallery or library while libby felt it was just like a uni building not a doctors as kraftl and adey note although each persons first affective relationship with the place will be different…there are similarities in the affects and affordances produced by such design elements in the case of the atrium we can see that while the places of comparison were different they were also all the same in that none of them regarded the architectural feature as expected for a health facility the atrium had a profound symbolic effect on participants as an unanticipated place of calm which was as penny put it complementary to the open approach to sexual health they have here from the atrium participants went on to their consultation and passed through the foyer again on their way out crossing through an openair corridor which brings more of the public street into view gradually until finally they are back on the pavement discussion and conclusion this research started with the question of how attendees experienced their visit to a fully integrated sexual and reproductive health care oss a question informed by concerns about patient experiences of a facility reshaped by major service change what i found over the course of fieldwork was that participants experiences of the facility were strongly shaped in advance by their preconceptions of the facility personal biography prior experiences of the care pathways and social narratives of stigma attached to sexual health i found that concerns about integration largely borne of policy debates and professional opinions had little relevance to participants actual experience which appeared to be shaped more by their own needs worrying about some aspect of their body or mind than with the practice of integrated services once at the facility these preconceptions were then challenged confirmed and reshaped by the affective propensity of the clinics affective landscapes existing evidence has highlighted little consensus as to the impact of integration on stakeholder experiences and preferences yet in many of these studies participants were made aware of and asked to focus on the integrated nature of the facility an approach which my research suggests may not capture the actual experience of many attendees my findings show the differences between measuring attitudes towards policy which often necessitates narrowing participants focus on a single issue and exploring attendee experiences of place ethnographically widening the lens of enquiry beyond the narrow scope of integration and seeking to explore participants experience of the facility in their own terms this study found participants accounts replete with complex and multiple understandings of the clinic making it hard to pin down exactly how someone does or does not experience integration thus in an era where the patient opinion is neatly parcelled as a sought after commodity richlyobserved qualitative studies which foreground patients own descriptions of their experiences can provide invaluable depth to inform plans for strategic healthcare change exploring the affective landscapes of the clinic my findings show how the physical landscape can reinforce or counteract expectations and anxieties of a sexual and reproductive health care facility the cramped crowded foyer reinforced the personal anxieties of attendees worried about the stigma of the walkin service in contrast the atrium served to disassociate the clinic from negative perceptions of sexual health care including ideas of the clinic as grotty and a place to treat deviant behaviour thus my findings demonstrate the power of physical landscapes to ameliorate or exacerbate the anxieties of attending a sexual and reproductive health care facility there is research to suggest that in therapeutic landscapes the physical landscape matters far less than the creation of a therapeutic social landscape for example in her ethnographic study of the dissident antipsychiatric spaces that survivors of mental health institutions appropriate for their grassroots selfhelp meetings laws points out that spaces do not need to be aesthetically pleasing to be experienced as therapeutic while i am sympathetic to laws summary i argue that a highly transient outpatient space such as my field site which is characterised by social stigma and associated felt stigma of attending where attendance is often experienced selfconsciously coupled with highly transient and rare attendance there is perhaps a greater need to create a therapeutic aesthetic in such a therapeutic landscape where people will not get to know one another the aesthetic can ameliorate anxieties present in the more transient social landscape when considering the implications of my findings for policy and practice i suggest that the most significant issue is that of the reputation of the integrated facility in terms of how it is viewed by the general public and those attending despite the hope that integration will bring with it a diminishing of the stigma associated with gum and hiv medicine integration itself as a policy shift and organisational change does not appear to be sufficient to diminish social stigma in a climate where sexual health remains a cinderella service within the nhs that is neglected and underresourced the question of how to challenge such influences is a pressing one not least because stigma serves as a strong deterrent to attending while it might be difficult for a clinic to challenge the stereotypes that result in making sexual health facilities stigmatized and potentially stigmatising places it is possible to change the impression of the facility among those who do attend in this regard and in relation to my findings i suggest an area for improvement and action gesler notes that therapeutic landscapes can be improved through design features that can be evaluated in terms of their effectiveness this study in the context of sexual and reproductive healthcare delivery supports these findings investments made to the aesthetics of the spaces that comprise the clinic such as the inclusion of artwork natural light and plants might serve to challenge the status of such services as places for the treatment of social deviance yet while there has been much interest in staging atmospheres of healthcare facilities such as palliative care units childrens hospitals and hospices sexual and reproductive healthcare facilities continue to be overlooked

this paper examines the role of affective landscapes in the formation of attendees experiences at a reprovisioned integrated sexual and reproductive healthcare facility the onestop shop oss is an example of the organisational shift towards integrated services occurring across the uk bringing together in one clinic the historically discreet services of genitourinary medicine hiv medicine and family planning an ethnographicallyinformed study of new spaces of care and changed organisation this paper focuses on the experiences of 29 attendees as they made their way along the clinics care pathways drawing on concepts of affect and atmosphere to augment the analytic lens of therapeutic landscapes this paper demonstrates how various spaces of the clinic influenced attendees experiences a cramped featureless holding pen the foyer served to exacerbate preexisting anxieties while creating new fears the main waiting room an organisational sorting space both soothed and aggravated attendees concerns serving as an architectural feature to connect the old victorian hospital with the new clinical extension the atrium was experienced as a space to breathe with an affective atmosphere that challenged the assumed unpleasantness of sexual health clinics this paper demonstrates how affective landscapes of the clinic shape attendee experiences in a novel setting

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introduction many people with intellectual disabilities in australia have lived with and been cared for by families and friends since birth community living in group homes boarding homes and nursing homes were developed to replace large residential centres operated or funded by state and territory governments however group homes were the main alternative to family homes for supported accommodation for people with intellectual disabilities when families or friends were not an option the new south wales government reviewed accommodation and support funding reporting that almost half of its disability budget funded care including supported accommodation for just 3 of the cohort who received governmentfunded services progress towards more person focused individualised housing for people with significant and permanent disabilities which advocates and researchers had long called for and australias 2008 commitment to the un convention on the rights of persons with disabilities requiresculminated in the introduction of australias national disability insurance scheme in stages from 1 july 2013 and the national disability insurance scheme act 2013 this article examines a unique case study selected from 11 doctoral investigations of new homes created by parents or nongovernment organisations for adults with disability taking action to improve their housing and support options housing systems in nsw have frequently excluded adult children living with parents from governmentfunded housing and applying for housing which would otherwise help them move into independent living arrangements the ryde area supported accommodation for intellectually disabled inc case is unique because rasaid families successfully secured nsw government funding to purchase land and australian government funding to build innovative cluster housing on a single large site for 15 adults by working together from 2004 to 2016 further the families collaborated with key politicians who acknowledged the need for housing and committed government funding indeed the research participants shared that the then minister for disability services the hon andrew constance stated that governments and other families could learn from the outcomes for adults with different types of disability living with friends and peers in the cluster the families and residents involvement in selecting and designing characteristics of the completed home environment was equally unique rapoport explained that choice is the central characteristic of the home environment contending that characteristics that are not chosen … are not home this choice is especially critical for people with disability who should be listened to and treated with respect and have a say in where they live and their key support workers the current case study demonstrates that the choice of where a person lives comprises three principal elements the built environment the home environment and home smith argued that a home is where a person has control over performing important social and personal behaviours smith identified essential indicators for a sense of home positive social relationships a positive atmosphere engendering warm feelings care and cosiness personal privacy and freedom opportunities for selfexpression and development and a sense of security and continuity obrien defined three essential elements of home for people with intellectual disability in a residential service setting a sense of place control over the home and supports for living there and security of place through tenancy or ownership including pride of ownership the participatory design activities began with the families identifying three broad goals to meet their housing aspirations for the residents social inclusion first housing in the community would replace the family home second care and paid support would replace the parents roles as caregivers for residents who could not live alone third the residents would remain connected with their social networks and familiar local communities in the families opinion housing good quality paid support and community were interdependent objectives however their initial ideas regarding care and support were nebulous because individual funding was not generally available in 2004 individual choice was the primary philosophy guiding the actions and decisions of the participating families and rasaid the families intended that the residents could choose to live with a community of adults they knew and who were members of rasaid because they lived in or close to ryde specifically they wanted to enable the residents to live in a community within the community parents worked with the residents so they their representatives could choose who would live as neighbours or housemates in the cluster at that stage one young man with high support needs who was expected to share a house with four other adults chose to live alone in his own home in the cluster the families including eight residents shared their visions of the future homes using a personcentred planning tool planning alternative tomorrows with hope with trained external facilitators engaged by nsw ageing disability and home care which oversaw the group home system at the time the rasaid path plan identified several goals for the new homes including houses located together proximity to families individual funding for paid support for each resident and acceptance of rasaids model for a community within the community the goalspecific objectives and who would help achieve them were documented in the path plan indifig 1 the three broad goals of the cluster housing vidual plans were also prepared with each residentfamily member based on their intimate knowledge of the adults needs and interactions with others rasaids concept of a clusterdesigned housing model is consistent with early urban planning research in the united states whyte studied the cluster as the grouping of houses for conservation purposes and using saved land for a common open space or other shared purposes a thoughtful design for the layout of houses sufficient open spaces and an attractive garden tailored to the site and its residents is important the aesthetic appearance of clustered houses must not be neglected whyte noted that cluster is not a frozen format and other connotations of cluster developments include density zoning planned unit development and environmental planning in the current case study the cluster model was chosen to help the residents maintain their existing social connections and gain support from their community by locating the individual homes together however it was also important to ensure that the design included adequate and appropriate private and shared spaces and an underlying unity regarding roof lines and setbacks which was aesthetically pleasing three research questions were addressed in this study what type of home did parents choose for their children with intellectual disabilities and why what type of home did they achieve how did they overcome challenges to accomplish building the home theoretical background housing housing research in australia has focused on affordability need and undersupply of lowrent stock which includes two social housing types public and community although many people with disability live in social housing they are considered just one among many disadvantaged groups needing governmentfunded homes because they cannot afford to rent or buy a house historically people with certain disabilities have been excluded from both social housing types in nsw for various reasons for instance public housing includes aged buildings that are inaccessible for some people with physical disabilities while social housing is not rentfree for support workers who need their own room in the persons home adults with disability living with family members have been considered a low priority in housing allocations because they were not considered homeless or at risk of homelessness group homes in nsw group homes have been the dominant model for supported residential accommodation although the model was used earlier richmond recommended that people with developmental disability moving from institutions be rehoused in normal houses in the community at that time normal houses comprised threeto fivebedroom households on single urban lots that a type of family had aspired to live in since the 1950s more recently bigby and bould described group homes as averagelooking houses in ordinary streets in other words the design format of the house and built setting for group homes has been relatively static in nsw regarding the home environment richmond assumed that group home residents would connect with their neighbours and participate in community life however no evidence exists that this generally occurred group home living is also inconsistent with the trend towards communal living and coliving environments where people choose their community and which reflects the wider pattern of australian households adapting to population growth housing affordability and changing lifestyles thus a community is no longer something out there where people must be placed residential institutions in australia state or territory governments provided or funded nonprofit organisations to operate group homes and support as a bundled service for people with disability with an increasing number of group homes when large residential institutions were closing down early research on this deinstitutionalisation of group living documented the negative aspects of large residential institutions for people with intellectual disabilities and critically examined community life for people with intellectual disabilities living in dispersed living arrangements like group homes the literature has established that institution in a residential setting is a composite concept with various characteristics regarding the built form staffing model purpose or function and experiences of people living in such places which was usually negative institutionlike features ranged from obsolete architecture and design lack of facilities and comfort segregation regimented living arrangements and daily activities and the mistreatment of residents other negative aspects included their location in out of the way communities creating issues with recruiting and retaining qualified staff at the same time wolfensberger developed the social role valorisation framework and translated it into goals and processes for delivering services to people with disabilities who have autonomy rights individual choice and valued social roles more recently researchers have asked why services in some group homes are often not as good as they should be and whether this is due to the operating pressures of the economy management and regulations on service providers or other factors however alongside these factors governments established group homes as segregated accommodations into which people who did not know each other and did not choose to live together were placed as housemates segregated accommodation has long been considered a type of institutional living in australia additionally being placed in any home is inconsistent with the person with disabilitys right to choose where they live clustered housing versus group homes by comparing the quality of support services ratio of support workers to residents support costs and mixed quantitative and qualitative measures across the different quality of life domains in both cluster housing and dispersed living arrangements mansell and beadlebrown concluded that people with disability experienced better qol outcomes in group homes with the exception of village communities however examinations of settings with institutionlike characteristics as a cluster have been common for example mansell and beadlebrown reviewed 19 studies on the experiences of approximately 2500 people from four countries clustered housing included clustered settings with at least 100 places clustered settings with 2055 places residential campuses providing day services onsite and smaller living arrangements in contrast with these large clustered settings as a service and staffing model mansell and beadlebrown acknowledged that village communities facilitated close personal relationships and were superior to dispersed living models like group homes conversely bigby criticised intentional communities in a cluster setting for people with intellectual disabilities as institutionlike and highlighted emersons findings of poorer quality care and qol outcomes for residents with intellectual disabilities in clustered housing in england however emerson noted that his findings might not fully represent adults receiving residential support in england some were used for shortterm care and his research lacked withinstudy reliability or data collection validity indeed the clustered housing emerson examined did not exhibit the characteristics of village intentional communities and his views that public agencies cannot provide cluster housing that shares the benefits of village communities or a connected community of people with intellectual disabilities are inconsistent with modern intentional communities for example the rougemont cooperative is a governmentfunded 105unit housing cooperative in ontario established for a small number of adults with different disabilities living with many other residents the benambra intentional community in canberra was established with governmentfunded public housing and paid support for three men living separately with their coresidents and neighbours who applied to live there additionally the literature review revealed a lack of longitudinal studies regarding qol outcomes in both group homes and cluster housing while the findings pertain to housing models and organisations that have subsequently evolved building rules and design standards the challenge of not rebuilding institutions when housing and support are established for people with intellectual disabilities is always present in the researchers opinion there are additional challenges with building new governmentfunded housing where many stakeholders with different priorities and interests must deliver the housing as a property development project building professionals focus on ensuring designs and finalasbuilt housing comply with standards and rules including technical standards and building contracts investors or housing providers who ownmanage housing assets focus on qualifying for government funding the quality of building work and maintenance for houses policymakers and government agencies monitor compliance with rules and administer housing under government policies however these stakeholders are not responsible for ensuring holistic housing designs or that home environments will meet future residents needs and preferences they may believe that a standard design that can be replicated on a large scale is less costly therefore it is important for people with disability their representatives and advocates to lay the groundwork for their inclusion in the design process of their housing building rules in australia are based on the function or purpose of a particular type of building the number and characteristics of people who will occupy that building the responsibilities of building professionals to achieve safety and quality standards and planning standards designed to mitigate the negative effects of the design or use of that building on its residents neighbours and nearby buildings governments also encourage innovation in housing but building rules design standards and policies regarding the choice of housemate or coliving must not limit innovation sections 251 to 253 explain the relevant design standards specialist disability accommodation australias ndis commenced in 2013 to replace disability services provided by each state and territory government for people with permanent and significant disabilities in 2015 all australian governments agreed to the ndis specialist disability accommodation pricing and payments framework developed to determine funding for sda individual funding has been available for people with an extreme functional impairment or very high support needs rules 2020 sda rules s 11 since 2017 however other eligibility criteria apply when a person is deemed eligible for sda funding the funding is included in their ndisfunded plan once the sda participant resides in the sda and has a service agreement with the provider the national disability insurance agency pays that funding to the provider typically monthly the sda participant pays a reasonable rent contribution to the provider currently 25 of their disability support pension and any rent assistance from the australian government funding cannot be used for sdas that are still under development or in planning the ndis specialist disability accommodation design standard lists requirements that must be incorporated into new buildings before they are eligible for enrolment when housing meets the enrolment requirements it is enrolled and becomes eligible for an sda participant subject to other criteria like the sda participants preferences and support needs the sda design standard was not developed when the cluster houses were designed or built instead the government construction contract required the houses to comply with the livable housing design guidelines for ageing in place livable housing design guidelines the lhd guidelines were developed to ensure new houses are built with design features that support ageing in place compliance can be a term of governmentfunded building contracts for constructing disability accommodation or other social housing in the current case study the building contract specified that the houses would comply with the lhd guidelines a more recent version contains 15 livable housing design elements regarding different specification levels for accessible housing there are seven core elements for achieving a silverlevel specification for minimum accessibility additional design elements must be satisfied to achieve a goldlevel specification for enhanced accessibility or a platinumlevel specification for full accessibility features of all 15 design elements specialist disability accommodation design standard the sda design standard specifies the minimum requirements for housing in four design categories improved livability robustness full accessibility and high physical support to ensure sdas are built to meet a persons specific disability needs for example sda designs for residents who need high physical support must provide power and an inbuilt structure for a ceiling hoist although the sda design standard reduces or removes some design choices of the sda participant the ndis provides new opportunities to consider the role of people with disability as designers of their own homes supported independent living funding for an individuals inhome support is separate from sda funding a person eligible for sil may have more choice over where they live including public housing and nonsda community housing but will require separate sda funding to live in sda further some sda participants will not qualify for sil depending on their circumstances participatory design conflict and contradictions even when a participatory design approach is adopted to build new sdas and people with disability or their representatives contribute as designers conflicts and contradictions in these development projects may arise when architects planning authorities certifiers and builders perform their designated roles to comply with building rules and design standards these experts practices reflect the expert mindset of professionals with agreed roles in design and construction processes sanders distinguished this expert mindset from a participatory mindset which includes people with lived experiences across different domains in the design process as true design experts burkett reported a third userled participatory design approach where people design and create solutions to their own situations like the independent living movement of people with disabilities who work for selfdetermination equal opportunities and selfhelp research has identified three principles in scandinavian participatory design approaches which focus on selfhelp first designs strive for democratisation for example to address the lack of access to decisionmaking power or facilitate greater influence over resources this includes advocates taking the lead for change by promoting solutions to their own issues that have been overlooked it can involve oneoff codesign activities or events if decisionmaking and power are shared and boundaries such as disability do not exclude their contribution second valueoriented designs explicitly embed values in design strategies and choices discuss values that are implicit and explicit in imagined futures and adopt participatory design methods for critiquing the present and envisioning change individuals with cognitive disabilities sometimes use the personcentred path tool to share their vision for their imagined future this principle should also include designs to achieve valuebased social change objectives third the approach requires recognising conflicts and contradictions as design resources for gregory conflict refers to different perspectives arguments heterogeneity or contradictions evidence of conflicts and contradictions includes delays a lack of progress and setbacks unresolved differences unmet agreements and objectives not being achieved notwithstanding iterative meetings workshops or other such efforts conflicts and contradictions create design resources when one or more stakeholders introduce new ideas resources tools or understanding to achieve their objectives foote et al used activity theory to explain design as a collective activity with contradictions that may generate new tools and understandings which can shift existing patterns of control expertise and legitimacy to provide solutions for example a participatory approach with a broader group of design experts such as people with disability who possess expertise and legitimacy through their lived experiences may contribute new dimensions and solutions not previously considered a participatory approach in building design and construction may also align different stakeholders priorities and enable interventions to achieve the desired solution a participatory approach that includes users as designers from a projects beginning has been recommended methods case study a case study was used to report the perspectives of rasaid and the families who challenged the government agencies policies attitudes and practices that failed to provide housing for the residents aged 21 to 50 years in 2004 their collective advocacy led rasaid to secure government funding to build new houses for the residents the land was purchased and building planning commenced in 2013 construction was completed in 2016 the cluster homes comprise a fivebedroom house six singlebed units and two twobedroom villas data collection data were collected through semistructured interviews with three consenting parents residents were not interviewed because the study specifically investigated the rasaid fami lies systemlevel activities participants were interviewed together on two occasions each lasting more than one hour the questions were based on themes drawn from the literature review for the doctoral research probing questions helped gain a deeper understanding of the families experiences strategies and activities including their interactions with other stakeholders to achieve their goals the university of technology sydney human research ethics committee approved the research and interview questions participants consented to the use of their real names in the study the disability types of some residents included cornelia de lange syndrome severe to moderate intellectual disability autisticlike behaviours and anxiety verbal skills included limited and mostly nonverbal for a few residents some residents could read and some were quite vocal although the researcher visited the cluster twice and met some residents she was unknown to them and their activities were not the studys focus constance who assisted the parents as the minister for disability services could not participate after the ethics consent form was sent to him at his request prior consent to interview adhc staff could not be obtained because the adhc ceased operating after the ndis commenced and nsw group homes had been outsourced by lease or sale the community housing providers project managers and relevant staff had also left their employer before this study historical data analysis included public documents media releases newspaper articles and the rasaid path plan some data were available on rasaids website including a draft architectural drawing for the cluster concept one participant checked rasaids diaries to count the meetings with stakeholders for different purposes over 12 years john alexanders speech which is publicly available also provided a relevant perspective a separate group of families who incorporated to advocate and establish independent living arrangements for their children were a second case study for the doctoral research one parent in that study created a record of attractive fixturesfittings in the rasaid cluster housing and made that record available in a third case study for the doctoral research ms clark advocated for her daughters home she shared a key document written by rasaid describing its aims for its members research analysis nvivo qualitative data analysis software was used for theming the interview and historical data for the doctoral research culturalhistorical activity theory was the appropriate framework for mapping thematic data to answer the rqs it provided a structured framework for studying the interaction of six elements of an activity system or unit of activity the desired goal who desired the goal who worked with the subject to achieve the goal what resources or approaches were used to achieve the goal how work was shared and what rules attitudes and practices supported or constrained the goal figure 3 represents an activity system as an analytical tool with key questions to be answered engeström demonstrated that activity systems are in constant movement and internally contradictory while foote et al noted that contradictions lead to learnings understandings and tools for new solutions for example in the current case study contradictions existed where the stakeholders interestspriorities and objectives were inconsistent or incompatible tools were inadequate or rules were barriers for the families to overcome this was illustrated by the adhc requiring families to secure construction funding before approving the land and the families acting to secure construction funding from the australian government social and contextual factors influencing activities are important when parties navigate politics policies housing and services over extended periods figure 4 illustrates that changes to social and contextual factors over time like the introduction of the ndis can influence prospects of success contradictions within the activity systems were analysed and depicted by lightning bolt symbols resolutions of contradictions were depicted by removing the symbols because the families and rasaids activities decisions and transactions occurred over many years it was necessary to create a timeline of key events to compare the interview data and parents activities with publicly available information this timeline helped identify when progress and setbacks occurred the relationships between activities or interactions between peopleorganisations and progresssetbacks the relationships between particular types of events resource contributions and the overall process of delivering the cluster model bias and reflexivity the researchers attitude was reflexive throughout the study because beliefs biases and values can always be present when conducting interviews merriam and tisdell reminded researchers to consider how their views affect the research process and findings the researcher for the current case study was a student volunteer in a psychiatric centre for a week in 1976 and observed inappropriate and aggressive behaviour involving vulnerable people between 2014 and 2022 she was a volunteer director on the fig 3 the activity system as an analytical tool board of three disability service providers and a chp she had also worked with politicians and bureaucrats and as a property and finance transaction lawyer she disclosed her assumption that the families government and other stakeholders collaborated to build the cluster as a shared objective because of the commitment of government funding and successful cluster construction she did not disclose her assumption that the minister for disability services would not participate because the study was not governmentfunded or controlled results three types of governmentfunded housing systems were not available for the residents even though some were in their fifties it was not possible to assume that these housing systems and government agencies that excluded the residents would respond appropriately when parents were too old or sick to provide caregiving or when they died therefore it was a priority for the families to help their children move into their own homes in a planned timely and orderly way particularly because some parents were in their eighties section 4 addresses the rqs by describing how the families achieved their goal of establishing their childs own home within their community fig 4 the contradictions experienced while developing the cluster housing note rasaid ryde area supported accommodation for intellectually disabled inc research question 1 a clusterdesigned home as the goal the families chose a cluster design for the built and home environment of the new homes to ensure the social inclusion of the residents and meet three broad goals living in a community within a community obtaining attractive housing with friendly neighbours and gaining personalised support from support workers chosen by the residents or their representatives following the philosophy of individual choice in the path plan the families expressed their vision that the residents would live together as an intentional community of people who are friends or know each other in a location that would help maintain their existing social networks the families agreed that each resident would live in an aesthetically pleasing house in an attractive street setting with friendly neighbours people driving or walking past the house should not consider the house or residents any different from themselves regarding paid support the purpose or function of the clustered homes was not a congregated careservice provider or employment model in which a provider would control both housing and staff allocations similarly they were not intended to increase the residents dependence on paid support instead the families opted for a familyled model with a support provider separate from the housing provider and matched to each residents needs although the residents or their representatives could terminate the support providers services the families aimed to partner with a provider that shared their personcentred philosophy while family members living nearby would help when needed it was intended that they would reduce their oversight as the residents became more confident and vocal in their own homes research question 2 personcentred clustered homes as the outcome individual choice the three broad objectives of the cluster housing project came to fruition when the residents moved into the completed cluster first before their move the families asked the residents whether they wanted to live alone or with a housemate the homes reflected their choice or their family representatives understanding of their preference and interaction with others rp shields i always thought my son would want to live in the fivebedroom house i thought he would need that level of support but one night we had the plan set up on the kitchen table and my son said very clearly i want to be by myself so that was the right thing for him second the families wanted to ensure that the residents would not feel lonely and could live with friends or people they knew as neighbours or housemates in the cluster rp shields we didnt know if it was going to be successful we just thought we were all good friends the kids didnt all know each other but they all knew somebody there wasnt anyone going in without any links at all … what we didnt understand at the time was how well it was going to work third the families decided that the cluster housing would not appear institutionlike thus the families codesigned the private and shared spaces to include the communal room and garden based on their understanding of each residents preferences and how they interacted with others fourth during construction the families rejected fixturesfittings that were institutionlike inappropriate or unusable insisting that such features be removed rp rollo it was a deliberate attempt to deinstitutionalise it make it look like any house in the street that was our aim and we actually achieved that because you can look around at any houses and you can pick out the disability houses but you cant do that with rasaid one example was the wheelchair access stencils for the driveways rp shields to show them where to park the bus like it was a council car park or something but we said no and we were able to get the independent living centre ilc onsite to tell them this was not needed other examples included installed rails that resembled cattle grids and glass doors in the fivebedroom house that allowed people outside to look in on the residents rp poole if you have a camber a ramp of a certain degree its got to have rails under the platinum standards so when it was designed we made sure that all of the paths up to the front doors and everything else was at the right level so we didnt have to have railings we drove past one day and theyd put all these railings in rp shields at another stage theyd put in seethrough glass doors for the front doors we made them take out all the glass doors rp rollo and all the rails rp poole they were saying they had to be in because of this reason we said but that was not in the design so we ended up getting the ilc out again the only way we could get around having the railings because they had installed the ramps incorrectly was by not having a gate to every front door which we didnt need so they had to be filled in fifth social connections with neighbours and the broader community were extremely important therefore the families invited the community to the sodturning ceremony to mark the beginning of construction and neighbours to visit the cluster after the houses were built during their visit relatives of the previous owner were delighted that a parent had planted the previous owners roses back in the garden near the fivebedroom house sixth social connection between residents was also critical thus the personcentred design balanced each residents need for privacy and control over their private space while ensuring they could visit each other if and when they chose generally the residents eat separately in their homes but they celebrate birthdays or special occasions in the communal room with its dining area television jukebox and barbeque last the home environments are personcentred with the fitout overseen by parents to the maximum extent possible each bathroom was individualised and each resident chose their feature tiles and bath or shower with shower screens for privacy each resident also chose the colour of the feature walls in their bedrooms some parents persisted in having a purposebuilt wardrobe which had to fit all their belongings including linen air conditioners and fans were installed for temperature control attractive features including plantation shutters were also added with their attention to aesthetic and functional details the parents created a home environment that was comfortable welcoming attractive and easy to use rasaid has continuously operated as a familyled group overseeing living arrangements house maintenance and paid support for the residents in 2014 rasaid appointed a service provider to employ support workers for the residents the paid support arrangement began in 2016 when the residents moved into their new homes years later family members still visit weekly or more regularly to keep an eye on different issues including attendance at individual appointments changes to rostered staff and the safety and happiness of the residents the parents do not require permission to visit and can freely access their family members files which their support worker maintains participatory design when the cluster was built each rp took a slightly different approach to enable the residents to choose to move into their own homes one rps son hates change of any sort so he started with a single night as a trial when his parents asked him about it he answered not sure he returned to the cluster for a second trial and has not slept at the family home since rp1 as soon as he understood this was his place he said this is my place they say of all of them my son is the most proprietorial and sometimes hell tell a staff person this is my place i dont want you i think it is good another rps son was meant to move into his new home gradually rp2 he went for two nights and he was okay now hell only come back to the family home for christmas and easter rp1 and hes changed a lot hes become much more vocal rp2 vocal outgoing and again he will say i dont want to do that hes completely changed rp1 hes also taken over the role of tour guide the third rps son was expected to transition slowly his mother chose the cluster because she felt he would be safer it was also important that he have people to interact with because he was used to having many family members around he visited the cluster when it was being built rp3 he knew this was where he was going to live i was afraid that he wouldnt transition well so i took him there for his first night thinking he would be back home the second night he hasnt been home since because thats his house rp2 actually he would not put his shoes on so he couldnt get on the bus this sons decision regarding his shoes was his way of communicating his decision to move into his cluster home rasaid successfully provided the residents with a sense of place they were so attached to their personal spaces that in 2019 they rejected some parents suggestion that they move around in the cluster the parents described this learning rp1 theyve attained ownership of their own little place researcher did you envisage that rp3 no rp1 they couldnt ever have ownership before rp3 its a really positive outcome theyre very houseproud for context the ndis was being implemented as the residents moved into the cluster housing policy changes included individual funding before the ndis commenced and the classification of the cluster housing as sda after the pricing and payments framework was implemented the residents receive individual sda funding of approximately aud30000 annually thus approximately aud450000 is paid each year to the chp as an sdaregistered provider it is expected that the chp will apply this funding to build more sdas because the nsw and australian governments funded the clusters construction and land purchase respectively the residents also receive sil funding for paid support workers who assist each resident in their home research question 3 overcoming challenges to achieve cluster housing the families overcame numerous challenges to ensure the clusterdesigned homes were completed they began monthly meetings in october 2004 rp rollo learnt about the importance of registering an organisation as a charity for fundraising when she started a support group for people with her sons type of disability their families and carers thus the participatory design activities to deliver the new homes included the incorporation of rasaid by rp rollo to represent the families as a collective and its registration as a charity to receive donations the families then developed rasaids objectives and strategies to secure government funding for the land paid support and construction the doctoral research rps explained that rasaids corporate status distinguished collective activities from individual activities and provided the families with corporate standing to lobby politicians and bureaucrats which was the first step in the design process the families then met with successive ministers for disability services however none agreed to fund the project it was a turning point when constance became the new minister for disability services and committed aud3 million to purchase land for the development in april 2011 and individual paid support for each resident at the same time political support for a national disability scheme was growing across australia including the productivity commissions recommendation to introduce the ndis nonetheless the families encountered new challenges to their participation in design decisions when other stakeholders with conflicting interests were engaged in delivering the project in particular the parents encountered unnecessary bureaucracy and the adhcs contention that the houses be built using a standard group home design which delayed their progress bureaucracy first the nsw government agreed to fund only the land for the project and required a chp to own the land and manage the housing to be built for the residents the registrar of community housing regulates chps in nsw under a registration framework that requires chps to report the efficient delivery of new housing for lowincome tenants and residents the chps had experience operating social housing however they generally had little understanding of disability accommodation or the philosophy of control and choice at this time the adhc and chps had limited experience sharing control in designing or constructing a property with future residents and the families could not control when the funding would be spent or new homes built second the minister for disability services handed the cluster project to the adhc and requested its staff to help the families build new homes however the aud3 million funding was insufficient to both purchase the land and build on it the adhc staff insisted that the land could not be purchased until the families provided or secured construction funding the parents approached the australian government for assistance and a key politician encouraged them to apply for grant funding from the aud60 million supported accommodation innovation fund which was established to help build innovative communitybased accommodation places for people with disability when rasaid informed the adhc that they intended to apply for saif funding the adhc responded that the saif was not for rasaid the families disagreed and applied for a saif grant in partnership with the chp in november 2011 in april 2012 rasaid and the chp were awarded a saif grant to build rasaids cluster design homes third the land selection process for the cluster housing was bureaucratic the location was important because the residents needed to remain close to their work or day programs and reduce the need for long and expensive travel however other stakeholders were seeking big blocks of land in industrial and other unsuitable areas therefore the families intervened and found the required land in a friendly neighbourhood with help from rotary macquarie park which the vendor was willing to sell at mates rates the land was a level block which was ideal for the residents unfortunately unnatural levels were created during the building work group home model the families next challenge arose when the adhc staff stated that the new homes should be built using the standard group home design because they did not approve of people with intellectual disability living together in clustered housing the adhc staff informed the families that the cluster would rebuild institutions rp rollo adhc staff said everybody has to have their own gate their own letterbox their own parking space … and we said but none of them drive … and they said well lets look at the design so they got this mock design … and everybody had a letterbox and front gate and the car space and there was no yard the house what was then a fourbedroom house had no windows you had a front door a back door and no windows the families rejected the mock design and were determined that the new homes would be an innovative cluster design the adhc and chp organised a workshop to discuss the adhcs design with the families and other stakeholders who were not known to the families using butcher paper and other tools the adhc staff and the chp produced 20 concept plans which the families would not approve the rasaid parents finally said no stop clear it two parents visited the draftsmans office and over two hours explained their aims and finally achieved a basic plan reflecting their concept they also refused to accept the adhcs objection to a communal room in the cluster that was a big fight thus the findings reveal that the design and construction processes involved numerous conflicts iterative meetings and interventions by the parents because the adhc staff chp project managers and builder had no understanding or experience with disability personcentred design or individualised funding building rules and design standards during construction two rasaid parents invited themselves to meetings with the builder chp and project managers to ensure the collective plan was accomplished they learnt that the application and interpretation of the lhd guidelines were problematic first the families were informed that the houses would be built following platinumlevel specifications due to government funding even though silveror goldlevel specifications usually apply several aspects of these specifications were unclear at that time and interpretation of the platinumlevel design elements was contested during construction and difficult to apply to housing for people with intellectual disabilities rp poole the housing provider and the people overseeing the build said everything had to be the platinum standard but everybodys definition of platinum was different they said everything had to be wheelchairaccessible but they were putting in basins too low toilets too high and benches were the wrong height … rp shields we werent going to have kitchen cupboards because we had to have wheelchairaccessible sinks and things we said … but our guys are not in wheelchairs rp poole two were in wheelchairs researcher their idea of disability was physical disability rp poole absolutely second although the parents were design experts in understanding their childrens needs and preferences they were not wellversed in the applicable building rules or design standards therefore they engaged a building expert from the independent living centre nsw who was a wheelchair user rp poole we got the expert from the ilc involved fantastic man he was a builder who had an accident so now hes in a wheelchair … he came around when wed started building and hed say the toilets too high i cant go across onto it and the basins are too low the cluster builder listened to and learnt from the ilc builder because he could interpret the building code technical rules and design guidelines from the perspective of a person with disability while explaining or demonstrating onsite when something did not work the ilc builder was both a disability and building expert while the families had prioritised the design requirements for the home environment and the residents functional needs and preferences the builders role was to build the cluster following architectural design and comply with relevant building rules and design standards for assetbased outcomes when construction began the builder and other construction experts were accountable to the adhc the chp the federal government agency that administered the saif grant and their respective project managers however none of these experts understood or had experience with the residents disabilities thus the families design activities during construction involved intervention by two rasaid parents iterative meetings and some disagreements rp rollo although they had our money we had our collective plan of what we wanted we knew what individuals needed within that plan we said its our place so were coming to your meetings from the families perspective they achieved personcentred outcomes using their cluster housing design by focusing on various typologies for the individual houses chosen by the residents family governance of paid support using rasaid social relationships for the residents and ways for giving them control and choice in their home environment the families agreed on what they wanted as a group and singly when asking the residents how they wanted to live for instance rp shields we did ask each individual that was going to move in where they wanted to live we built the place for the people that were going to live there as they requested it indeed from alexanders perspective the stateoftheart rasaid cluster was accomplished through the parents perseverance tenacity and strength discussion this case study aimed to use three rqs to examine community living and a cluster home model for adults with intellectual disability requiring paid support the rasaid families chose clusterdesigned housing for the residents to live in a community together in an inclusive and friendly neighbourhood close to family and friends they achieved personcentred homes that were individualised according to the residents requests engeströms activity theory framework was used to map familyled systemlevel activities across different sectors and examine how families achieved their goals the relevant systems were identified by the resources needed to create the new homes and people in positions with authority who could commit those resources including politicians responsible for government agencies that supplied or operated housing assets or services for people with disability the resources or tools used to build the families participatory approach included housing advocacy lobbying politicians across different government levels community campaigning persistence and determination and incorporating rasaid to represent them when meeting with key stakeholders including government agency staff ministers for disability the chp project managers and building professionals a chp began working with the adhc and families learning the design requirements for individualised personcentred homes when the minister for disability services required that the homes be owned and operated as community housing assets instead of funding rasaid to build the cluster the families had not invited assistance from a chp because the community housing system had not been available to people with disability who needed paid support in their homes seven days a week although the families could not fund the land purchase or construction they contributed their advocacy knowledge of their childrens disabilities and understanding of the design requirements for the individual homes which would be nested within a modern familyled clusterdesigned community the families included the residents in the design process and empowered them to choose their new homes most importantly the residents have attained ownership over their homes pride in where they live and security of tenure family oversight remains in place the families monitor the quality of paid support chosen support workers and the chps maintenance of the houses to maintain an inclusive personcentred community of friends or peers rasaid manages vacancies with a waiting list of people who wish to become residents when the opportunity arises some people on the waiting list require either a single unit the highcare house with five residents or a lowersupport house living with another resident the main criterion is compatibility with the current residents however vacancies are rare with only two in seven years conclusion the families and rasaid defied the beliefs of the adhc staff that the residents should not live in a group they withstood criticism of the cluster housing model from the adhc which argued that the cluster would simply recreate institutions however this case study has confirmed that housing is institutionlike if it creates barriers to the critical elements of community participation social connection personcentred support and individual choice regarding private and shared spaces conversely the clusterdesigned homes were chosen to access and improve those critical elements indeed the families argued that if other people could live together in groups the residents who knew each other should also be permitted to live as neighbours or housemates further the study demonstrated that the smaller fiveperson group could live in a highsupport home not controlled by the support or housing provider in the cluster these residents can visit each other if they choose and continue to participate in outside employment or daytime activities the overriding priority is that negative institutionlike practices are challenged and residents needs are funded and met the families demonstrated that the social outcomes for the residents were positive in ways neither residents nor families anticipated the cluster design as a built and social format achieved individual personcentred homes for residents who were proud to live there offering a model for existing groups with strong community ties or who choose to live together the model is for groups of people with intellectual disabilities who receive ndisfunded sil and can be replicated this case study demonstrated that the social benefits of individual and group living warrant further study the credibility and transferability of the findings from a single case study with only 15 residents require further research on the clusterdesigned model future research could also investigate living arrangement models from the social relationship government and chp perspectives developing this knowledge and using participatory approaches would improve the design of communities and homes in governmentfunded housing enabling better social and housing outcomes for residents further researchers should continue exploring the relationship between the design or typology of physical housing individual choice of housing locations and living arrangements control of paid support and outcomes finally institutions are not just a form of housing or the number of residents or key workers rules regarding how many people can live together must accommodate opportunities for stronger social connections different community types and choice of location and housemates government attempts to innovate and improve housing systems including access to all housing systems for people with disability can fail if policies require segregated living or limit group sizes a home for living specialist disability accommodation innovation plan anticipated that modern sda designs would promote independence community inclusion and governmentfunded housing that is not populationdense the families offered such innovation through their alternative housing approach notably ndis funding was offered and received after the cluster was built demonstrating that it will fund innovation when governments welcome new ideas and flexible funding rules data availability interview transcript is saved on stash storage system

a case study of 20 families investigated a cluster design of new homes for 15 adults with intellectual disabilities in australia it explored how families created a cluster home model for adults to live in their own homes with paid support in a modern context by answering three research questions what type of home did parents choose for their children with intellectual disabilities and why what type of home did they achieve how did they overcome challenges to accomplish building the home families adopted a participatory design approach collaborating as learning partners to secure government funding for purchasing land and constructing their cluster design however it was a complex project requiring many stakeholders with conflicting interests and priorities specifically families rejected the group home model preferred by government agency staff shifted the focus from technical building rules and design standards to prioritise each adults needs and preferences for their home rejected institutionlike fixturesfittings when installed and used family governance to choose key support workers directly ultimately the families created security of place through tenancy in attractive homes with government funding welcoming neighbours and chosen support workers

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introduction much is known about how wages have grown or stagnated and become more unequal across a range of countries though to differing extents and about how these trends may be linked to changing technologies work organization labor market institutions and intensified global competition it should also be illuminating due to interest in the role of labor market institutions to observe how job quality trends for areas other than wages vary across countries and between varieties of capitalism since the inception of the european employment strategy in the late 1990s there has been some emphasis in european policy discourse on the quality as well as the quantity of employment and the link between job quality and wellbeing at work has entered as an ingredient of the advocated broader approach to the measurement of national wellbeing yet changes in nonwage aspects of job quality across countries have been less well documented than the evolution of wages there are studies of particular features such as insecurity or intensification usually in single countries but few which take a perspective over a range of countries and multiple domains of job quality and none which are able to present an uptodate picture following the great recession of 20089 the aim of this paper is to examine trends in several nonwage aspects of job quality in europe we examine these trends in the light of existing theories and expectations about the evolution of job quality taking the analysis up to 2010 and covering 15 countries across europe 1 in line with developing practice we utilize an objective concept of job quality which defines it as a set of features that help to meet jobholders needs from work this approach means that we include only variables characterizing jobs leaving out those applying to individuals lives or their preferences 2 also omitted are variables capturing the labor market environment of jobs such as the unemployment rate and the level of social protection thus our analysis is more focused than others using wider classes of variables such as the international labour organisations decent work index or the quality of employment indices being developed by the united nations economic commission for europe in addition to wages job quality comprises the jobs prospects features conducive to a good worklife balance and several intrinsic aspects of jobsincluding the quality of the work itself its physical environment and its pace or intensity and the social relations at work 3 while all of these features are captured to some degree in our data for 2010 not all are available over a sufficient time interval to permit an analysis of trends nevertheless basing our analyses on successive waves at 5year intervals of the european working conditions surveys we are able to report for the first time on trends in multiple domains for which previously there has been little information theory and previous literature generate contrasting predictions as to how the level and dispersion of job quality is thought to have evolved there are optimistic predictions that job quality will have improved with economic growth and that regulatory forces and workers demand will have reduced differences in working conditions but these predictions are contested by those who emphasize the persistence of neofordist labor processes and are set against expectations that the inequality will have increased derived from extrapolation of the theory and evidence on rising wage inequality there are also different perspectives as to whether job quality trends are similar in many countries or whether national differences in regulations and in labor market institutions have induced different paths of development both varieties of capitalism and power resources theories of how institutions affect the functioning of labor markets expect to find job quality differences between nations and there is some evidence of better job quality in nordic countries discovering whether there are divergent paths of change provides a useful test of the importance of nationallevel institutions we therefore focus on the dispersion as well as the level of nonwage job quality and on the extent to which there may be divergent or convergent trends between countries we first report on the construction of four job quality indices covering work quality work intensity the physical environment of work and features of working time conducive to a good worklife balance we expect to find considerable continuity but are also interested in the directions of change to study dispersion we examine both the gaps between socioeconomic groups and the differences among individuals within countries to study the levels we investigate mean values and how they evolve overall and within countries for both the levels and the dispersion the issue of convergence and divergence is studied by examining whether the variation across countries is narrowing or widening to set the context section 2 presents a brief overview of existing theories expectations about the levels and dispersion of job quality dimensions section 3 notes the rather scarce previous evidence in this field and we identify relevant questions about the evolution of job quality sections 4 and 5 focus on the data and on the construction of indices of job quality section 6 presents our findings about change over the 19952010 period looking both at the overall sample and at individual countries section 7 gives our discussion of what the findings amount to theories of change in the level and dispersion of job quality theories about how job quality is expected to have changed in the modern era may be broadly divided into those that take a universal perspective and those that emphasize differentiation across countries or across groups of countries with similar institutional regimes in the universal approach it could be held that more affluent countries will have jobs of better quality and that increasing affluence in the long term signaled by rising gdp per capita will be reflected in rising job quality with jobs having multiple characteristics an assumption of homothetic preferences would be enough to ensure that as wealth rises workers would choose to buy improvements in all features that they value 4 if however production relations evolve as neofordist it remains possible that job quality could stagnate or decline even while wages increased per contra in a postfordist world nonwage job quality features such as autonomy and challenge would be expected to rise as well as wages in so far as one might expect to see the technologies behind these evolutions as ubiquitous the trends in job quality could be expected to be common across countries when the relative demand for skilled labor bolstered by skillbiased technical change outstrips the growth of supply there is the further expectation that just as there have been increasing wage returns to skill so other aspects of job quality would become more unequal this prediction is counterbalanced however when the predominant new technology leads to the automation of programmable manual and nonmanual tasks previously important in middlepaid jobs while complementing nonroutine aspects of highskill jobs in this nuanced theory of skillbiased technical change it is expected that there will be an asymmetric polarization of jobs a relative growth in the number of jobs with low pay relative to the number of jobs with middlerange pay and the largest growth in highpay jobs increased subcontracting and outsourcing of jobs reinforce this tendency because there is overlap in the jobs that can be automated or outsourced if the nonroutine content of jobs is associated to some extent with higher levels of task discretion the relative growth of nonroutine tasks at the lower end of the occupational spectrum would imply reductions in the inequality of this aspect of job quality but the simultaneous growth of nonroutine task content at the top end where autonomy is already high means that the prediction about the overall effect of technological change on the inequality of task discretion is ambivalent organizational changes such as the growth of teamwork and the rise of highperformance management practices also have substantive implications for job quality to some extent these organizational changes are complements to technical change and could be expected to affect jobs in all countries however organizational changes also reflect heterogeneous management cultures and choices with the implication that job quality could change in different ways across countries and regimes technical and organization changes may be biased not only in terms of skill requirements but also in their implications for other aspects of jobs that are important for job quality for example it has been argued that new technology is also effortbiased in that the increments to productivity arising from innovation are disproportionately greater for those workers who put in greater levels of intensive effort as new technology diffuses this theory predicts that work intensification is likely to be widespread technologys effect on effort would also be predicted to be greater for those workers who were previously working below their physical and mental limits hence we would expect a reduction in its dispersion finally one might anticipate some generalized changes in job quality in response to changing demands from workers and consumers one pertinent example is the growing demand following steadily increased female participation in the labor force in all countries for jobs with characteristics that help to reach a worklife balance another is the impact of ageing and of rising education on the structure of services demanded in contrast to universal theories other writers stress the influence of nationallevel institutions in affecting jobs whether in respect of pay or of other aspects of job quality the broad consequence is the expectation that there will be persistent differentiation across countries in distributions of job quality in the varieties of capitalism framework it is hypothesized that job quality will vary across production regimes and in particular be greater in coordinated market economies than in liberal market economies since in the former employers strategy is to commit to longterm employment relations the implication is not only better job security but also better job quality in all dimensions in the cmes coupled with this prediction from the perspective of the system of production however is the uneasy link with social reproduction systems the greater probability of career interruptions for women leads in cmes to gender gaps in job quality reflecting the segregation and segmentation that follows from employers investment in firmspecific skills in production regime theories these ideas should apply to all cmes but in contrast the employment regime framework differentiates within the cmes between social corporatist and dualist regimes the distinctiveness of these regimes is driven by the nature and strength of trade unions and the balance of power between labor and capital with social corporatist regimes the state supports employment policies to promote good work opportunities across the population whereas in dualist regimes the historical strength of the core male workforce of skilled longterm employees persists in short these institutional theories predict not only that job quality is higher in cmes than in lmes but that job quality is more equally distributed in the social corporatist regimes found among the nordic countries production regime and employment regime models are less decisive about the pattern of change in job quality that is to be expected 5 if employment regimes persist because they constitute an institutional equilibrium with selfreinforcing financial and employment systems one might also expect a pattern of job quality change with coordinated economies more resistant than liberal market economies to global competition other universal pressures for change such as new technology would also be differentially resolved however the stability of institutional regimes may be in question 6 in addition across countries the different paces of institutional change or continuity could be expected to give rise to a varied pattern of change in job quality as employment institutions evolve reflecting in part a changing balance of power one can expect to see differential change in job quality where trade unions have been most weakened as for example in the united states or britain one would expect to see the greatest changes in both the levels and inequality of job quality reinforcing this point job quality in key domains reflects national regulations about working conditions working time wages equal treatment and health and safety as a general rule regulations can be expected to lower inequalities in job quality in that it is primarily in the lower quality jobs where controls bite regulations develop at their own pace towards either deregulation or reregulation varying across countries yet to some extent regulation patterns spread across countries through processes of demonstration and policy learning an example is the case of smoking constraints in workplaces moreover several labor market regulations in europe stem from supranational government the european unions directives have had widespread implications for job quality across member states as national governments are required to bring their own laws into line in the last fifteen years such directives have driven the adoption or confirmation of national regulations on working time rights to workplace representation and fair treatment of parttime workers workers on fixed term contracts and most recently temporary agency workers these supranational regulatory influences imply both some equalizing forces within countries and some convergence between countries the extent of convergence or divergence between countries has been seen as something of a litmus test for the growing or declining importance of the universal pressures on job quality if the relative impact of institutions has been diminishing over time it is argued that countries would converge by contrast if institutions role is becoming more important then it is possible that countries job qualities could diverge we shall examine the evidence below however this test is asymmetric a finding of divergence suggests an increasing role for institutions relative to universal pressures but the opposite finding of convergence leaves the case open if institutional changes are in the same direction across countries or if supranational regulation is important one could still expect to witness some degree of convergence finally theories of the overall level and distribution of aspects of job quality also have implications for job quality gaps between socioeconomic groups universal technology pressures and supranational regulatory forces could be expected to narrow gender gaps but national institutional differences for example in the strength and policies of unions could be expected to maintain and even widen patterns of differentiation in light of this brief overview of existing theories of workplace change we can summarize the context for our examination of trends in the distribution of job quality as follows it is expected that there is a positive relationship between job quality and per capita gdp that the cmes would tend to have higher job quality and that in particular the inclusive cmes would have the lowest levels of inequality in multiple dimensions in so far as there is a generalized increased affluence in the economy a diffusion of postfordist workplace regimes and a widespread regulation of working conditions rising job quality is expected even so technological change may also stimulate a widespread intensification of work effort rising returns to skill andor universal deregulation suggest that job quality will become more unequal in multiple dimensions not just wages but this prediction is also modified by the nuanced theory of technical change which emphasizes the survival of nonroutine tasks in lowpaid jobs by increased demand for a better worklife balance and by evolving regulation of important job features such as environmental hazard and working time above these generalized themes we also expect differentiation across regimes and countries with the cmes showing the greatest resistance to upward pressures on inequality evidence of divergence among countries would then be indicative of the maintained or increased importance of an institutional determination of job quality previous quantitative evidence about changing job quality a commonality between all these theories is the expectation that some substantive change in the distribution of job quality is expected yet a further possibility is that theorists have overestimated the effect of transformations in the workplace on job quality institutional resilience and cultural persistence may limit the speed at which working conditions are altered and perspectives of change could be based on a distorted perception of the past which gives a false impression of radical change past analyses and projections for example of an end to work or of a brazilianisation of european labor markets have proved very wide of the mark handel using general social survey evidence finds substantive continuity in perceptions of job quality over almost a decade and concludes that both optimistic and pessimistic schools may have overstated their case whether this is a generalized finding deserves investigation on a broader scale hitherto most evidence about change in job quality has focused on wages since 1980 wages have become much more unequal but more so in some countries than others within europe sweden germany the netherlands and the uk are all countries with widening differentials but there was much more stability in france and finland for nonwage job quality features some evidence is available for certain individual countries examples are finland the us and britain kim and park and france while a number of these broad trends are brought together in green the comparatively rare crossnational studies of change in job quality have relied primarily on the international social survey programme surveys which include periodic work orientation modules and the european working conditions surveys using the former olsen et al find evidence of convergence in job security and work intensity between four countries while across a very wide range of countries green found that job insecurity approximately tracked the unemployment rate both these studies found that job quality was highest in the nordic countries but no higher in the other cmes than in liberal market economies similar to gallie who also finds with different data that jobs in nordic countries afford relatively high levels of personal discretion the first three ewcs were drawn on by the oecds analysis of more and better jobs to show that work intensity was increasing across many european countries while the trend in good physical environment was mixed these trends were confirmed by the 4 th ewcs in 2005 while a pattern of stable or slowly declining autonomy and of convergence among the older member states was revealed in none of these studies could the observed changes be termed radical and in many cases rather little change is observed similar to handels observation on the us data none carry their analyses forward to the period following the onset of the great recession 7 regarding trends in the dispersion of job quality kalleberg reports rising inequality in worker autonomy and workplace participation but stability in the dispersion of intrinsic rewards over a quarter century interval in the us no other study appears to have investigated how job quality dispersion has changed in other countries nor is it known whether traditional gaps in job quality between socioeconomic groups are persisting diminishing or even expanding in the face of the heterogeneous trends outlined in the previous section we ask therefore the following questions about trends in job quality in recent years  has there been a substantive generally upward trend in the nonwage aspects of job quality as suggested by an increasingly affluent economy and the postfordist perspective or has there been a downward trend more consistent with a neofordist perspective alternatively is the change characterized mainly by continuity in existing patterns  has there been a trend towards greater inequality in the nonwage aspects of jobs  is there a pattern of divergence or convergence between countries in their average job quality levels and in the degrees of inequality and are the changes consistent with institutional determinations implied by employment regime and production regime models  are trends in inequality mirrored in changing gaps between the sexes between young and older workers across education levels among occupations and according to job contract status 7 mention should also be made of another attempt to plot job quality trends where a synthetic index is constructed primarily from elements in labour force survey while the latter has the advantage of providing annual data for all ec members it lacks information on intrinsic job quality features and is therefore less informative the european working conditions surveys to address these questions we draw on successive waves of the european working conditions survey the 5 th and latest wave comprises a sample of 44000 people over 15 and in employment drawn from 34 countries in 2010 this is a harmonized survey comprising representative samples ranging from 1000 to 4000 per country earlier waves took place in 1991 1995 200001 2005 and 2010 the surveys have evolved both as new members joined the eu and as items were improved added or subtracted in successive waves it is possible to analyze trends in the distribution of job quality over time but only for countries that have been members in multiple surveys and using items that have been asked in identical ways in multiple waves we therefore restrict our analyses to the 15 eu countries that have subscribed since the 1995 wave while very many items of continuous entry are available since then refinements in 2005 facilitate extensions and modifications to the indices and a small part of our analysis centers on the period 20052010 8 constructing indices of job quality in this section we present how the indices of job quality were constructed from multiple response items available in the waves of 1995 onwards of the ewcs we follow some general principles for index construction as outlined for example in muñoz de bustillo et al after being normalized to the 01 range the selected items were grouped into summative indices of four key aspects of job quality work quality work intensity good physical environment and working time quality some items have missing values but in most cases these are few which is a good indication of data quality to avoid loss of information when items are aggregated into indices we average over the items with nonmissing values once constructed each index was transformed to range from 0 to 100 the work quality index was constructed using items covering aspects of skills use or activities known from the literature to be proxies for skills usespecifically complexity problemsolving use of technology training and learning participationand task discretion none of these items on its own is ideal but collectively they formed an index with an alpha statistic of 074 suggesting that it may be just acceptable to regard them as capturing a single latent construct the work intensity index was constructed using two items that capture features of a job that require intensive work and five items capturing sources of work pressure the items are conceived as heterogeneous manifestations of work intensity in various situations rather than as variables reflecting an underlying single construct the included items are does your job involve aworking at very high speed bworking to tight deadlines each item has a 7point proportionoftime scale which was normalized to the 01 range then the index was constructed as an average of these items and the normalized number of sources of work pressure where the latter was obtained from the following items on the whole is your pace of work dependent or not on athe work done by colleagues bdirect demands from people such as customers passengers pupils patients etc cnumerical production targets or performance targets dautomatic speed of a machine or movement of a product ethe direct control of your boss these items are conceived as heterogeneous manifestations of work intensity in various situations rather than as variables reflecting an underlying single construct present in all the good physical environment index was constructed using items that capture exposure to environmental hazards and posturerelated risks for each item below there is a 7point scale running from never to all of the time to which we ascribe values 0 to 6 please tell me using the following scale are you exposed at work to avibrations from hand tools machinery bnoise so loud that you would have to raise your voice to talk to people chigh temperatures that make you perspire even when not working dlow temperatures whether indoors or outdoors ebreathing in smoke fumes powder or dust fhandling or being in skin contact with chemical products or substances please tell me using the same scale does your main paid job involve atiring or painful positions bcarrying or moving heavy loads crepetitive hand or arm movements the index is constructed by averaging the responses across items with the small number of missing values being recorded as 0 one may hypothesize that there is an underlying construct in all workplaces capturing the absence of exposure to health risks in support the alpha statistic for the items in the index is 082 the working time quality index aims to captures job features that affect worklife balance the extent to which a person achieves worklife balance depends on personal circumstances which as noted in our introduction are not included in the index the focus is on the characteristics of the jobs and not those of the individual doing the job ideally these would include facilities connected with the job such as child care but the most important aspects of the job that affect worklife balance involve working timeits extent its conducive scheduling and flexibility these anyway are the features that are consistently available in the survey the items combined in the index available from 1995 are the following 1how many hours do you usually work per week in your main paid job 2how many times a month do you work at night for at least 2 hours between 1000 pm and 0500 am 3how many times a month do you work in the evening for at least 2 hours between 600 pm and 1000 pm 4how many times a month do you work on saturdays 5how many times a month do you work on sundays in addition an expanded variant for 2005 and 2010 of this index is available including an item that captures the workers discretion over working time arrangements and a subsequent item capturing how much notice is given when those arrangements are changed by employers we combine these derive a 5point scale capturing these aspects of control over working time identically as in de bustillo et al 2011a 186 to what extent are these indices valid indicators of job quality one aspect of their criterion validity is whether they are associated as expected with outcomes and in this case we have suitable items within the survey capturing workers perceptions of the impact of the job on their health and their worklife balance we present this analysis in the appendix9 findings figure 1 gives the basic descriptives for each of the four indices available since 1995 together with a histogram of their distributions each index occupies more or less the whole range while good physical environment is bunched towards to the top end reflecting the fact that only a minority of jobs have a preponderance of environmental or posturerelated hazards the indices are all lumpy reflecting the fact that they are constructed from limited numbers of items each with categorical scales figure 1 about here to gain an idea of the variation that lies behind these indices one can compare some illustrative features of jobs where the indices are notably below or above their mean values in the case of work quality contrasting the set of jobs falling in the range 4150 with those in the range 7180 in the former set the proportions of jobs that involve solving problems learning new things and leeway to choose the methods of work are 83 50 and 65 respectively while in the latter set the same proportions were 97 95 and 92 in the case of work intensity one can compare the set of jobs in the 2130 range with those in the 5160 range in the former set only 3 of the jobs involve working at very high speed all or almost all of the time and the workers are subject to an average of 15 sources of work pressure this compares with 22 and 24 for the latter set with higher work intensity for good physical environment in jobs in the 6574 range 18 of jobs entail breathing in smoke fumes powder or dust at least half the time and 51 involved tiring or painful positions at least half the time while for the jobs in the 8594 range the same proportions are 06 and 13 finally for working time quality with jobs in the 4554 range the average working week is 45 hours and 32 of workers go to work on sundays at least twice a month compared with 36 hours and just 3 for jobs in the 7584 range a overall trends we begin our analysis of trends by presenting in table 1a a description of changes in the means and in the dispersion of job quality for all our nonwage job quality indices across all five waves of the survey for all the older member states of the european union taken as a whole the aim in initially taking an aggregative approach is to obtain an initial picture of the extent and overall direction of change treating these countries as if they were a single labor market something that is more a longterm objective of singlemarket policy rather than a realistic assumption about the present state of affairs the risk of this approach as we shall see is that it may hide the considerable underlying heterogeneity in the sample a problem that is common among analyses of europe as a whole the data have been weighted to take account of the differential size of the working population as well as survey and nonresponse weights for our measure of dispersion we use the gini index table 1 about here the first point to note from table 1a is that job quality according to three of the indices is quite stable over time to assess stability with a simple formal test we regressed each index against time table 1a records with an asterisk whether there is a statistically significant trend at the 5 level since the full sample is quite large even small changes are significant statistically yet we are interested in substantive changes relative to the standard deviations of the indices we have therefore adopted a rule of thumb for identifying substantive changes whenever the mean value of an index changes significantly between 1995 and 2010 and by at least 3 points table 1a and subsequent tables show this by a directionofchange arrow in the final column similarly we use a directionofchange arrow to indicate a substantive rise or fall in inequality when the gini coefficient changes by at least 002 points 10with this convention it can be seen that the mean level of work intensity index rose by 22 points significantly but not amounting to a substantive change while the mean values of work quality and good physical environment were each stable for these three indices the dispersion also changed very little as indicated by the gini coefficients by contrast there is a substantive rise of 54 points over time in the working time quality index accompanied by a fall by 0025 points in the gini coefficient the rise in the mean is comprised of both declining work hours and falling use of shift work at weekends and night time to illustrate with a specific example from one of the ingredients of this index the proportion of workers in the eu15 countries who never worked on saturdays rose from 44 to 50 over the period the simultaneous fall in the dispersion and rise in the mean partly reflects gains at the low end with the indexs 5 th percentile rising from 208 to 292 between 1995 and 2010 but it also picks up improvements for the large majority of workers the median rose from 667 to 750 since job quality varies across industries it could be that some of the improvement is associated with industrial change within our sample period service industries and public administration increased their share of employment from 65 to 73 while manufacturing and agriculture declined moreover working time quality is well below average in agriculture and well above in public administration to see whether such compositional change was important we regressed working time quality on year and then on year and industry with the result that the coefficient on year was reduced by only a small amount from 035 to 032 we therefore conclude that the changes largely occurred within industry rather than through industrial recomposition 11 table 1a also shows the pattern of change between 2005 and 2010 in the expanded working time quality index there is no change over this short period implying that the picture is not as optimistic as suggested by the more limited index that is available from 1995 the above trends in working time and weekend working are counterbalanced by an unfavorable change over this short most recent period in the extent to which employees can exercise choice over their working time should these indices which capture quite distinct concepts be reduced and brought together in a single index of job quality while some writers argue that a single index facilitates a stronger impact from job quality research despite the extra assumptions that have to be made about the weights to be attached to each elements we have not been persuaded of the presentational advantages of a single index over those of a small number of separate indices whose names convey a reasonably direct relation to a known concept nor as we shall see could it be argued that a unified index would suffice because the indices are closely related or move in parallel table 1b records the correlation coefficients between the four indices that are available from 1995 onwards none of the coefficients are especially high the largest in absolute terms being between work intensity and good physical environment there can be seen no trend towards a closer linkage over time these low correlations and the fact that the indices are moving if anything in opposite directions make a strong case for examining the indices separately and not combining them into a single index of job quality b job quality gaps the aggregate picture of stability and change in europes 15 can hide substantive differentiation between and within countries and groups moreover since the statistics are weighted by population size the patterns of change in table 1a can be dominated by a few large countries failing to reveal evolutions taking place in the smaller countries we next therefore examine how the indices differ between groups tables 2a to 2d present the averages of the job quality indices by socioeconomic groups for this analysis we retained gender age groups education levels type of employment contract and type of occupation 11 the same pattern is found for other trends reported below table 2a2d about here gender differences in aspects of job quality not only in respect of wages are especially relevant to an evaluation of progress towards gender equality as can be seen work quality is slightly higher for men but the gap has been closing the mean level of work quality rose by 058 points for females and dropped by 038 points for males meanwhile work quality for older individuals increased by 118 points while it dropped by 127 points for individuals younger than 40 when it comes to education the findings suggested that work quality dropped by 288 points for those who have finished their education at the age of 15 it dropped by 231 points for those who finished their education between the age of 16 and 19 and finally it remained almost the same for the those who finished their education at an older age than 20 work quality is slightly increasing for all types of employment contracts the biggest increase in work quality is for those with a temporary employment agency contract however one should keep in mind that the sudden jump between 2005 and 2010 may be related to the economic recession in other words more of those with temporary employment agency contract lost their jobs raising the average quality of the remaining jobs looking across occupations work quality increased for professionals by 34 points over this period of time while it decreased by 88 points for service workers it is also worth noting that professional workers started at a high average of 745 points in 1995 while service workers started at an average of 592 in 1995 and ended at 504 in 2010so the gap widened between these groups in contrast to earlier findings for britain and the united states across the eu15 work intensity is greater for males than for females and there is no indication of this gap closing on the contrary the work intensity index for males increased by 26 points over the 19952005 period while that of females increased by 19 points work is also intensifying faster for individuals younger than 40 and for individuals with the highest level of education while work was intensifying for all employment contract types there was a striking and large increase after 2000 for those with a temporary employment agency contract12 among occupations work was intensifying for professionals technicians and associate professionals craft workers and plant and machine operators but there was volatility among agricultural workers and little change among service workers good physical environment was about 8 points higher for females than for males it was also greater for those with more education and in higher status occupational groups these gaps remained stable over time as did those between age groups employment contract type and occupational groups the only exception was craft workers where good physical environment dropped by 42 points working time quality has increased for both genders with males having a lower value than females in all periods one should also note that males and females are slightly converging on this index working time quality has also increased for both age groups over the period and the gap between the two is shrinking when it comes to education the highest increaseof 63 points is for the lowest educational group these small diminutions in the working time quality gaps are in the same direction as the overall decline in inequality of this index reported in the previous section while working time quality has gone up for all types of employment contracts with the highest increase for apprentices working time quality also went up for all occupational groups but the variation ranged between 18 points for professionals and 10 points for skilled agricultural and fishery workers one should note that skilled agricultural workers and craft workers started at a relatively low level professional workers from a high level indicating some convergence c job quality distributions between and within countries the above analysis of table 2 has shown that aggregate stability can hide heterogeneous patterns of change among different groups of workers however to examine whether the changes are consonant with universal theories that emphasize common causes or with differentiated theories that allow for national labor market institutions and policies to generate divergent patterns with table 3 and figures 2 and3 we now investigate the picture for each index across the international dimension and across time we study countries separately though in the light of what has been said about the differences between regimes this method has the advantages of not prejudging whether countries fit with particular institutional categorizations and of allowing us to include many countries that do not neatly fit the regimes literature table 3a3d about here as a baseline we look briefly first at the intercountry differences in job quality in 1995 in respect of three of the indices one can detect a clear general association between job quality and a countrys affluence work quality is low for greece and for portugal while it is high for the netherlands and for finland similarly with good physical environment and working time quality less affluent countries are to be found at the lower end of the range with work intensity however the relationship with affluence is far from clear given that some of the richer countries have a high score and some a very low score to formally confirm these impressions we regressed each index on the 1995 gdp per capita with the following estimated coefficients for work quality 13 for good physical environment 10 for working time quality 13 but for work intensity 04 indicating no significant relationship 13 it thus appears that affluence buys the workers in a country a higher job quality in some but not all dimensions though the process of causation might also be in the opposite direction variations in job quality across countries only partially conform to those proposed in the literature from table 3a it is confirmed as previous studies have found looking at task discretion that the social corporatist countries are highly ranked with jobs in denmark having the highestranked work quality many of the cmes are highly ranked in terms of average working time quality the netherlands having the highest score on this index however in terms of the other indices the cmes do not stand out as having better job quality for example the uk is among the top for good physical environment while the cmes range from high to low it can also be seen from table 3a that work quality in the cmes with dualist regimes varies quite a lot and does not stand out as being collectively better than in the uk overall the variation among countries appears to vindicate our preference for presenting the data for countries separately except for one generalization that the social corporatist countries are ranked among the lowest for dispersion of job quality in respect of all four indices looking at the gini coefficients shown throughout table 3 sweden finland and denmark indicate low inequality in each of these four dimensions of job quality figures 2 and 3 about here with this baseline we now consider the trend patterns for each dimension over 1995 to 2010 illustrated in table 3a and figure 2 shows that the average level of work quality increased substantively in 8 countries these are austria belgium denmark finland greece ireland luxembourg and spain the highest increase is in luxembourg this picture of change differs from the aggregate narrative of stability reported in table 1 and the contrast is attributable to the fact that in the three large countries which dominate the overall sample france germany and the ukchange was largely absent despite these changes for the mean values there is little evidence of national divergence work quality is high in the social corporatist countries both in 1995 and in 2010the range between the highest and lowestranking countries came down a small amount from 22 to 20 points we conducted a simple formal test for convergence by regressing the change in the countrylevel mean against the initial mean value evidence of a significant negative coefficient on the initial mean would signify convergence the coefficient though negative was insignificant 14 in contrast to the level the dispersion of work quality measured by the gini coefficients was relatively stable in the large majority of countries the only countries where inequalities increased by more than 2 points were france spain and the uk by 2010 spain had become the most unequal while the nordic countries remained by far the least unequal turning to work intensity most countries in the eu15 experienced a progressive intensification of work over the period while inequalities on this index decreased in the same time these countries are belgium france germany greece ireland italy luxembourg spain and sweden there are however three contrasting countries in austria and portugal work intensity has been volatile and while it arrived at a low note in 2010 it was high in 2005 in the uk work intensity was at an exceptionally high level in 1995 and subsequently declined somewhat however it turns out that the early 1990s was according to both the ewcs and other sources a period of very substantive intensification comparing either the late 1990s or the 2000s with the start of the 1990s work effort in the uk rose according to multiple sources both the means and the dispersion of work intensity converged between countries over the period for example the coefficient of variation of the means across countries fell from 063 to 061 and the abovementioned formal test confirms that a lower initial level is associated with a greater increase the coefficient of variation across countries of the gini indices fell a small amount from 011 to 010 even so the dispersion remained lowest in the nordic countries the results are mixed for good physical environment the average levels rose in three countries and dropped in two others on the other hand the gini coefficient dropped by more than two points in netherlands portugal spain and the uk thus the major pattern consists of a limited change in average good physical environment and a somewhat more generalized drop in the inequality there is evidence of convergence of the mean levels and indeed the largest rises were in greece and the uk both of which had below average good physical environment in 14 the fall away of the uk from being one of the highest on the work quality index in 1995 reflects a decline in task discretion that has also been found from data in the uk skills surveys 1995 yet there is some divergence in the inequality with the coefficient of variation across countries of the gini index rising from 019 to 023 working time quality increased in 11 countries namely austria belgium finland france ireland italy luxembourg netherlands portugal spain and the uk the highest increase was about 11 points in france one should also note that average working time quality did not decrease in any of the 15 countries on the other hand the dispersion of working time quality decreased in 9 countries austria belgium finland france ireland italy portugal spain and the uk and rose only in sweden the nordic countries remain among the most equal joined in respect of this index by france at the other end of the spectrum workplaces in greece stand out as having both the lowest and most unequal working time quality yet over time both the means and the gini indices converged between countries in short underpinning the overall change reported in table 1 in most countries separately there was a clear trend consisting of an enhancement in working time quality combined with an equalization process within and convergence between countries discussion continuity and change in patterns of job quality we have presented a picture of how several dimensions of nonwage job quality vary between groups and countries and how they have changed over a recent 15year period in addition to examining together 15 countries we have for the first time placed an emphasis not only on the levels of job quality indices but also on their dispersion across groups and countries the literature led us to look for differences among countries according to both their level of affluence and their institutional regimes and for certain trends over time which might be consistent with either optimistic or pessimistic perspectives and which could conceivably be either universal or differentiated among countries while it is beyond the scope of this paper to test specific explanations for the changes reported it is of interest to review to what extent the pattern of change is consistent with the tenor of the theories of change outlined in section 2 our baseline analysis confirmed that as expected the average levels of job quality tended to be higher in the more affluent countries while we have not attempted to gather countries in groups predefined by employment or production regimes the results also confirmed some predictions about the differences between countries associated with their institutional structures the countries typically seen as coordinated market economies show high levels of working time quality and of these the subset of social corporatist countries have high levels of work quality this superiority in work quality has been attributed to a long history of trade union concern with issues of job design in the social corporatist countries and a rather more equal balance of power than elsewhere yet there was no support for the view that countries with coordinated market economies had systematically higher job quality in the other respects examined here where the social corporatist countries are systematically different is that they have especially low dispersions of job quality according to all indices and this is consistent with their wellknown low levels of income inequality attributable to the tradition of centralized solidarity bargaining as for the trends taking as a whole all the 15 european countries that formed the european union in 1995 the levels and distributions of the job quality indices across individuals and groups remained relatively stable over the period underneath the current of change we have been describing there is a strong pool of continuity in both the level and the inequality of job quality in these countries there is no evidence of radical disjuncture in job quality even taking into account the time span of the great recession nevertheless there was a steady rise in the working time quality index while the trend might need qualifying once further features associated with flexibility are included this rise appears consistent with universal optimistic theories about the changing nature of work including the idea that work features do respond positively if slowly to changing needs as in the case of worklife balance to some extent however the relative stability reflects the size dominance of france germany and the uk when countries are considered separately a somewhat different pattern is found several countries experienced rises in the work quality index though arguably these rises are surprisingly slow given that the great recession might have been expected to selectively diminish the share of low quality jobs in this dimension meanwhile the widespread rise in work intensity can also be seen as reflecting universal trends in technology andor work organization and the pressures of global competition but in this dimension the implications for job quality are negative with regard to good physical environment the high degree of continuity is not consistent with the optimistic view that there should be general increases in job quality nevertheless this is an index that starts from a fairly high level and for which improvements rely as much on the gradual spread of health and safety awareness as on the changing industrial structure for certain hazards it is probably necessary to look for focused advances a notable achievement for example of the recent 5year period is the decline from 771 to 641 in the percent of employed people exposed to tobacco smoke at work 15the trends in inequality that we have reported have also been fairly widespread even if not universal the falls in the dispersion of good physical environment can be seen as reflecting the spread of national and supranational regulation similarly the fall in the inequality of working time quality partly reflected also in slowly declining gaps between high and low education groups could be interpreted as responding to a generalized demand that grew with the ubiquitous rising trend for female participation in the labor force the observed widespread reductions in the dispersion of work intensity are consistent with the impact of technology being greatest among those whose required effort was below average as implied in the theory of effortbiased technological change if there was no change in the association between intensive work effort and pay a reduction in the dispersion of work intensity would also amount to a fall in overall inequality 16 these falls in inequality stand in contrast to previouslynoted rises in wage inequality an account of why in several countries one observes opposing trends for wages and other aspects of job quality should be the focus of future research while all these patterns of change are seen in many countries they are unsurprisingly not found in all the question arises then as to whether different countries trends show divergence this being a possible indicator of the power of heterogeneous countrylevel institutions to take job quality on different paths we have found this not to be the case indeed there has been a pattern of slow national convergence in the means and dispersion of working time quality and of work intensity and in the means of good physical environment only for the gini indices of good physical environment is there some evidence of minor divergence and otherwise there was little change in the spread across countries this pattern does not necessarily imply that generalized forces of technology and global competition are behind the changes within europe regulation patterns can become generalized through policy learning copying and the open method of coordination and through brussels directives that are subsequently enacted by national governments and it is plausible to expect regulation to have an equalizing effect on job quality finally we have also found mostly stable gaps in job quality between men and women and between socioeconomic groups which are in most cases unsurprising the stability is a reflection of the slowchanging inequality across the whole sample of countries17 nevertheless we have identified certain striking shifts that have implications for further analysis including the dramatic rise in work intensity of temporary agency workers and the decline in work quality among service workers the indices presented in this paper are far from perfect tools for understanding the changing workplace even if they represent an advance on previous quantitative descriptions notably the items on skills requirements of jobs need development until recently the ewcs has not generated data on social support within the workplace so we cannot look at longterm trends and it is only recently that the survey has been extended to encompass as many as 34 countries a broader spread of trends will be revealed in time as long as continuity is maintained meanwhile the surveys hitherto are all crosssections of data rather than longitudinal thereby limiting the extent to which they can contribute to identifying causal processes a the variable capturing the subjective effect of work on health takes three values 0 if the effect is negative 1 if there is no effect and 2 if the effect is positive estimation by ordinal logit b health and safety risk at work takes the value of 0 if the work does not perceive any risk caused by his work and 1 otherwise estimation by logit the variable capturing subjective work life balance takes four values on a four points scale c hours fit in general do your working hours fit in with your family or social commitments outside work very well well not very well or not at all well scale from 0 to 3 estimation by ordinal logit appendix job quality and subjective wellbeing table a1 presents simple tests of the criterion validity of the four job quality indices available from 1995 used in the paper it is argued that there is expected to be a correlation between subjective wellbeing and the satisfaction of need and that job quality indices are designed to capture aspects of need satisfaction from work hence we do expect an appropriate relation between each index and subjective wellbeing and this expectation provides a test of criterion validity we apply this test using the 2010 data controlling for sex age and age squared the first column looks at an indicator of positive wellbeing the workers selfperceived effect of the job on hisher health this is positively related to work quality good physical environment and working time quality and negatively related to work intensity as expected not surprisingly given the nature of this outcome variable the index that has the largest estimated association with the outcome is good physical environment the second column provides further equivalent validation but with a negative indicator health and safety risk the signs are reversed with the exception that work quality is positively related to the perception of health and safety risk the third column focuses on worklife balance the survey contains an item capturing the workers assessment of how well hisher work hours fit family or social commitments outside work this assessment is expected to be positively related to the working time quality index as a control to capture outside commitments we include the number of dependent children below 16 in the household again the index performs as expected all these coefficients are not presented as unbiased estimates of causal impacts of the indices on wellbeing since other variables could be affecting both the dependent and independent variables there could for example be a common rater bias hence this is only a weak test of validity however the maintained assumption is that these biases are either downward or if upward are not of such great magnitude as to reverse the sign of a coefficient 661 716 709 733 ↑ directional arrows record that the trend is statistically significant at the 5 level and that the change is substantive that is at least 3 points 0300 0307 0332 0325 ↑ directional arrows record that the trend in the average level is statistically significant at the 5 level and that the change is substantive that is by at least 3 points for the gini index an arrow indicates a substantive change by at least 002 that the trend in the average level is statistically significant at the 5 level and that the change is substantive that is by at least 3 points for the gini index an arrow indicates a substantive change by at least 002 that the trend in the average level is statistically significant at the 5 level and that the change is substantive that is by at least 3 points for the gini index an arrow indicates a substantive change by at least 002 that the trend in the average level is statistically significant at the 5 level and that the change is substantive that is by at least 3 points for the gini index an arrow indicates a substantive change by at least 002

this paper examines trends in nonwage aspects of job quality in europe with a focus on their dispersion as well as their level theories differ in their predictions for these trends and on whether they expect national convergence data from the 5 th european working conditions survey are used in conjunction with earlier waves to construct four indices of nonwage job quality work quality work intensity good physical environment and working time quality we track them from 1995 to 2010 across and within 15 european union countries the social corporatist countries had the highest work quality and lowest dispersion for all four indices while continuity is found work quality and work intensity each rose in several countries and working time quality rose in most the dispersion of working time quality work intensity and good physical environment each fell in many countries and there was little sign of national divergence

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introduction entering the field of science implies meeting a series of demands meant to test the graduates capacity to propose original scientific approaches but also to comply with the requirements generally set and agreed to by the research community while thesis committees a priori are transitory communities set up only for the sake of awarding a doctorate the guiding hypothesis of this article is that they are shaped by some previous social density supervisors must embody disciplinary expectations compliance with scientific ethos norms validating the required work and capacity for a critical evaluation of results the group of peers thereby selected must assess the work presented but must also stand for the broader research community working in the field that the graduate will join there have been few studies so far to understand the complex processes at work in setting up thesis committees to grasp the dynamics of scientific validation as well as the different types of relationships developed between and with committee members some studies have focused on the genderbased or linguistic distribution of phd students when graduating others have underlined the influence of first publications on careers without precisely measuring the concrete impact of the supervisors and committee members support we suggest a novel approach focusing on committee members copublishing practices and as an aside on whether and to what extent phd students are included in these research communities our hypothesis is that setting up a thesis committee may well be an opportunity for reinforcing previous collaborations actually evidenced by joint publications simultaneously phd graduation which signals phd students entrance into the field of science may be doubled up by a joint publication with one of the committee members phd students contribution to scientific production is consistent and helps reinforce their recognition as fully fledged members of the research community in this article we use social network analysis to reveal the various types of thesis validation communities this methodological and heuristic choice relies on a great number of research works carried out in sociology of science our investigation focuses on the formation of phd thesis committees in three research departments from 2003 to 2008 in the city of toulouse france the choice of this specific period allows us to grasp the way thesis committees were formed before the significant institutional changes that affected the french university system in 2009 a generalized trend to shorten thesis duration parity of standards in the constitution of juries and the gradual disappearance of unfunded theses we compare the actual publishing practices of phd students and of their committee members in three different disciplines to grasp the disciplinary specificities observed and to shed light on certain internal differences within the research departments under consideration we complement the social network analysis of jury composition and coauthorship networks with qualitative material a series of 10 interviews carried out with phd thesis directors makes it possible to qualify the links observed and to understand the structuring of some of the thesis committees in our study this article advocates a close articulation between quantitative and qualitative practices in science and technology studies we therefore follow the path outlined by leydesdorff ràfols and milojevic this is why we do not separate in the analysis the study of copublications from the specific conditions of their realization section 2 examines previous attempts to characterize the scientific community and graduates admission carried out in sciences and technology studies section 3 details the material collected explains the method used to process it and provides a general description of the data section 4 is an analysis of the various copublishing networks which permits us to single out the formation of structured peer communities for the purpose of phd validation a community and its candidates organization of the scientific community inbetween hierarchies and networks the organization of the scientific community has been the object of numerous sociohistorical studies which have demonstrated the importance of the entry fee and the way social boundaries are quickly delineated the position occupied by phd studies has often been studied by sociologists of science from the perspective of the hierarchic relationships between supervisors and their phd students hagstroms work provides the twofold advantage of articulating the issue of thesis supervisorphd student relationships with the issue of the differences between disciplines he describes the scientific world as rather individualistic made up of dyadic relations governed by individualistic norms of independence this type of relationship mostly fosters exchanges along the logics of reciprocal giftgiving which also characterize the phd studentssupervisors relationships the former complying with the latters domination in return for being trained into research however hagstrom insists that the forms of collaboration differ according to three types of disciplines theoretical sciences functioning rather individually and where phd students merely contribute to their professors growing influence laboratory sciences requiring assistants mastering scientific instruments and field sciences which demand distant investigations for which phd students are extremely useful pierre bourdieus sociological concept of fields corroborates the way socioepistemic relationships between phd students and supervisors are structured when characterizing the scientific field pierre bourdieu points out that the pretenders or candidates confront the dominant via antagonistic strategies according to him the dominant wish to keep their positions and all the institutions that have brought them where they are on the other hand candidates may be geared towards succession strategies securing safe and rather stable positions or towards subversion strategies which are riskier but whose potential benefits in terms of field redefinition are significant those phd students are not yet in a position in which they can a priori define their own strategies they are caught in power struggles which structure their disciplinary field in homo academicus bourdieu suggests carrying out studies that could grasp the logics of the exchanges academics get involved in to form thesis committees or for the sake of elections … terry shinn also analyzes phd studentthesis supervisor dyadic relationships as being based on implicit reciprocity phd students reinforce their supervisors power as he or she finds the topic and helps with publishing shinn also demonstrates that researchers in the course of their career establish extensive social networks and consolidate their results through more fully developed phenomenological explorations the social hierarchy of the scientific activity is therefore as much a hierarchy of relationships as a strictly cognitive hierarchy network analysis is definitely a particularly fertile field to study the communities involved in research dynamics processing data collected by such analysis evidences some global structures that go beyond the organizational boundaries of scientific institutionsparticularly all the studies on copublishing invisible communities tied up by coaffiliations by citations or by joint qualifications therefore network analysis supplements more classical studies which focus on the organization of this activity in the literature there are two types of sna research work on the relationships established while supervising or validating a thesis on the one hand in 2017 chariker and his colleagues published a networkbased analysis of mentormenteedoctoral studentthesis supervisor relationships from the academic family tree a webbased database of theses defended over two centuries in the united states their analysis indicates that the pattern of nobel laureates mentoring relationships is nonrandom nobel laureates had a greater number of nobel laureate ancestors descendants menteesgrand mentees and local academic family on the other hand some studies combined an analysis of research groups through their objective relationships with an analysis of differentiated individual positions such as phd students in front of thesis committees the additional advantage of these studies is to acknowledge the social and relationship component of thesis committees instead of only using the rather naïve criteria of academic excellence according to godechot invitations to phd committees are an indicator of disciplinary relationship patterns through which the concept of social capital can be explored at both individual and collective levels concerning the ehess 1 recruiting process the study demonstrates that statistical links exist between the probability for a phd student of being granted a position and her or his supervisors network as well as that of her or his committee by mobilizing network analysis and data on phd committees our article fits well into this recent line of work it contributes to enriching this emerging field of research by offering a comparative point of view on three disciplines with very distinct characteristics whereas the previously cited articles each focused on specific disciplines 2 role played by disciplines in shaping publishing practices our research does not concern offground disciplinary scientific communities but starts from phd theses carried out in three departments of the same major provincial city 3 we selected them along two sets of crossover criteria first their disciplines are very distant from one another second they stand for three major cognitive areas third they are part of three departments of similar importance at least for their respective host universities last of all the three doctoral schools they belong to are located in toulouse the three departments studied correspond to three disciplines therefore we must clarify what is meant by discipline yves gingras listed the characteristics of disciplines a discipline is characterized by its practice its institutionalization and the development of a social identity disciplines are a combination of a knowledge base some knowhow orthodox references and the central base for a set of people recognized 1 école des hautes études en sciences sociales 2 pierre verschueren has nevertheless used the data on postwar thesis committees held in physics in paris to show the chain existing between disciplines 3 by doing so we meant to avoid the parisian tropism that is to say an overrepresentation of parisian committee members on parisian thesis defenses and to make it easier to conduct interviews with phd directors as we were all based in toulouse at the time this research was done 4 we also started looking at theses defended in another social science department of toulouse 2 university but collecting theses defended over the selected period in this history department looked quite difficult for their qualification disciplines are rather autonomous but remain connected to one another by a series of metaepistemic conventions that provide some scientific convergence our analysis means actually grasping the publishing practices of the groups studied at the very core of the specific conventions of each discipline david pontille in his thesis about scientific authorship has shown that the ranking of authors characterizes the particular way in which a discipline organizes functions and determines socioepistemic hierarchies according to us the issue of publication visibility is central to our study of coauthorship because graduates are bound to engage in some publishing practice that both determines their relationship to their discipline and their relationship to other more experienced researchers by building on three departments and three disciplines we attempt to account for the most marked differences existing in young candidates practices of scientific coauthorship the differences in collaborative practices depend on the specific epistemic concerns structuring each of the disciplines in astrophysics the instrumental dimension comes first and requires that teams should work on common subjects or shared techniques less systematically so archaeology and its field constraints also imply collaborative practices economics is oriented more towards humanities or fundamental mathematics and values individual production as shown below we found that this overall organization of publication modalities in astrophysics archaeology and economics was actually the case and should be contemplated as the background to the various specific patterns of copublishing practices as instantiated at the time of a thesis defense data and methods data collection although our research focuses on the thesis as standing for a specific writing moment in the young candidates experience our sampling design is longitudinal we have built a comprehensive corpus of theses defended in each of the three departments over the 20032008 period the data collected concern phd students using thesis covers and laboratory databases we pieced together the committees and collected information about each members status teaching andor research place nationality and their publications as well as their overall publishing profile second we carried out some systematic research concerning phd students copublications with the members of their committee to build up our corpus we first used public bibliometric data in the case of the institute in astrophysics and planetology we used the nasaastrophysics data system database which collects articles published in astronomy astrophysics physics and geophysics concerning the doctoral school of economics we drew on the econpapers database for traces we used the french database daphne which provides bibliography information convergence obviously it may be objected that the use of three different databases might have biased our analysis but we did not choose to draw on a single database partly because this type of multidisciplinary database tends to overrepresent some disciplines at the expense of others on the other hand for the sake of balance the web of science database was tested to assess the differences with the databases chosen the specific databases we used proved systematically better stocked we opted for accurate corpora and preferred to conform to the usual publishing practices in these disciplines moreover although we limited the thesis chronotope to the 20032008 period we did not set any time limits on the phd students and committee members copublications selecting theses defended at that time enabled us to observe expost publications up to 2012 a database was built on the information collected from both phd students and committee members thus we collected the number of publications of each phd student as well as those of each committee member in addition to these individual data we collected relational data concerning the number of copublications between committee members and the number of copublications between committee members and phd students then we listed those who were thus interconnected through their copublications a series of 10 interviews complemented our statistical data so as to confront researchers with the networks exposed by their copublications this exercise clarified several aspects concerning the way in which local teams were structured descriptive analysis table 1 presents descriptive statistics about the phd students in our corpus of theses for the same period the number of theses per discipline is therefore different which is consistent with the difference in size of the three departments when focusing on phd students there are both heterogeneous publishing practices which will be commented on later and diverging professional careers half of the astrophysicists and economists did not become researcherlecturers or researchers with a tenured position committee members from cvs on the departmental websites we collected some statistics concerning the supervisors presented below our set of extended data characterizes the overall composition of committees per department and so per discipline our sample of theses defended in economics displays an almost exclusive majority of male supervisors who were european but not local the median year of birth is 1960 with rather low standard deviation they supervised an average of five theses over the period considered in astrophysics female supervisors are more numerous therefore this group looks more local than the previous one astrophysics is singled out by the total number of committee members and the bigger size of their committees over the period each supervisor supervised an average of 15 theses in archaeology our corpus comprises nine phd supervisors of whom three are women they supervised an average of 27 theses with a standard deviation of 2 in the group one supervisor supervised 10 theses committee members were born around 1948 copublishing before presenting our analyses from the data collected in the three toulouse departments it is necessary to briefly introduce the publication practices in the three disciplines of our corpus in astrophysics the average number of authors per publication is 318 it is only 76 in archaeology and only 271 in economics these copublishing collaborations are shaped by factors linked to common practices common both to each of the disciplines and to their research communities and not specific to the phd students or to the committee members of our corpus similarly the average number of copublications per researcher in each of the three disciplines is disproportionate 144 in astrophysics against 28 in archaeology and 26 in economics it shows that research in astrophysics is far more collaborative but also more prolific than the other two disciplines which share similar characteristics of scientific production criteria let us start with the global copublishing modes between phd students and their committee and supervisor in economics 65 theses were defended 46 of them with a phd committee copublication in archaeology out of the 22 theses defended 11 led to copublications last of all in astrophysics all the theses were accompanied by a copublication this is a standard approach to work in astrophysics where theses are most often made up of a series of already published or about to be published articles in our study copublishing practices between phd students and committee members and then between committee members themselves are seen as evidencing collaborations these publishing practices precede the thesis defense and concentrate the social relations that are the object of our study copublishing involves a specific mode of socializing within the scientific community it implies some epistemic and sometimes hierarchical proximity in the case of phd students and thesis supervisors our sample of phd students and committee members has enabled us to collect their copublications so as to establish the statistics in table 3 our sample of phd students is characterized by a big difference in the number of publications between astrophysics and archaeology compared with economics which is less prolific but the fact that the institute in astrophysics and planetology depends on the thesis charter of the doctoral school which requires candidates to publish articles that will make up the body of their thesis should be taken into account in other words the publishing process itself is encapsulated in the thesis sequence 5 then the observation of the phd students copublications with members of their committee and with their supervisor reveals that both archaeology and economics break away from the more collaborative model in astrophysics copublishing between committee members in astrophysics is thus much more important and more collaborative than in the two other disciplines at the institute in astrophysics and planetology the salience of major space projects with the associated instrumental platforms and the abundance of results also accounts for the great number of cosigned publications in terms of copublishing archaeology falls between astrophysics and economics their relation to fieldwork may account for this particular type of publishing practice one of the former directors of traces and the supervisor of numerous theses explained that the specific fieldwork logics definitely characterizes archaeological work what ive always loved about archaeology is that you are right at the confluence between literature and history to me history is part of literature a particular form of literature and life and natural sciences geology archaeozoology history all of them mixed up and so its fascinating because you deal with everything historians love it its their calling we do make everything by ourselves our documents field material objects there are no instructions for us an object is found and we have to invent our instruction manual you experience such joy when you find propose interpretations nevertheless always based on scientific reasoning therefore archaeology is not instrumental like astrophysics but it conjures up the doityourself practice identified by claude lévistrauss to single out practices combining material methods and heterogeneous approaches even if mathematization plays an increasing part in economics copublishing seems to rely on common research work based on models mastered by some teams made up of two or three people this means that scientific citations reinforce relationships hence committee membership invitations are then taken for granted by the researchers involved as part of their scientific exchanges about a committee member bruno a cnrs research director told us ive known him since … so i first met x i didnt know him before my thesis he contacted me on my return back to paris so id say ive known him since about 89 … he started inviting me here i remember coming here for the official opening he had invited me to the opening ceremony of the industrial economics institute and before to one or two thesis defenses at that time when you used to put on a toque etc … for thesis committees … weve had quite a few exchanges we used to discuss a lot but we have never written together we had one or two projects of articles together but we never did it … the proportion of phd students copublications with committee members is extremely variable and the same applies to their copublications with thesis supervisors to sum up systematic publishing in astrophysics must be interpreted in the light of the compulsory contract compelling phd students to publish in order to be able to defend their thesis and of the more collaborative nature of space projects the invisible communities surrounding the thesis by applying social network analysis to our data we first constructed and analyzed comembership and next stronger networks associating both comembership and copublications from the point of view of their structural characteristics the professional relationships between scientists within their department are multiple that is to say they involve several types of collaborations from participating in projects and sharing courses to copublishing committee membership etc in this article the method used consists in superimposing comembership in the same committee and copublishing collaborations the network analysis of comembershipwhichever network involvedreveals that the structure of these communities almost match at times the structure of the department at times that of the doctoral school they quite systematically reflect the departmental teams and it is to be noted that very few committees are made up with members from different teams comembership networks and copublishing networks we have successively analyzed the three disciplines in the three toulouse departments astrophysics archaeology and economics for each discipline committee comembership comes first followed by that of comembership paired with copublishing dealing with comembership networks the tie taken into account is x and y share the same jury this has nothing to do with the nature of the social relationships that may exist between the two members one might have supervised the other one might be the latters departmental colleague they might know each other very well and be friends etc on the contrary the second tie points to strong relationships of shared research work intensified by committee membership astrophysics the comembership network in astrophysics displays three components around three researchers among which the first two are structurally equivalent and the most central the third one is less dense one can make out an axis of oblique symmetry going through two researchers the most central researchers after the first two when comembership and copublishing networks in astrophysics are overlaid the previous structure remains salient as if the extra copublishing with relation did not appear as a strong constraint it merely intensifies the previous type of collaboration the comembership and copublishing network in astrophysics shows strong homogeneity of specialities in the formation of the candidates publishing environment team specialities and their themes of study are key elements and tend to isolate copublishers from the same department this network contains 152 members and 609 ties and only one component which is rather striking all the institute in astrophysics and planetology committee members are indirectly interconnected the network density is 531 and the average distance between two members is 313 which is rather weak two supervisors in the network stand out henri rème and peter von ballmoos who are respectively connected with 29 and 28 of the sample and who are not only thesis supervisors but also team leaders in the institute in astrophysics and planetology department the other professors are interconnected with between 3 and 15 of the sample rème and von ballmoos also hold the most intermediary positions in the network it may be noted that these two professors participate in the highest number of committees 10 for rème and eight for von ballmoos to avoid overemphasizing comembership ties that might prove occasional and hence rather weak it is necessary to raise the selection threshold up to comembership at several committees in figure 3 the tie is x shares several thesis committees with y the number of ties greatly decreases down to a maximum of three common committees for two professors the professors are thus rarely associated more than once the network is made up of six components away from a larger group structured around 13 other researchers by only keeping the ties with rème and von ballmoos only those professors sharing comembership with at least one of the two are selected they are exactly 79 out of 149 which amounts to 53 of the total henri rème chaired nine juries out of all these theses and supervised a thesis only once peter von ballmoos also chaired five committees supervised two theses and was only once a simple member they are definitely far ahead of the other members and they also participated in the greatest number of thesis committees in the course of an interview with one of the institute in astrophysics and planetology team leaders he told us that he did not share any collaboration with van ballmoos as they worked on completely different subjects he added peter is my friend but there is no reason for publishing together6 van ballmoos works in the field of highenergy astrophysics while rème works on interactions in the upper atmosphere when copublishing criteria are included the two subgraphs come apart most of the ties remain but it is to be noted that none of the eight professors on the same thesis committees as rème and von ballmoos copublished with the two of them among the eight five copublished with rème and three did not publish with either one can see that rème seems to have copublished with the highest number of researchers archaeology in the case of thesis defense comembership each committee displays a minimum of three ties the network density is 784 the average distance is 261 it can also be observed that a group of five people is cut off from the rest of the committees it means that this group of five researchers participated on the same committee but none of them participated on another committee with one of the other sample members it is no surprise that yvan pailler and michel barbaza hold the most central position as both of them are supervisors and participated in the greatest number of committees respectively 10 and six during an interview with michel barbaza he wondered at the ties existing with the group of researchers badillo perrot helly and ferjaoui whose names he did not know and yet this set connects the two bottom and top subcomponents of the network this observation calls for caution some relationships between committee members happen to be circumstantial and temporary all the ties displayed do not necessary imply strong epistemic involvement they may also be the result of incidental opportunities a committee member may represent a circumstantial compromise the network of stronger ties between committee members actually provides three isolated and not very dense components around three central professors from traces it should be noted that comembership of at least two thesis committees in archaeology is much more occasional as it leaves us with 21 ties that is 06 density the maximum number of common committees for two members is three the new network includes three components around three main traces professors barbaza pailler and sablayrolles when one of them was asked what accounts for his choice of inviting this or that colleague to a thesis committee he answered that the teaching or research staff the pool is rather limited above all at that time of the year you are bound to know everybody weve got great relationships with paris i bordeaux with aixenprovence even though things are less smooth with the latter we enjoy tight social friendly tactical and scientific relationships of course one should try … whenever possible you know to coordinate so that it doesnt look like convenience committees that wed arrange together it may be the case back then it did happen its more difficult now back then you just did whatever you wanted to do with theses when i think of all the constraints we have today that was how he used many strategies more particularly to ensure the stability of the departments relationships with those in paris and with the ministère de la culture concerning more specifically thesis committees and their composition he finally listed four criteria without prioritizing them he first justified invitations by referring to the researchers expertise and specialization he next mentioned strong budgetary constraints forcing him to finalize juries by resorting to cheap people from bordeaux carcassonne or toulouse he third pointed to some polite invitations for spanish researchers last of all he remarked that working relationships with paris had undergone some changes before toulouse was too small to be attractive and those in paris were rather reluctant to move whereas provincials would more easily go paris now things have slightly changed in short finding the right sort of arrangement between keeping up relationships holding up scientific requirements and preserving friendships is the thesis supervisors main task in ensuring a positive defense in archaeology the challenge consists in holding together heterogeneous logics while taking into account the whole set of institutional political personal and epistemic constraints the comembership and copublication network in archaeology shows that 35 members had never copublished with any other member of the same committee the network only displays 67 ties which corresponds to 188 density comembership within the same committee is represented by 280 ties therefore this means that 32 of comembership ties within the same committee are also copublishing ties the average distance is 263 economics concerning comembership of a thesis defense in economics each member has at least two ties there are 163 members and 1180 ties hence density is 45 the average distance is 29 which means that going from one member to another implies an average of 29 intermediaries the network of comembership on at least two thesis committees in economics displays those researchers who attended several thesis committees together it is no surprise to see that quite a number of ties have vanished the network density is no more than 06 and three components stand out the main one being around jean tirole but with a rather low local density when copublication and comembership at a thesis defense in economics are paired up there are far fewer ties than in the comembership network only the network density is 07 whereas the comembership network has 1180 which means only 14 of the ties remain in the copublishing network the average distance is 417 a series of eight interviews conducted in 2013 with some of the economists in our corpus helped specify the part played by copublishing between committee members and phd students 7 these interviews throw some light on their own career path on research training practices through supervising theses and on copublishing with phd students regarding copublishing between supervisors and phd students three recurring practices stand out first it is usual that each thesis chapter should be a version of an article already published sometimes with the supervisor or with another department member the thesis therefore 7 these interviews were carried out by author 1 as part of a research program funded by the agence nationale de la recherche conducted by béatrice milard between 2012 and 2015 studying citations of scientific articles condenses publishing practices second it is common practice to provide phd students worth encouraging with a 1year research contract to help them valorize their thesis into an article that will also be coauthored by their supervisor and yet supervisorphd student copublishing is not systematic and appears to depend on the supervisors involvement in the thesis for instance alban explained that the work he shared with one of his phd students consisted in sharing tasks and competences they were exploring a research area little studied so far which required devising new methods this involvement in concrete scientific work is also advocated by michel as the usual norm talking about an article cowritten with a phd student he said that in economics supervision is usually much more than merely brainstorming ideas it is actually real collaboration not for all the chapters you hope that the student will be fully autonomous for a number of chapters but its true that at the beginning or with some chapters it is quite common to see both of them together the professor working really hard as much as the student to try and train herhim … this is what happened then the educational dimension adds to the original scientific work it is about learning to be a researcher by coworking with ones supervisor last of all all these interviews demonstrated that the economists shared the same approach to supervision as facilitating students entry into the academic field as well as a time for acquiring research rules talking about supervision relationships a researcher referred to filial bonds between researchers and phd students he explicitly developed this idea when alluding to an article cowritten with two other colleagues there is a kind of lineage in connection with the thesis luigi was herberts phd herbert was pierres phd student and i was nobodys phd student in the group luigi is colombian he defended his thesis here he is now a professor or the equivalent of assistant professor in bogota in colombia and back then he would often come back to toulouse to carry on everything he had started here if there is no compulsory lineage in economics like in astrophysics the logic of copublishing remains fundamental to encourage an early career this implies that the supervisor has noticed the graduates potential qualities and has somehow forecast her or his future as a researcher but this is not systematic as opposed to what happens in astrophysics where writing a thesis necessarily implies being committed to publishingin most cases with the supervisor in charge of the research project comparing networks comembership and copublishing networks reveal two forms of socioepistemic relationships comembership indicates loose relatedness and extended affinities copublishing signals close relationships and shared practices subjects themes and issues in our analysis of the way committees participate in developing a form of sociability it is necessary to grasp the specific characteristics of these two types of networks in the three disciplines the results from comembership networks show that density is higher in archaeology than in the other disciplines that is to say concentration is more important or fewer committees are more frequent besides in archaeology the average distance between two members is shorter which means that it is a smaller world in which a great number of researchers have been invited to the same thesis committee in astrophysics density is lower but average distance is higher the scientific community validating theses is less concentrated the most scattered discipline is economics but it is also the one with the greatest number of thesis committees but even in this latter discipline the average distance of 29 between two members remains short as for comembership and copublishing networks they ought to be analyzed with respect to the evolution of indicators as compared to the first networks economics has lost a greater number of ties than the other two and the result is corroborated by the very low number of common ties between the two types of networks that is to say committee comembership is more frequent than copublishing between members of the same committee both networks in astrophysics display the greatest similarity comembership reinforces copublishing archaeology stands in between the other two disciplinary practices therefore comembership networks and copublishing networks single out disciplinary practices the lack of personal connections in economics expresses some form of disciplinary individualism in contrast in astrophysics which is based almost exclusively on vast projects requiring instruments that mobilize a great number of researchers comembership and copublishing necessarily tend to tighten up conclusion identifying how committee sociability is constructed enables us to single out some specific academic patterns of conduct when examining members comembership and copublishing practices with one another and with supervised phd students we note first that disciplinary identities remain very strong copublishing practices between phd students and committee members bring to light publishing practices reflecting concrete scientific practices collaborative work should not be mistaken as some possible move of historical or social sciences towards hard sciences publishing practices are first and foremost determined by the specificity of research methods the clear thematic structuring definitely turns resources into those competences that committee organizers will request members are actually selected from the largely identified stock of interpersonal relationships already secured by some possible copublications these two activities do not overlap as much in economics as this discipline has only a few or very few collaborative research practices research in astrophysics is centered on vast programs and massive instruments which at least partly accounts for the relative scientific proximity of committee members although the trend is less so in archaeology collaborative fieldwork is a rallying factor which then plays a unifying role for thesis defenses in our study committees stand not only for networks of interpersonal relationships achieved through the participation in an academic ritual of integration but also for the working communities built up by disciplines finally the peermaking process characterized here is shaped by setups that are specific to each discipline astrophysics as practiced at the institute in astrophysics and planetology puts copublishing and more generally research team work at the very core of scientific activities dedicated to instruments economicsabove all at the highly mathematized toulouse doctoral school relies on a repeated methodology in the training process experienced during the thesis which means that the collaborative dimension is less important lastly in archaeology which requires collaborative fieldwork copublishing is therefore quite common we also propose two further consequences of this network approach for the delicate phase of training for article writing and publishing via ones phd on the one hand the very heuristic nature of networks can bring to light some other elements structuring the scientific world which other approaches cannot reveal from this particular methodological perspective our work is the continuation of other contemporary research using network analysis in science studies by combining bibliometric data and comembership and copublishing network analysis our method reveals both the relationships that are in the background of the composition of thesis committees and also reveals the mentors relationships to the phd students that they supervise or whose final research work they assess indeed most studies do not highlight the social setup at work behind either the formation of committees or the work of writing here the social setup distinctly pertaining to each discipline can be clearly identified as an indicator of the different disciplinary practices more or less collaborative and more or less guiding for phd students on the other hand the written material allows us to situate the construction phase of a committee by exposing just like in the case of citations imprints of social relationships agreements passed between individuals working relationships developed and scientific coalition engaged as well as the whole training involvement provided to young candidates are all perceptible in the various ways of coauthoring or of involving coauthors data availability the coauthorship and phd thesis committees data that support the findings of this study are available in the github repository marionmaipeermaking with the zenodo identifier all personal data are available from marion maisonobe upon reasonable request these data have been collected by and under the supervision of mariepierre bès funding information the inquiry was supported by the labex sms université toulouse jean jaurès

this article relies on the analysis of social networks to compare the networks at work in the composition of thesis committees between 2003 and 2008 in a french provincial university in three very different disciplines astrophysics archaeology and economics so as to test the hypothesis that connections actually existed before graduation were members coauthors of scientific publications or were committees constituted only for the sake of awarding a phd astrophysics and its equipment ethos is the one that most often superimposes committee membership and copublishing archaeology falls somewhere in between due to the greatest scarcity of committee members the last of the three economics actually separates the two types of collaboration by most frequently inviting international researchers a n o p e n a c c e s s j o u r n a l

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introduction pregnancy and perinatal periods are significant risk factors of intimate partner violence a major public health problem that could begin or intensify during these periods perinatal care providers have a major role in the identification and the management of ipv this study aimed to crossculturally adapt into french the physician readiness to manage intimate partner violence survey tool a reliable instrument to assess the knowledge attitudes and preparedness to address ipv and to evaluate its psychometric properties methods the premis was crossculturally adapted by conducting forward and backward translations following international guidelines an online crosssectional study was conducted to assess the psychometric properties of the premisfrench in perinatal care providers data completeness factor analysis score distribution floor and ceiling effects internal consistency itemtotal correlations intersubscale correlations and testretest reliability results the premis was successfully translated and crossculturally adapted to the context of metropolitan france the results obtained from 360 perinatal care providers showed good acceptability exploratory factor analysis of the opinions items resulted in a sixfactor solution with six of the eight subscales of the original structure identified good internal consistency and good testretest reliability for the background and opinions subscales were found introduction intimate partner violence is well recognized as a major public health problem 1 ipv prevalence in europe is estimated to exceed 20 in women aged 15 years and older and is higher in women of reproductive age 2 pregnancy and perinatal periods are significant risk factors of ipv that could begin or intensify during these periods in 2013 a metaanalysis reported a mean ipv prevalence rate among pregnant women of 198 for 23 countries the mean reported prevalence of abuse was 284 for emotional abuse 138 for physical abuse and 80 for sexual abuse 3 acts of violence during pregnancy affects directly and indirectly the mortality and the morbidity of the child and the mother ipv is associated to unwanted pregnancies termination of pregnancy 4 and adverse maternal and neonatal outcomes 5 6 7 moreover the prevalence of maternal death by homicide was estimated between 13 and 24 considering all causes of deaths during pregnancy 8 given these serious health consequences healthcare professionals specializing in the perinatal period have a major role in the identification and the management of abused women the french national health authority recommended in 2019 that perinatal care providers screen all women for ipv during the first prenatal visit and continue at least once per trimester and during postpartum visits 9 in accordance with international guidelines 10 pregnancy is recognized as a privileged moment to detect past or current violence suffered by a woman indeed the frequency of prenatal consultations and the bond of trust that is established between the care provider and the women offer the opportunity to disclose ipv however several studies shown that ipv screening was not always done by healthcare professionals often in reason of insufficient preparedness 11 12 13 in 2014 the french interministerial mission for the protection of women victims of violence and the fight against human trafficking conducted a national study to evaluate the midwives ipv knowledge and their ability to screen ipv with a nonvalidated questionnaire 14 they reported insufficient education on ipv and limited knowledge almost one third had never assessed their patients exposure to ipv and in case of ipv 81 felt insufficiently prepared nonetheless 90 considered that midwives had a role to play in the disclosure and management of ipv the reasons given for not screening were the lack of training the absence of clear referral procedures and the ignorance of appropriate response or local specialist ipv services similar results were found among italian midwives 15 an american study identified in 2015 that 312 of obstetriciansgynecologists screen all pregnant patients at specific times of their pregnancy and 368 report insufficient training to assist their patients in addressing ipv 16 thus the creation of specific ipv education and training programs for perinatal care providers teaching how to recognize and respond to ipv is primordial 1718 as well as assessing the effectiveness of these educational interventions with reliable outcomes among them the premis developed by short et al in 2006 is a valid and reliable selfreported instrument designed to measure the knowledge attitudes and preparedness of physician to manage ipv 19 they demonstrated evidence for its construct validity internal consistency predictive validity external validity and temporal stability over 12 months in the absence of ipv education or intervention the developers shown that the premis could discriminate between trained and untrained physicians 20 this instrument has been adapted and widely used in multiple populations cultures and languages 16 21 22 23 24 25 26 27 28 29 30 31 32 33 it was also used to measure the effectiveness of ipv training programs proposed to physicians 20 practicing general practitioners and residents of general practice 34 nurses 35 and healthcare providers working in fracture clinics 36 to our knowledge no study in france assessed with a valid and reliable tool neither ipv knowledge of perinatal care providers nor their ability to identify and address ipv victims thus we performed a study to crossculturally adapt and evaluate the psychometric properties of a french version of the premis tool methods study design and participants this crosssectional online study was conducted from may 2017 to december 2019 in two phases first the original premis was crossculturally adapted from english to french then psychometric properties of the french version of premis were assessed the study was approved by the french regional ethics committee comité dethique des centres dinvestigation clinique de linterrégion rhônealpesauvergne cecic grenoble the aims and procedures were explained to participants who gave their written informed consents an online link was created and data were collected using redcap electronic data capture tools hosted at clermontferrand university hospital the french federation of perinatal heath network invited by email its care providers memberships to take part in the study and spread the internet link to complete the questionnaire a reminder was done one time during the period of the study to assess testretest reliability of the premis the internet link to complete the questionnaire a first time was sent by email to a subsample of memberships of two regional perinatal networks who were identified by their email address they completed a second time the same questionnaire online between fifteen days and one month after the first assessment respondents who reported having a training course about ipv between test and retest were excluded for this reliability analysis the sample size of the study was determined according to quality criteria established by cosmin 37 and terwee et al 38 that recommend a minimum number of 100 subjects to ensure satisfactory factor analysis and internal consistency evaluation and a sample size of at least 50 subjects in order to guarantee an acceptable assessment for reliability the premis tool the premis selfadministrated questionnaire contains 67 items comprising five sections respondent profile background actual ipv knowledge opinions and practice issues from the background section two subscales scores are obtained by calculating the mean of the individual scores of the items listed in the subscale the perceived preparation subscale includes 12 items asking respondents how prepared they feel to assist ipv victims and rated on a 7point likert scale from 1 to 7 the perceived knowledge subscale includes 16 items asking respondents how much respondents feel they know about ipv and rated on a 7point likert scale from 1 to 7 in the actual ipv knowledge section a combination of 7 multiple choice items and 11 truefalse items form the actual knowledge subscale scored by the number of correct items the opinions section includes 36 items rated on a 7point likert scale from 1 to 7 and evaluating attitudes beliefs and physicians role in ipv management on which 31 items forms six reliable subscales in the original version of premis preparation legal requirements workplace issues selfefficacy alcoholdrugs and victim understanding two other subscales constraints and victim autonomy needed future testing for validity and reliability scores are obtained by calculating the mean of the individual scores of the items listed in the subscale with reversed scores for negatively worded opinion items the 13 items of the practice issues section evaluated selfreported behaviors and personal ipv experience of the respondent with various responding options translation and crosscultural adaptation of the french version of premis the premis questionnaire was translated from english into french and crossculturally adapted to be relevant to the french context following international guidelines for the adaptation of selfadministered instruments 39 forward translations were independently made by two bilingual translators fluent in english with french as mother tongue and naïves to the outcome measure a multidisciplinary expert committee reviewed the two translations and edited a first consensus french version cultural adaptations and linguistic equivalence with the original english version of premis were discussed then a native english translator fluent in french blinded to the original english version then made a backward translation the expert committee compared source and target versions and resolved discrepancies item translation semantic idiomatic cultural experiential and conceptual equivalents were discussed the consensus french version was pretested on a sample of ten health care providers in order to evaluate the comprehensibility of instructions and items their responses and comments were reviewed the evaluation of psychometric properties was then conducted statistical analysis statistical analysis were performed with sas software and conducted at a twosided alpha 005 significance level sociodemographic and professional characteristics of participants were described the psychometric properties evaluation of the premisfrench consisted in data completeness factor analysis descriptive statistics and score distributions internal consistency itemtotal correlations intersubscale correlations and reliability data completeness the respondent acceptability was assessed by looking at the frequency of missing values data quality was considered satisfactory if less than 15 of the item data were missing factor analysis factor analysis with an oblique promax rotation allowing the factors to correlate were performed to study the multidimensionality and distribution of the items of the opinions section in subscales 40 as attitudes and clinical practice in ipv management could vary from culture to culture there was no guarantee that the french version reproduced the subscales of the original premis questionnaire hence we chose an exploratory analysis of the structure of the items 39 41 42 43 the kaisermeyerolkin statistic and bartletts test of sphericity were used to check the appropriateness of running the factor analysis kmo values higher than 050 are acceptable 44 bartletts test requires to yield significant result eigenvalues higher than 1 and cattells scree plot 45 were used for factor retention the solution giving the most adequate factor structure was retained 40 descriptive statistics and score distributions the premisfrench subscales scores distribution were described by mean standard deviation median and range the variability of the premisfrench scores was investigated for each subscale with the floor and ceiling effects these effects were considered to be present if more than 15 of the subjects obtained the lowest or highest possible score 46 internal consistency cronbachs α coefficient was used to evaluate the internal consistency of each subscale of the background and opinions sections 47 the minimum required for the coefficient was 070 according to the standard used for group comparisons 48 internal consistency was not evaluated for the actual knowledge subscale as it is a criterionreferenced subscale 1949 itemtotal correlations itemtotal consistency was used to evaluate the extent of the linear relationship between an item and its subscale for the background and opinions sections corrected for overlap 43 a minimum correlation coefficient of 040 was considered indicative of good itemtotal consistency 50 intersubscale correlations spearmans coefficients were used to evaluate intersubscale correlations of the opinions section subscales correlations were considered very small for coefficients lower than 030 small for coefficients between 030 and 050 moderate from 050 to 070 and strong if higher than 070 51 convergent validity spearmans coefficients were used to evaluate correlations between the number of hours of previous ipv training perceived knowledge perceived preparation and actual knowledge subscales the subscales from the opinions section and the number of hours of previous ipv training perceived knowledge perceived preparation actual knowledge subscales positive correlations were expected reliability stability over time was assessed by the testretest method reliability of the subscales from the background actual ipv knowledge and opinions sections was estimated by intraclass correlation coefficient based on the twoway mixed effect model the following categories were selected to interpret the agreement levels 002 small 021040 fair 041060 moderate 061080 substantial and 0811 almost perfect 52 results translation and crosscultural adaptation cultural adaptations were made during the forward translations in respondent profile section an item was added including you how many midwives practice at your work site in actual ipv knowledge section child protective services was adapted to the french context using cellule de recueil des informations préoccupantes in opinions section item 17 was adapted to the french context as the joint commission did not exist in france in practice issues section one item was not culturally relevant in the french context and was removed adults moreover local dvipv hotline and child protective services were omitted from the list of referral resources in item 4 as these support services are not available in france in pretesting the french version none of the ten health care providers reported any understanding difficulty or completions problem consequently the expert committee adopted this version as the prefinal crosscultural adaptation we named this version the premisfrench psychometric evaluation of the premisfrench participants the online survey was answered by 360 perinatal care providers the characteristics of these respondents are described in table 1 ands1 3 and the more frequent type of training was to attend a lecture or talk in the last 6 months 637 made at least one new diagnose of ipv data completeness in the respondent profile section the percentage of missing values per item varied between 0 and 161 in the background section the percentage of missing values was 114 for the item on the amount of previous ipv training and ranged from 0 to 17 for items of the perceived preparation subscale and from 06 to 22 for items of the perceived knowledge subscale the percentage of missing values ranged from 03 to 28 for items of the actual ipv knowledge section and from 19 to 78 for items of the opinion section in the practice issues section with items on the screening and management of ipv victims in the last 6 months the percentage of missing values per item were higher and ranged between 42 and 164 factor analysis factor analysis with an oblique promax rotation were performed to study the distribution of the 36 items of the opinions section in subscales the significance value of bartletts test of sphericity was 00001 and kmo measures of sampling adequacy was 0846 indicating that the data were suitable for factor analysis an initial maximum likelihood factor analysis identified a 11factor solution that was statistically sound however four factors contained only two items ten items crossloaded on two or more factors indicating a complex solution that lacked a good theoretical basis thus new factor analysis were performed after discarding items with loadings lower than 032 with loadings greater than 032 on two or more factors or items that significantly lowered internal consistency the final factor analysis identified six factors with eigenvalues greater than one and accounting for 591 of the total variance all items loaded higher than 040 on its subscale the first factor comprised five items and was named preparation it had four items in common with the original preparation subscale and one item from the original selfefficacy subscale the second factor named workplace issues comprised six items four items were in common with the original subscale item 2 was from the original selfefficacy subscale and item 18 was from the original victim understanding subscale the third factor comprised the four items of the original legal requirements subscale and was labeled identically item 17 loaded higher than 032 on two factors 055 on its factor and 038 on factor 2 the fourth factor comprised four items and was labeled selfefficacy it had three items in common with the original subscale and one item from the original workplace issues subscale the fifth factor comprised the three items of the original alcoholdrugs subscale and was named identically the sixth factor comprised three items of the original victim understanding subscales and was labeled identically item 15 loaded higher than 032 on two factors 071 on its factor and 033 on factor 4 two original opinions subscales were not found in the current model the items of victim autonomy and constraints subscales were discarded during the selection process of the most adequate factor structure descriptive statistics score distribution floor and ceiling effects the descriptive statistics and score distributions of the premisfrench subscales are presented in table 3 the percentage of missing values were less than 7 except for the actual knowledge subscale with 25 of missing values neither floor nor ceiling effects were found for the background actual ipv knowledge and opinions subscales internal consistency and itemtotal correlations the background subscales showed good internal consistency with cronbachs α equal to 095 and 097 for perceived preparation and perceived knowledge subscales respectively all corrected itemtotal correlations were higher than the required 040 ranging from 054 to 087 for perceived preparation subscale and from 050 to 090 for perceived knowledge subscale for opinions subscales cronbachs α ranged from 054 to 088 showing good internal consistency for four subscales and moderate internal consistency for the alcohol drugs and victim understanding subscales which did not obtain the minimum required coefficient of 070 all corrected itemtotal correlations were higher than the required 040 ranging from 040 to 085 except for item 21 from alcoholdrugs subscale with a value of in addition each item of the opinions section correlated better with its parent subscale than with the other subscales except for two items of the selfefficacy subscale for item 14 the itemtotal correlation with its subscale was 057 and the correlation with the preparation subscale was also 057 for item 26 the itemtotal correlation with its subscale was 054 and the correlation with the workplace issues subscale was 057 intersubscale correlations correlations between premisfrench opinions subscales ranged from 0003 to 054 the preparation subscale had a significant moderate correlation with the workplace issues subscale the legal requirements subscale had significant small correlations with preparation workplace issues and selfefficacy subscales the selfefficacy subscale had significant moderate correlations with preparation and workplace issues subscales the alcoholdrugs subscales had significant very small correlations with workplace issues and selfefficacy subscales and no significant correlation with the others the victim understanding subscale had only significant very small correlations with preparation and workplace issues subscales convergent validity correlations between the amount of previous ipv training the background subscales the actual knowledge subscale and the opinions subscales are shown in table 5 the amount of previous ipv training was moderately correlated to perceived preparation and perceived knowledge subscales and very weakly to actual knowledge subscale the perceived knowledge and perceived preparation subscales were strongly correlated correlations between the actual knowledge subscale and the background subscales were significant but very small r 022 with perceived preparation and r 027 with perceived knowledge hours of ipv training showed moderate correlations with preparation and workplace issues subscales almost moderate correlations with legal requirements and selfefficacy subscales and no significant correlation with the two other opinions subscales all opinions subscales except for the alcoholdrugs one were significantly correlated to the perceived preparation and perceived knowledge subscales correlations were strong with the preparation subscale moderate with workplace issues legal requirements and selfefficacy subscales and very small for the victim understanding subscale correlations between opinions subscales and the actual knowledge subscale were significant but very small ranging from 014 to 023 except for the victim understanding subscale with a higher correlation of 033 reliability of the fifty perinatal care providers randomly selected for the testretest 40 completed the test questionnaire among them 24 completed the retest testretest reliability was almost perfect for the background subscales with iccs equal to 092 for perceived preparation and 088 for perceived knowledge agreement was substantial for actual knowledge subscale with an icc of 069 reliability was also substantial for opinions subscales with iccs ranging from 065 to 083 except for alcoholdrugs subscale with a moderate icc of 046 discussion the present study describes the crosscultural adaptation and the evaluation of the psychometric properties of the french version of the premis named the premisfrench in a national sample of perinatal care providers the premis was successfully translated and crossculturally adapted from english to french the premisfrench had good acceptability with low percentages of missing values per item except for some items from the practice issues section evaluating practices or workplace specificities that could be not relevant for some participants it also had good response distribution neither floor nor ceiling effect were found for the subscales indicating that the instrument was adapted to the studied population the sixfactor structure of the premisfrench opinions section differs slightly from the eightfactor structure of the original version of the premis 19 only the two original victim autonomy and constraints subscales were not found in our validation however in the original premis this subscales were not sufficiently reliable and only kept for future testing the preparation subscale groups together four items from the original preparation subscale and one item from the original selfefficacy subscale this item was more related to the feeling of being prepared in the french context the premisfrench workplace issues subscale comprised items from the original subscale and two items related to the systematic abuse screening of patients from the original selfefficacy and victim understanding subscales ipv screening in france depends on the institutions policies where health care providers work and not all encourage ipv identification unfortunately the selfefficacy subscale comprised one item from the original workplace issues subscale being able to gather the necessary information to identify ipv as the underlying cause of patient injuries is more related to selfefficacy than to work site the victim understanding subscale comprised three items on the seven items of the original subscale lastly legal requirements and alcoholdrugs subscales were identical in the french and the original versions 19 the other premis versions also presented factor structures that were somewhat different from the original version two subscales were identified in all other studies preparation and alcoholdrugs subscales the greek physicians version 23 identified a 2item ipv screening subscale the legal requirements subscale was not found in this version where the items were excluded during the adaptation of the premis 23 as the victim autonomy subscale the spanish version for physicians and nurses identified a barriers subscale 24 the american pharmacists version identified one single subscale for selfefficacy and workplaceefficacy 22 the american health care students version identified a 2item ipv screening subscale 21 the workplace issues and the constraints subscales were not identified as it was not appropriate for students 21 the australian paramedic and nursing students version did not find the workplace issues and constraints subscales 25 the legal requirements subscale was not found in this version as the items were excluded during the adaptation of the premis 25 internal consistency of the background subscales was high and comparable to those of the original subscales with cronbachs α superior to 090 19 same results were found for the physicians greek and spanish versions 2324 the american and australian healthcare students versions 2125 and the american pharmacists version 22 for opinions section preparation workplace issues legal requirements and selfefficacy subscales demonstrated good internal consistency comparable to those reported in the original version 19 alcoholdrugs and victim understanding subscales displayed moderate internal consistency lower than those reported in the original version 19 this moderate internal consistency was also found in the greek physicians version 23 in the american healthcare students version 21 and in the australian paramedic and nursing students version 25 the spanish physicians and the american pharmacists versions reported higher internal consistency for the alcoholdrugs subscale 2224 the very small to moderate correlations between the opinions subscales imply that they measures related but relatively different constructs alcoholdrugs subscale displayed the lowest correlations with the other subscales results found in the original development of the premis 19 and in the other studies 21 22 23 24 25 convergent validity was explored by assessing the intersubscales correlations the majority of the correlations replicated findings of previous studies only the spanish validation did not explore these correlations 24 perceived preparation and perceived knowledge subscales were strongly correlated in the previous studies correlations ranged from 074 to 089 19 21 22 23 24 25 these subscales were not significantly correlated to alcoholdrugs subscale as found in the original version 19 the greek physicians version 23 and the australian healthcare students version 25 correlations between the amount of previous ipv training and the background subscales were moderate and higher than those found in all previous studies 19 21 22 23 24 25 actual knowledge subscale had small correlations with the amount of previous training the background and opinions subscales the higher correlation was found with the victim understanding subscale which was the only significant correlation in the greek physicians 23 and american healthcare students versions 21 short et al in the original version found significant but small correlations between actual knowledge and perceived knowledge and between actual knowledge and opinions subscales except preparation and legal requirements subscales 19 in the american pharmacists version actual knowledge was only significantly correlated to legal requirements subscale 22 testretest reliability which is an essential property 53 showed substantial to almost perfect iccs except for the alcoholdrugs opinions subscale with moderate reliability only the greek physicians validation reported iccs for testretest reliability over a 3to 4week period 23 in our study iccs for the perceived preparation perceived knowledge actual knowledge and selfefficacy subscales were higher for the other similar opinions subscales our iccs were lower 065 versus 083 for preparation subscale 078 versus 093 for workplace issues 074 versus 081 for victim understanding 046 versus 079 for alcoholdrugs our study has some limitations first participants were mainly women this could be explained by the fact that midwives are widely represented in perinatal care occupations in france in 2017 only 26 of midwives were men as women these participants certainly felt more concerned about this topic and this could have affected their responses almost one quarter of the participants reported no previous ipv training in the other crosscultural validations this proportion varied from 457 21 to 95 23 nevertheless short et al reported that 135 of their first sample and 313 of their second sample used to validate the original premis reported no previous training which was closer to our results 19 besides it was not possible to distinguish between town and clinic caregivers and those who are regular employees of the hospitals or health care institutions practice variations could be explained by the work site in particular by the presence of protocol for dealing with abused women ipv referral resources or institutional policies for the reliability test 24 respondents completed the retest a number lower than the 50 subjects recommended by terwee et al 38 but higher than in the other validation studies10 subjects for the spanish version 24 18 subjects for the australian version 25 and 20 subjects for the greek version 23 further studies are needed on sample with more men to confirm the psychometric properties of the questionnaire and in other settings like in primary health care physicians the responsiveness to change that is the ability of the premisfrench to detect changes after ipv training had to be evaluated as well as convergent validity as no validated instruments was validated in french to serve for comparison conclusion this study provides evidence of the good psychometric properties of the premisfrench when delivered to perinatal care providers to assess their readiness to manage ipv as the original and the other versions of the premis the premisfrench could be used in several ways to assess knowledge attitudes beliefs behaviors and skills in order to assess needs that could be addressed during ipv education program as a pre and posttest to measure the changes over time or after ipv trainings or interventions to compare perinatal care providers who had received training and those who did not have it this is a valid and easy instrument to use which will help to understand perinatal care providers barriers to ipv screening and management and will help to focus on specific lacks of knowledge for developing ipv education programs this measure of educational outcome would also allow the evaluation of ipv training courses that will be developed in the near future in accordance with the recent recommendations of the french national health authority the data underlying this study have been uploaded to guiguetauclair

this study provides evidence of the good psychometric properties of the premisfrench this valid instrument will help to understand perinatal care providers barriers to ipv screening and management and will help to focus on specific lacks of knowledge for developing ipv education programs

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introduction meaning in life has also been seen as crucial to wellbeing and especially in later life manifested for example in the need for life review and adjustment to changing roles in the family and society in this article we focus on the role of religion and spirituality in the process of meaning making in later life although viewed as central the contributions of religion and spirituality to meaning making have not been examined in research adequately or in their full spectrum the role of religion and spirituality for meaning making in later life is particularly salient for the postwar baby boom generation a generation differing from its predecessors in a significant way although the boomer generation has been shown to either stay quite stable in their religious orientation and its intensity or to become more religious by age and in various existential challenges it is also the first generation whose bonds with traditional religious institutions started to loosen at the same time this generation developed a profound interest in spiritual practices advancing personal growth and development often leading to complex trajectories of spiritual seeking as a result many older people nowadays no longer feel at home with traditional religious institutions and their teachings and practice and are searching for their own spirituality often they are creatively using sources from different religious traditions to fulfill their need for meaning a profile that can be characterized as hybrid religiosity influenced by the broader societal transition toward a culture of authenticity and personal fulfillment the relationship between spiritual authority and religious institutions has become selfchosen rather than inherited or nonchosen for the boomer generation and subsequent cohorts as a result taking an active role in identity building and meaning making in the global framework of religion and spirituality facing various types of religious and nonreligious convictions has increasingly become a necessity members of the boomer generation characteristically rely more on their own judgement feelings and intuition regarding their beliefs what to accept and what to reject than on eg traditions or religious authority at the same time the social and communal settings of religion and spirituality remain profoundly important in meaning making we may conclude that the boomer generation is exemplary for a generation immersed in the religious and spiritual transitions characteristic of a secular age its diversity in religious and spiritual orientations makes this generation particularly interesting for studying the role of religion and forms of spirituality in meaningmaking practices in this article we will look specifically at how their meaning making practices unfold in an interplay of personal and social orientations toward religion and spirituality and how these meaningmaking practices are connected with religion and spirituality we study these themes in a specific social context namely a finnish retirement migrant community in the costa del sol spain the specific characteristics of this population provides us with an opportunity to study the interaction between individual and social aspects of meaning making in the light of religion and spirituality because as we will discuss below both communal bonds and personal searching motives are strongly present in this community as well as the stimulus for meaning making in the transmigrant context our study thus aims to increase the understanding of meaning in life as an influential wellbeing factor of the current and future generations of older persons and to shed light on the social complexity of meaningmaking processes in relation to the role of religion and spirituality for these people to that end we will answer the following research questions 1 how are meaningmaking practices connected with religion and spirituality for finnish retirement migrants of the boomer generation 2 what does the role of religion and spirituality in meaningmaking practices teach us about the relation between individual and social aspects of meaning making background meaning and later life research on meaning and meaningmaking is an exciting and growing field that has been approached from different disciplinary angles including theological philosophical and psychological studies partially because of this disciplinary variety however consensus on how to define meaning is still lacking though an integrated approach is generally agreed to be desirable whether meaning is defined in terms of a set of psychological or psychosocial needs a global system of beliefs and values or rather a set of situated practices of course impacts methodological choices in the study of the phenomenon of meaning as well in the literature there exists many distinct ways of defining meaning these include wongs model which defines global meaning in life to consist of the following four components purpose understanding responsibility and emotionenjoyment stegers approach which distinguishes among purpose significance and coherence defines the following needs for meaning purpose efficacy moral worth and selfworth to which derkx et al added needs for coherence comprehensibility and excitement park who distinguishes between global and situational meaning or edmondson who takes an ethnographic approach and presents meaning not as answering a predefined set of needs but rather as an emergent phenomenon created in the daily life practices of people meaningmaking practices are often linked to frameworks of meaning also called meaning systems they are to be distinguished from the scientific conceptualization of meaning listed above rather these are frameworks held by individuals who serve as background of their understandings of themselves and the world meaning systems are theories and beliefs about both self and the surrounding realities used in decisionmaking planning defining the internal and external relationships and attitudes of an individual in general making sense and giving meaning to the experiences of an individual meaning systems are contextual both in relation to the social and historical settings where experiences happen and in relation to the personal history and life course of an individual this conceptualization of meaning system comes closer to several other concepts including horizons of interpretation in the way it refers to guiding the meaningmaking processes of individuals on the one hand meaning systems are personally and individually appropriated but on the other hand they are always at least partially shared with otherspersons communities and larger social entities like societies shared meaning systems contribute to the shaping and preserving shared realities in a group and to create a shared sense of communality and belonging by using shared meaning systems the communities and their members are able to direct their behavior and interpretation of events including historical ones the shared realities shaped by meaning systems not only affect the everyday life of individuals and communities but also more abstract issues and experiences including views on what is meaningful in life and where meaningful experiences can be searched for religions are examples of social phenomena which can be approached as global meaning systems as they most often explicitly deal with questions related to the sacred and the transcendent they can constitute an influential framework not only on meaning and meaning making relating to beliefs but also on contingencies expectations and goals however it is vital to note that religions are by no means the only possible frameworks for a meaning system also explicitly nonreligious as well as spiritual but not religious meaning systems are found in diverse social groups including the baby boomer generation george and park suggests that global meaning systems always encompass dimensions of cognition motivation and emotion with regard to situational meaning parks model distinguishes between appraisals of a certain situation in terms of its meaning comparison of this appraisal with the global meaning system meaning making which describes the efforts people make to create or restore coherence between the global meaning system and a given situation and meanings made aging and old age can pose specific challenges when it comes to meaning making first of all as krause suggests the emphasis in meaning making may shift during the life course so that setting goals may be more important in constituting meaningfulness for younger people whereas the ability to reconcile the past and look back on the life of an individual with peacefulness and contentment gains in importance during later life second modern western societies are often hostile toward aging people because old age is associated with decline and fear and this cultural hostility impedes the chances of older people having to experience their life phase and social roles as valuable and meaningful on the other hand the second half of life has also been traditionally seen as a phase in which the human potentials for wisdom and spiritual growth can be fully realized in the current literature the function of religion and spirituality for meaning in later life is particularly explored with regard to the confrontation with death and with regard to coping with health problems manning states that religion can serve two important functions in coming to terms with the existential reality of finitude ones own death or the death of others first religion can provide people with a framework in which events of life can be experienced as ordered and coherent rather than random or chaotic this makes it easier to feel a sense of purpose and accept that death is part of the human condition second religions can offer people action steps to deal with death that give them a sense of control and reduce possible feelings of helplessness and despair in the face of death the role of religion and spirituality in meaning making is also linked to coping with health issues in older age although meaning can be searched for and found in both religious and nonreligious contexts there are differences between how different meaning systems propose to deal with health issues for example with regard to how they define the ideal emotional state and its path leading studies show that being nonreligious need not lead to worse health results compared to being religious and that atheism or nonreligious forms of spirituality and hybrid religiosity are equally functional in providing sources of meaning in diverse life situations including confrontations with diminishing health and death what remains mainly unstudied is what the role of religion and religious or nonreligious spirituality can be in meaning making aside from situations where one is confronted with death or diminishing health religion and spirituality the concepts religion and spirituality are both fuzzy and overlapping where religion often refers to beliefs behaviors rituals and ceremonies related to an established tradition spirituality evolves more around the theme of transcendence within or without organized religion in this article the concepts are useful especially as tools for working with and illustrating the cultural and linguistic richness and differences related to these phenomena these differences and variations have been observed in various cultural contexts including in japan from longitudinal and narrative data pertaining to the relation of religion belief and spirituality in old age bengtson and johnson drew some interesting conclusions about how the role of religion and spirituality has transformed across different generations during the twentieth and early twentyfirst centuries first they observed how conceptualizations of god have changed showing that older cohorts are more likely to see god as a transcendent omniscient and distant being whereas the younger cohorts often see god as an imminent and internalized power to whom they have access in themselves second a comparison between the older and younger generations shows an increasing separation of religious practice from religious institutions whereas for older generations it was selfevident that religion is practiced in church synagogue or mosque the younger generations increasingly came to the conviction that leading a religious life did not necessitate regular church attendance but could also be realized in other practices outside traditional houses of worship third religion and spirituality have increasingly become two different domains for younger generations as compared to older cohorts while religion is increasingly identified with organized institutionalized traditions spirituality became the term for an internal personal relationship with the divine to be obtained through processes of spiritual development growth and transformation the contemporary religious and spiritual landscape is best understood as a complex and multilayered structure it is typical for the quest culture of modern spirituality that traditional boundaries characteristic of religious traditions and institutions no longer suffice to understand the meaning making processes that people engage in instead in the process of spiritual seeking people are shaping their own lived practices of religion freely drawing on sources both inside and outside traditional religious frameworks as roof puts it agency or the role of the individual actively engaging and creating an ongoing personal religious narrative in relation to the symbolic resources available is crucial to our understanding of contemporary spiritual quests thus in this article we put emphasis on meaning making as an active process in which people may or may not draw on religion and spirituality to create meaning meaning making and spiritual seeking in this article we specifically aim to look at meaning making which we broadly define as the active component of the engagement of people with meaning in life meaning making not only pertains to global life meaning but also occurs as people ascribe meaning to specific aspects of their existence making meaning can be distinguished from finding meaning which implies a more passive role for the individual also the verb making emphasizes the active construction of meaning by individuals in their lifeworld whereas finding assumes that meaning has an existence independent of individual consciousness in the outside world meaning making is related but not equivalent to searching for meaning according to park meaning making occurs when a discrepancy is experienced between the global meaning system that people adhere to and to a specific situation for example experiencing a traumatic life event such as the loss of a loved one may alter the philosophical or religious outlook of an individual on life and affect the view of the world of an individual and the perception of an individual on himself the process of meaning making then facilitates the repair of a coherent match between the global and situational meaning however as ethnographic approaches to meaning in life suggest meaning making is not necessarily restricted to our response to situations of distress but can also be approached as a continuing practice throughout our daily life activities we would like to take this broader perspective to not only focus on the distress that discrepancies with global meaning systems pose but also on more ordinary instances of meaning making as an active process of creation manning suggests that meaning making processes in which we assign meaning to the past are different from meaning making processes in which we try to find meaning in what happens to us in the present this is relevant in the context of aging because evaluating the life of an individual with the purpose of finding what erikson has called egointegrity is generally seen as an important meaninggoal in later life whereas manning conceives the pastoriented type of meaning making as a mainly intellectual exercise where events from our past lives are put in an interpretive narrative framework the presentoriented type of meaning making is less about reflection and explanation to create a retrospective coherence and more about action emotion and motivation to create a sense of purpose and control amidst the events one lives through at that moment the reflective and retrospective orientation characteristic of meaning making about the past is consistent with the philosophy that people are narrating beings whose meaning making relies heavily on narrative people tell narratives to shape their identity and express their relationships with other people and with the values and practices of their societies for older persons narrative seems to gain an increased importance as an instrument of creating meaning as many authors in the tradition of narrative gerontology underscore in looking back at the life of an individual and construing a coherent narrative about it people come to terms with themselves and ideally can perceive their life in retrospect as purposeful and significant in this article we relate our focus on meaning making to processes of spiritual seeking according to wuthnow we can observe a transition from religious dwelling where people feel at home in a particular tradition and community usually provided by religious institutions toward spiritual seeking where people undertake a highly personal journey of transformation and hopefully growth in which they aim to discover and create their own meaninggenerating spiritual orientation the process of spiritual seeking can take place in a fruitful dialogue with more traditional religious institutions such as church communities but can also involve distancing oneself from them and creating new forms of communion with likeminded spiritual seekers though the study of wuthnow focuses on the north american context the transition from religious dwelling to spiritual seeking can be found throughout the entire western modern world the shift from religious dwelling to spiritual seeking comes with a strong focus on inwardness subjectivity and authentic personal experience as the focal point of religious and spiritual energy this is exemplary of the modern turn toward an ethics of authenticity described by several authors taylor has provided an eloquent historicalphilosophical analysis of this shift toward an ethics of authenticity the study of taylor sketches the genealogy of the meaning systems relied upon by people in western modernity as they relate to their selfunderstanding and identity the search for meaning has evolved into an inner journey that is perceived as highly individual and authentic a problematic side of this discourse is that it seems to present a rather atomistic image of the human agent with hardly any sensitivity for how agency is embedded in social practices rather social influence is presented as a threat to living authentically however as taylor pointed out it would be a mistake to see the pursuit of authenticity as a purely personal process instead it is deeply intertwined with the moral horizon of the culturesociety in which it takes place and therefore always socially mediated according to taylor it is impossible to develop an individual vision of the good without knowing where you stand in a field of socially constituted goods that form the moral horizon of the culture of an individual we can learn from the analysis of taylor that the spiritual seekers of our research population may have an ambiguous relationship with traditional contexts of religious dwelling but that their search or quest for meaning is nevertheless a deeply social process it would therefore be a simplification to state that spiritual seeking as opposed to religious dwelling is predominantly an individual process and that people no longer feel themselves to be part of traditional religious and social communities with potentially detrimental consequences for their sense of belonging and for social cohesion in society instead the population of spiritual seekers experience multiple religious belonging though no longer identifying as exclusive members of a certain religious institution people can still feel at home and experience a sense of authentic relation with multiple religious sources and traditions traditional boundaries between religious and spiritual traditions have become irrelevant to some extent but the sources of meaning they provide gain significance in new creative combinations materials and methods this article examines these questions within a particular group of older persons finnish retirement migrants in costa del sol spain this group is characterized by constant change and fluctuation the typical lifestyle includes spending summers in finland and winters in spain members of the community come and go and a large proportion of social activities and networks are bound to time and place either finland or spain also the individuals engaging in this lifestyle experience transitions from work to retirement from a country to another from a social or family role to another many of these older migrants are best described as transmigrants sharing their time and interests in varied proportions between finland and spain this is one of the reasons why this particular population is an intriguing context for studying meaning making retirement migration and transmigration involve not only various transitions and challenges which require selfrealization personal coping and social relating but also adaptation to new things and coping with lossall of which are circumstances where meaning making is especially needed another reason for focusing on this particular finnish group of older persons are the countryspecific characteristics of the baby boomer generation in finland both the size of the baby boomer generation and its timing and span are exceptional when compared to other countries the exceptionally large afterwar birth cohorts were proportionally larger and their birth years fewer than in most other countries after the second world war for example the annual birth rate curve almost doubled in finland during the second half of the 1940s whereas in great britain the annual growth was only about 25 thus in finland the concept of baby boomers as a sociological phenomenon may have a greater explanatory power than in several other countries and the shift from previous behavior patterns to those adopted by the boomer generations might be more dramatic related to meaning making behavior a significant shift has been observed in several european and north american countries in finland where the prevailing narrative has been of cultural and ethnic homogeneity the choice contexts for meaning making have been relatively limited thus for many older finns especially those belonging to generations preceding the baby boomer generation the search for meaning in life has taken place in a religious framework here arises a third reason for focusing on this community of older persons according to earlier studies the retirement migrant community is much more active in religious and spiritual activities than the corresponding demographic groups would be in finland in finland religious attendance is at the north european low level in the year 2019 about 687 of finns were members of the lutheran church but only 6 participated in a service at least once a month according to an earlier questionnaire survey it was found that a finnish religious service was the second most popular finnish event at costa del sol about 46 of the informants had attended a service and 29 had attended some other finnish religious activity during the last winter season in a study regarding the finnish seasonal migrants and regular tourists in spain and the canary islands it was found that during their stay in spain 57 of finnish migrants attend more to religious services than they do in finland whereas only 12 attend more in finland than in the canary islands also many of the persons attending the services in spain do not take part in church activities in finland in an earlier study 28 of questionnaire survey informants who stated that religion is not important to them still had attended a service during their winter stay in spain a significantly understudied phenomenon is the emergence of meditation and alternative spiritual practice groups this can be observed in the social media pages of the community advertisements in newspapers and in other traditional media from around 2015 onwards but has not yet been studied the obvious and explicit explanation for the higher attendance in spain than in finland is meeting other finns social connections and activities in various associations have been proved crucial to the wellbeing of retirement migrants and in the creation of social capital like many migrant churches and congregations globally the finnish religious communities in spain are important platforms for forming social networks however there are various other instances contexts and events outside the religious ones where the finnish migrants in the costa del sol could and do meet each other while social factors explain some of the attendance it leaves a particular demand for religious events in hiding in a danish case reported by warburg the church was the only or one of the very few available organizers of national and cultural activities and the participation was the highest at the nonreligious events organized by the parish on the contrary the finnish community at the costa del sol has a variety of clubs associations and institutes to organize cultural educational and entertaining activities also the weekly services are clearly the most popular activities organized by the lutheran parish religious activities have been strongly associated with the wellbeing especially the mental wellbeing of the migrants where nonreligious activities did not have the same effect the reason might lie in the ability of religion to function as a tool of connectivity both in diasporic and transnational ways for these reasons the retirement migrant community with its abundance of religious and spiritual activities is a very interesting context to study given our aim to shed light on the social complexity of meaningmaking processes in relation to the role of religion and spirituality the material for this study was collected in the finnish community of costa del sol during the years 20092019 the material consists of 58 texts 10 semistructured interviews and 30 responses to an online survey with openended questions the material is also presented in table 1 datasets of this study together this combination of narrative material gives a rich multidimensional view to the life of the retirement migrants and their community across time and allows for the examination of their meaning making from various points of view the texts for the dataset 1 were collected by letters and emails with the cue write about religion in the finnish community at costa del sol the invitation to write was published in the finnish language magazines and newspapers in the area and also advertised through the biggest finnish religious communities the evangelicallutheran parish and the tourist church this collection resulted in 64 texts approximately half a page long the shortest 10 sentences and the longest two and a half pages the informants represented various religious affiliations and age groups in this study we excluded six texts where the informant was known to be under 60 years old as we focus here on the meaning making especially in the later life thus 58 texts constitute the dataset 1 and were used in our analysis from the texts we picked the themes and approaches for the interviews constituting the dataset 2 eight of the interviewees in the dataset 2 had also provided a text to the dataset 1 the remaining two interviewees were recruited in the finnish events in the area and were persons especially willing to contribute to research on religion and spirituality in the area the interviewees of dataset 2 were aged from 60 to 82 where half of them were men and half women and they represented lutheran pentecostal and nonreligious orientations the interviews were carried out by the first author of this article mostly in the homes of the respondents and they lasted from 15 to 3 h dataset 3 was created by a survey distributed online in march 2019 to a facebook group of finns in costa del sol and sent by email to persons affiliated with a meditationnonreligious spirituality group the survey material provides an interesting incremental point of view to the community reaching out to specifically spiritual but not religious persons and the emergence of new spiritual but not religious activities in the community the survey was anonymous so there is no means of telling whether the respondents have also contributed to the first two datasets this study examines the replies to openended questions included in the survey which focused on discussing and reflecting on meaning in life as well as religiousspiritual orientation and practices we received altogether 65 replies to the survey of which 30 were from informants aged from 60 or over and thus are included in this study focusing especially on meaning making in later life the material was analyzed with qualitative content analysis and adapted a grounded theory methodology using the atlasti analysis software the first author analyzed the first two datasets and the third dataset was analyzed by the two authors together first taking turns and then each author checking on the analysis of the other all categories and codes used were extracted from the material then grouped and regrouped to form themes as responses to our research questions one significant decision made in the analysis and writing process for this article was the question of translating the terms related to religion and spirituality both the phenomena and the vocabulary around religion and spirituality evade clearcut definitions and are contextspecific to a large extent in the finnish context in everyday language the field of religiosity and spirituality is often described using three words uskonnollisuus hengellisyys and henkisyys the word uskonnollisuus would refer to religiosity through dimensions such as attendance practice and dogmatic beliefs related to institutionalized religion such as a churchthus we decided to translate that as religiosity the word hengellisyys would refer to a type of spirituality relating to institutionalized religion but in contrast with religiosity or uskonnollisuus hengellisyys focuses more on the personal practice and experiences such as praying singing hymns and having a religious worldview in this article this is translated as a religious spirituality the word henkisyys then would refer to spirituality characterized by experiences and personal practice not connected to institutionalized religions interestingly this term could also include phenomena in the fringes between the spiritual and the secular factors such as philosophical interest or personal growth results meaning making in the retirement migrant community in our material meaning making was displayed in a wide variety of ways for some informants meaning making was quite comprehensive touching not only the person in question but persons in general and also even larger entities like the cosmos or god i believe in the ability of a person to perceive his or her modest part of the earth and therefore to work for himself and his immediate surroundings both mentally and physically this can be god in us for some informants accounts of meaning making are centered around the little things in life such as volunteering but volunteering it has been the spice of lifeit is very pleasant to be around people in everyday life and at the same time feel united with all the parish members to feel that you can be of help and to be helped yourself at the same time for this informant an important part of volunteering in the parish was to be united with others and this sense of unity was created through the tasks in everyday life in addition to the pleasantness of doing together this activity was given the meaning of unity with all the parish memberswhich might judging from the word ykseys the interviewee uses be a particular spiritual kind of unity volunteer activities had a strong spiritual importance for some of the informants an interviewee from the dataset 2 a female in her 60s ponders that this is really only temporary that a time will come when i dont have to worry or take care of anything yes exactly and then you can rejoice and rest and just enjoy and that gives me strength to strive for that goal here in the parish and in my own life and toward other people and for that reason too participate however i can whatever small contribution i can make to make that possible for others who dont know god thats really our task here we want to take others with us there too some with a bigger and some with a smaller contribution mm yes like washing the dishes or sweeping the floor there that somebody a seeker can come here that were here for them this informant makes meaning of her volunteering in cooking and cleaning duties in the context of religion for her volunteering was not only keeping up the hope for a better life after death but also in this life giving strength in everyday struggles in addition she makes meaning for her duties in the religious community as helping others to find god our material also reminds that meaning making happens in a place and time i go to worship and ponder the sermon on my way home and at home i help others whenever i can it gives strength and good spirits the moments of meaning making are not something separate from the everyday life but take place during the usual activities like walking home or embedded in the everyday deeds of helping others the informant tells about pondering a sermon and then continues to write about practice helping others which also has benefits for the helper herself the practice and the sermon come together a practical meaning is given to the religious message and a religious meaning is given to the spiritual practice in addition to everyday life religious practices festivities and customs linked to them are also one of the frequently mentioned contexts of meaning making for us it is very important to celebrate the religious holidays in the finnish way for example christmas is a very emotional and an important holiday all the childhood christmases come to mind with christmas matins sleigh rides etc we also reminisce about persons who have passed away parents siblings and all relatives and the message of christmas the informant describes how christmas is given the meaning of looking back but also reaching out to others in the spirit of christmas the message of christmas seems to be one of connectivity both to the past but also to the present as for the past the personal life stories appear in the material as important contexts of meaning making for these older persons i was born into a home where religion and the morals behavior and good manners that come with it are not unfamiliar these give good guidance on the journey of life to take into account others and to respect their view of life and conviction no matter which religious branch they belong to interestingly for this informant the tolerant and accepting way of life was given meaning through their strong religious upbringing morals and good manners were seen in the religious context and shaping the whole journey of life of the informant one of the key findings of our analysis is that meaning making is integrated in the everyday lives of the people not only in the times of festivities but also in the quite usual chores and activities like volunteering or walking home religion and spirituality in the meaning making our analysis showed that both religion and spirituality played a role in the meaning making both in the religious and nonreligious context in the religious context one of the social phenomena framing the meaningmaking processes is a religious participation which is described to be more religious and active for finns in spain than in finland a clear majority of informants in the dataset 1 stated even if that was not explicitly asked in the call for texts that religious participation was much more common and the participation style was much more active for the finns in costa del sol than in finland the place and change of place seemed to play an important role for meaning making for many respondents as sunshine and the palm trees were often mentioned as pleasant elements but at the same time constant reminders of being in a foreign environment i think that in spain people are more open and receptive to religion they are older and the departure from this world is approaching for everybody but here also those people go to the church who wont do it in finland because of bashfulness or other reasons the songs and hymns are sung at full blast although everybody isnt always hitting the right key it also seems that everyone goes to receive communion in addition to the higher age and approaching the end of life the informants mention openness and receptiveness as central factors for increased engagement and attendance but in addition to the increased frequency this and several other informants write about the difference in participation style more open more personal a result of an individual choice and stressing more an active role in participation the specific social context and the transitions linked to the life in it seem to play a key role in the increased and intensified religious engagement the church here is like a mother duck who calls her ducklings under her wings for shelter and protection and nourishes both physically and spiritually the church and religion is much more important to us here than in our homelandarent we here like scattered in the winds of the world here the religious context was seen as framing the meaning making in a new uncertain and insecure situation the perceived safety and protection provided by the religious context was very often mentioned in the texts it was mainly left unclear which were the threats to safety that religious context was perceived to be protecting from building a social network and social capital in a new community might be a factor here in addition the sense of safety seemed to be also spiritual as in the quote above and for this informant and often its because problems caused by a certain homesickness loneliness or troubles in integration develop to be a curious internal longing and emptiness where spiritual circles are starting to give meaning to ones life the informant describes how external factors like moving to a new country and social environment create experiences of longing and loneliness which in turn create internal needs longing to be fulfilledwhich in turn leads to meaning making in a new context and with a new sense of urgency interplay between personal individual aspirations and the social framework was not always easy many informants such as the persons quoted above also mentioned possible obstacles on why they themselves or their peers have not engaged in religious activities in the home country the peer pressure for not participating while in finland and the absence of it in spain was explicitly mentioned in several texts belief is a personal encounter with lord jesus the coast gives the same possibilities for it as finland does sometimes even better when relatives friends and neighbors are not there controlling the lower threshold to engaging in religious and spiritual activities in spain than in finland mentioned explicitly in 10 of the 58 texts in the dataset 1 gives a reason to think that the need for this engagement exists also in the finnish context and is not only related to transitions such as moving to another country to retire also it underlines the need for active negotiation between the personal needs for meaning and the social context the meaning making practices adopted in the later life depend on many factors neither on the social norms nor the pursuit for authenticity however the search for meaning was not linked exclusively to the specific social context of being a retirement migrant in spain but also and very firmly to the life stage of older adulthood and retirement it is as if you could start your life anew now that youre retired and do what you really want to and feel its the right thing to do thats spirituality today interestingly the writer not only placed spiritual practices as the engagement they were longing for but also vice versa to do what you really want to do to explore ones own agency was indeed a form of spirituality religion and spirituality also play a role in making meaning of severe illnesses in later lifeand the threat they pose one of interviewees in dataset 2 a woman in her seventies tells about a person living with several illnesses how she is a very positive and joyous person and how she often discusses the possibility of an illnessridden elderhood we just always remind each other that if he our lord puts us through that schooling i wont be there alone hes there with usso im not afraid no interestingly the religious and spiritual framework is here related to togetherness and connectedness explicitly not only with god but also with the person and persons sharing similar views also informants who did not consider themselves as religious saw spirituality as significant contexts for meaning making i do not believe in god as seen by christianity i believe there is something bigger i believe things tend to arrange themselves and that something is behind that i also like to think that my dead father is somewhere but where i havent figured it out yet for this informant nonreligious spirituality helped to make meaning and sense of life and its events for others engaging in meaning making processes in a spiritual context was primarily motivated by selfrealization or selfdevelopment i treat religion and religious spirituality in the same way as exotic flowers i look and marvel i understand nonreligious spirituality more broadly i think it is a work and an exercise that a person does to change themselves this informant saw the selfdevelopment motive to be especially linked with the nonreligious spiritualityin contrast with religion and religious spirituality the informant thus described what they found to be a key difference of religious and nonreligious spirituality the other is to be looked at and the other to be exercised another informant describes how religion and religious spirituality affects her everyday life especially having found god its had a great effect like when i think how ive ever been able to make decisions before for example and i thought i was good at decisionmaking now i dont need to do anything more than just ask heavenly father how is it now with this thing here do i sell this flat or not and i get answered in all my matters i get answered in a way or another although the context where this informant practices her religion is strongly religious as she is an active member of one of the religious organizations in the area the effect in her life described here arises from a personal spiritual practice praying thus another key finding is that religion and spirituality are not easily segregated from each other in the data and they are manifested intertwined also for this respondent asking god for advice seems to be a personal process not involving any religious professionals or key figures in this narrative getting answered involves agency in asking and defining an answer thus it is vital to inspect meaning making as an activity in the lived context following the course of research on aging in context ethnographical approaches and in aging and everyday life in this study further examining is to be included on the role of the older persons as active subjects of the meaning making process meaning making as an active process one of our key findings is that meaning making is an active process for these older persons and it involves a negotiation between authenticity and selfexpression on the one hand and the social framework on the other for some informants this is very explicit this is my own thought interpretation about belief and deity we must grow and develop by ourselves no pastor or preacher is able to do that after presenting the development of his spiritual thinking the informant comes to the conclusion that everyone is responsible for his own spiritual development another informant who is not very active in any religious community uses the religious context to make meaning of his aspirations to help otherseven if he would have to disagree with others well i dont know if my christian conviction is that strong but it comes to me from early childhood from my mothers milk the defending of the weak and ive seen christianity so that it should focus on exactly defending the weakthis is how i see the teachings of jesus too some disagree and say that it is not only about helping the weak but i think it is thats the core of everything later in the interview the informant tells that for him personally helping others is the primary way of practicing spirituality it is not only a moral obligation but also a spiritual act part of a larger whole that ethos has especially affected his life after retirement as he feels he now has more freedom and time to do good to others for some informants the focus of the meaningmaking processes was in the self like for this informant describing the meaning of religious service to her hearing the gospel helps revitalize and strengthens me i dont have to accomplish anything but i can just rest and be taken care of by god this is something ive been missing through many years of work to safely be a child of god now that i have time i can read the bible and other spiritual literature now i have time to pray either specially to settle for prayer or then pray by myself while doing the daily chores my wish here in the sun is to get closer to god religious context had for this informant an uplifting and caring effect retirement also offered the much needed time to explore the spiritual dimensions of life perhaps earlier subdued by work and the related lack of time to focus on oneself for this informant however the individual meaningmaking process is launched in a shared context having heard the gospel with others also in nonreligiously spiritual contexts both a social aspect and the emphasis on the individual agency as well as authenticity were present for some meaning making was the first and foremost linked with social connectivity live in such a way that my deeds my presence and my words would enable my loved ones to fulfill the purpose of life theyve chosen with joy and confidence in their own abilities for others the motivation was linked more clearly to selfdevelopment i want to find myself through the wisdom of spirituality who am i these individual experiences and fulfillments do not appear in vacuum many informants relate the individual sense of meaning in a relational context i find it unlikely that living on a large scale has any purpose instead i think it is good for individuals to experience that their lives matter to someone or something this kind of individual sense of meaning can be found in different things for different people in fact quite often individualist and relational motivations were intertwined become the best person possible that is kind helpful and spiritual toward all living things this informant connects personal development with contribution to the lives of others and even nature the best possible person is also the best person for others not only for oneself meaning in life is actively made and measured by kindness helpfulnessin everyday life discussion the lives of the finnish retirement migrants we have studied in this article are vibrant with meaning making both the written and told narratives from our informants paint a lively picture of a community whose members actively engage with each other and with themselves to infuse their daily lives with meaning an important finding is that the engagement in meaning making contrary to what has been suggested in some of the literature about meaning in later life does not only occur in response to confrontations with health issues death or other major life events instead we found that meaning making occurs as a process that is often inherent to daily activities which may seem trivial but in fact turn out to be important sources of purpose values and connectedness this has been noted also in previous and recent studies this speaks in favor of studying meaning from an ethnographic phenomenological perspective and not limiting research on this topic to more dominant quantitative approaches using measurement instruments such as the meaning in life questionnaire it also resonates with the emerging literature about lived religion in the sense that through studying this engagement it is possible to examine how meaning making is practicedquite alike how the study of lived religion focuses on the practice of religion in response to our first research question we found that religion and spirituality are present in the lives of our informants in a variety of ways and play a significant role in their meaning making some of the informants find their spiritual and social home within traditional religious institutions such as the lutheran church and find comfort and a sense of belonging through practices such as worship and reading the gospel others have chosen the paths of spiritual seeking that lead them away from these traditional religious practices and toward new expressions of spiritual meaning making such as meditation or yoga in this sense the finnish retirement migrants in this study confirm the findings from the literature in our theoretical framework about the varied religious and spiritual orientations of the boomer generation a significant finding is that for some informants traditional religious settings such as church services serve a meaning making function that is more social than it is substantially religiousfor them meeting other finns and belonging to the community seems to surpass the importance of religious teachings yet it is important to note that despite these seemingly rather functional reasons to stay connected with religious institutions the sense of social belonging and connectedness they gain from their engagement with it has acquired a spiritual status for many informants feeling related to other people and being there for one another in a religious and spiritual context are highly important values in this community with a great potential for meaning making individual spiritual journeys are often interwoven with more traditional religious practices though for some respondents their spiritual path has led them to turn away from institutionalized religion permanently a finding related to the above is that religion and spirituality turn out to be not so easy to separate in our results there exists a variety of religious and nonreligious forms of spirituality in this population and all of these forms can be relevant factors in meaning making it is noteworthy to mention that the distinction between religious dwellers and spiritual seekers as laid out in the literature cannot be clearly drawn in our sample in a sense many of our informants appeared to be seeking in some way and this seeking could occur both within and outside of more traditional religious practices this is consistent with the idea that the baby boom generation is characterized by multiple religious belongings these results underline the importance of looking beyond dichotomies such as religiousnonreligious or even religiousspiritual when the aim is to understand the role of religious and spiritual phenomena in the lives and meaning making of individuals and communities the results also emphasize the need to come to a more nuanced understanding of the diversity of experiences related to religious and spiritual meaningmaking of older personsbe they in religious or nonreligious contexts another important finding to mention is that people exhibited a variety of different motives for including religion andor spirituality in their meaningmaking practices as indicated before socially oriented motives such as seeking connectedness or belonging caring and taking responsibility for others or doing good deeds that benefit individual recipients or the community as a whole play an important role in meaning making and are explicitly framed as spiritually inspired motives on the other hand there is a group of more individually oriented motives that we propose to unite under the heading of authenticity which covers the striving for personal growth and spiritual development while many respondents continue to feel a connection to religious institutions even if only for its social functions it is characteristic for most of them that they want to actively create their own spiritual journey as atchley puts it people are actively creating mosaics of spiritual practice lifestyles and communities specifically designed to nurture their vision of the spiritual journey the spiritual journey is a much different prospect and experience in the evolving dwellingseekingpractice framework than that experienced in a more static framework that emphasizes authority structures and onesizefitsall approaches to the spiritual path this leads us to an interesting direction to answering our second research question in this paper with regard to how the role of religion and spirituality can enhance our understanding about the relationship between individual and social elements of meaning making it seems to be the case that whereas individual and social factors are both indispensable in the religious and spiritual meaning making of these retirement migrants it is vital to them that an authentic and active subject position is maintained always but contrary to the dominant modern ideal of the authentic selfsufficient human agent with its problematically atomistic anthropology for our respondents their authentic subject position is embedded in the social practices of their daily lives which nourish their individual spirituality and are vital to meaning making this study has its limitations the respondents in all the three datasets are individuals who are at least somewhat intrigued with meaning making and questions related to religion or spirituality in the future it would be interesting to examine meaning making with representative material or in a population not inclined to ponder their lives in any spiritual framework however exactly by focusing on persons willing to describe their meaning making this study offered insights into meaning making in later life as an active process taking place in the social and lived context these insights should be employed not only in further studies examining meaning in life but also in the wellbeing and good life in older age as this study was one among many highlighting the fundamental importance of meaning making for older persons 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 conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher appendix a interview questions 1 how did you end up living in the costa de sol 2 how do you spend time here 3 how finnish would you say your life is here 4 what is your relationship to religion andor spirituality 5 there is a lot of volunteering here whats your relationship to that 6 quite a few finns attend religious services here how is it with you 7 what do you expect from the future

meaning in life has also been seen as crucial to wellbeing and especially in later life this study focused on the social complexity of meaning making processes and the role of religion and spirituality in them by finding out the following 1 how are meaningmaking practices connected with religion and spirituality for finnish retirement migrants of the boomer generation 2 what does the role of religion and spirituality in meaningmaking practices teach us about the relationship between individual and social aspects of meaning making this was done by examining a particular group of older persons finnish retirement migrants aged 60 or over in costa del sol spain the material for this study consists of 58 texts written correspondence dataset 1 year 2009 10 semistructured interviews dataset 2 year 2011 and 30 completed online surveys with openended questions dataset 3 year 2019 key findings include that religion and spirituality are present in the lives of our informants in a variety of ways playing a significant role in their meaning making and that they appear as intertwined and not so easy to separate a variety of religious and nonreligious forms of spirituality exist in this population and all of these forms can be relevant factors in meaning making also the engagement in meaning making contrary to what has been suggested in some of the literature about meaning in later life not only occurs in response to confrontations with health issues death or other major life events instead we found that meaning making occurs as a process that is often inherent to daily activities which may seem trivial but in fact turn out to be important sources of purpose values and connectedness contrary to the dominant modern ideal of the authentic selfsufficient human agent which is based on a problematically atomistic and individualistic anthropology for our respondents their authentic subject position is embedded in the social practices of their daily lives which nourish their individual spirituality and are vital to making meaning

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swartz bhana 2009 despite enduring public stereotypes that portray nonresidential fathers as disengaged and shirking their responsibilities recent research demonstrates that many men do not fit this image one study in urban johannesburg for example found that over 60 of children under age 5 received uninterrupted financial support from their fathers perhaps more surprisingly qualitative research indicates that some nevermarried nonresidential fathers are increasingly playing caregiving roles beyond economic provider helping with homework and providing moral instruction because of the vital roles that both residential and nonresidential fathers are believed to play in promoting positive child outcomes understanding the factors that inhibit or foster fathers engagement is important previous research on this topic has identified high levels of poverty and labor migration as major impediments to fathers coresidence and engagement in the apartheid era men were traditionally engaged in mining or other industrialized activities leaving their female partners and children behind in designated homeland areas although the strict pass laws ended in 1986 these high rates of male migration without accompanying family members have continued with up to 60 of men age 3554 reported as temporary migrants in rural south africa much of this migration is in fact driven by the poor economic prospects for young men who face an unemployment rate of nearly 40 for those age 1624 nonetheless although many fathers are forced to leave their childs household to find work successful migratory black fathers in particular are likely to send back remittances and thus fulfill one of the important roles of fathers as a breadwinner in addition to low levels of employment young south african fathers are particularly unlikely to live with their children because of the precipitous decline in formal marriages among black south africans fewer than half of men and women living in kwazulunatal reported being in a formal marriage by age 40 in rural south africa about half of all births to women age 1226 occur out of wedlock the practice of lobola whereby the grooms family is expected to pay the brides family before marriage is often blamed for delaying marriages and increasing premarital childbearing because many families find it difficult to accumulate the full brideprice the dependence of most young men on their families to help negotiate and pay the lobola highlights the importance of extended kin in south africa in fact to fully understand the fatherchild relationship in south africa it is essential to consider the role of extended kin fatherhood among young men in south africa happens to families rather than individuals paternal kin not only help pay lobola but they also assist in the payment of isisu which are paid if the young father does not intend to marry the childs mother and wishes to acknowledge his paternity fathers often complain that their contact with their children is curtailed if neither lobola nor isisu payments are made the childs maternal kin also play an integral role in making decisions about how children are raised and by whom much has been written about the importance of maternal grandmothers helping to raise young children in south africa in particular if their daughters are unmarried maternal kin may also act as important gatekeepers refusing to acknowledge paternity or grant fathers access to their children if isisu payments have not been made in short as madhavan and roy argued the care of children including the role that young fathers will play is often a negotiated process between the biological parents and their respective kin in this study we explored how these family ties are related to three measures of fathers engagement with their children coresidence frequency of contact and financial support we focused on young fathers because these men face the highest unemployment rates and are least likely to have established a stable marital or cohabiting partnership with the childs mother as a consequence they are most likely to depend on extended kin both to assist in raising their children and to help them navigate their roles and responsibilities by using exceptionally rich longitudinal data collected in cape town our study offers two main advantages over previous analyses of fathers engagement first we assessed the association between prior indicators of the relationships between mothers and fathers mothers and maternal grandmothers and fathers and paternal grandmothers and current levels of fathers engagement to minimize the potential for reverse causality second unlike many previous studies which have relied primarily on young mothers reports of fathers involvement we analyzed representative samples of both young fathers and mothers to explore fathers engagement from both male and female perspectives by looking at mens engagement in childrearing in the context of broader family relationships our analyses help identify the complex factors that can encourage or discourage young men from being active participants in their childrens lives conceptual framework our conceptual framework draws on family systems theory which views families as dynamic and interdependent systems in which different relational subsystems influence other subsystems specifically we were interested in how the key dyadic pairsmotherfather mothermaternal grandmother and fatherpaternal grandmotherare related to the fatherchild relationship the family systems approach has frequently been applied to the study of young fathers involvement in lowincome african american families in the united states several of these studies have found that the quality of the relationship between mothers and fathers is strongly related to the involvement of nonresidential fathers other studies have emphasized the central role of maternal grandmothers not only in caring for their grandchildren but also in facilitating or hindering fathers contact with and financial support of their children paternal grandmothers have received less attention although they too appear to be important although this research demonstrates the value of taking a family systemsbased approach to studying fathers involvement this theoretical perspective has not been applied to research in south africa which primarily draws on theories of masculinity to explain mens roles within the family structures ties between fathers and mothers in south africa the vast majority of young children live with their mothers thus whether mothers and fathers are currently in a cohabiting relationship would likely determine whether or not fathers lived with their children yet relationship statuses change over time and some types of conjugal bonds may be weaker than others marriages and cohabiting unions dissolve and fathers move out of the household to seek work in other instances couples who had been living apart may form an independent household thus we would expect that the type of relationship between mothers and fathers at the time of pregnancy would strongly but not perfectly predict whether fathers subsequently lived with their children and that fathers with weaker initial conjugal bonds will be the least likely to currently live with their children similarly nonresidential fathers who are in a committed relationship with the childs mother would be most likely to provide economic support and assist with child care conversely lowquality parental relationships could result in little support from nonresidential fathers as participants in one qualitative study asserted where the motherfather relationship was not good or it was nonexistent it was most likely to result in minimal if any support for the child from the father other qualitative research however suggests that even if mothers are not in a romantic relationship with the childs father mothers may encourage fathers to play an active role and will welcome financial support from them young men in particular felt that being a good father revolved around being present and supporting their child irrespective of whether they had an ongoing relationship with the mother of their child thus we expected that the effect of the type of the conjugal relationship on fathers contact with and financial support of their nonresidential children may be weaker than that for coresidence ties between fathers and paternal grandmothers patrilineal kinship structures are common throughout south africa this strong vertical lineage system traced through paternal lines reinforces the central role of fathers in providing social standing legitimacy protection and economic support for their children as a consequence paternal grandparents and other relatives have a keen interest in helping fathers build and maintain strong ties to their children paternal grandmothers appear to play a particularly important role in helping young fathers adjust to parenthood by encouraging young men to participate in parenting the child young men often describe their mothers as provider as emotional supporter and encourager as mediator and protector and as counselor or teacher thus we would expect that young men who maintained strong ties to their paternal kin especially their mothers would be more likely to marry and to maintain an active and ongoing relationship with their nonresidential children ties between mothers and maternal grandmothers although the majority of ethnic groups in south africa are patrilineal most groups including the xhosa recognize bilateral descent whereby kin from both sides play an active role in sharing childrearing responsibilities moreover traditionally until lobola is paid children remain members of the maternal family in these instances the maternal grandmother rather than the biological father may act as the primary coparent the support that young unmarried mothers receive from their mothers and other family members may come at a cost however because the childs maternal relatives have primary responsibility for the childs care they often have power to determine the degree to which young fathers have access to and are involved in raising their children although some young men report that the childs maternal grandmother would help arrange for them to visit their child others note that maternal grandmothers tended to side with their daughters and formed a formidable barrier to seeing their children particularly if the isisu had not been paid as one young mothers relative commented in our culture there is no role a young father can play quantitative data also suggest a negative correlation between support from maternal kin and fathers involvement in johannesburg nonresidential fathers are less likely to provide financial support or to keep in contact with their children if the childrens mother lives in a household with other adults thus we hypothesized that stronger ties between mothers and the childs maternal grandmothers will decrease the likelihood that fathers live with their children regularly visit their children or provide financial support mens employment although the primary objective of this study was to assess how family ties are related to fatherchild relationships other factors have also been shown to be related to mens engagement foremost among these are economic factors as mentioned above both the need to migrate for employment and to pay lobola limits fathers ability to live with their children fathers who are unemployed or underemployed are also unlikely to be able to provide regular financial support shame associated with being unable to pay for child support can spill over into other aspects of the fatherchild relationship for example in qualitative interviews some young fathers reported feeling too ashamed to see a child if they could not pay for clothing food or other essentials thus poverty may affect not only fathers financial support of their children but also their likelihood of coresiding and having frequent contact with their children parents race and age race is intrinsically linked to fatherhood in south africa the majority of blacks living in the cape area belong to the xhosa ethnic group which is characterized by high migration because most were confined to nearby homeland settlements following the end of apartheid family structures and household dynamics changed dramatically as restrictions on mobility and urban residence for blacks were lifted coloureds a heterogeneous mixedancestry ethnic group historically categorized separately from both blacks and whites make up approximately 47 of cape towns population followed by blacks and whites with less than 1 of the population reported as asian rates of fathers absenteeism are higher among black south african children than among coloured children and are lowest for white children last both the age of the parent at the time of birth and the childs age are related to whether fathers live with their children and how often fathers see or provide financial support for their nonresident children young fathers are less likely than older men to live with their children because many young fathers are finishing school and attempting to save sufficient resources to marry and establish an independent household the age of the child may also determine fathers level of involvement one study of children in johannesburg for example found that financial support declined with the age of the child method for our analyses we used data from the cape area panel study caps was designed using a twostage probability sample of households with an oversampling of black and white households in order to obtain samples large enough to make meaningful comparisons across groups the baseline wave of caps conducted in 2002 surveyed 4751 young adults in 3304 households located in the metropolitan cape town area of south africa as in most south african household surveys response rates were high in black and coloured areas and low in white areas largely because whites disproportionately live in gated communities to which interviewers have limited access second third and fourth rounds were conducted in 20032004 2005 and 2006 respectively in the fourth round 3438 young adults now age 1826 were interviewed representing approximately 72 of the original sample less than 2 of our sample in wave 4 falls outside of this age range because of slight age misreporting we removed one woman who reported a very large age difference across waves attrition rates differed significantly by race by wave 4 coloured youth had the lowest attrition rates followed by blacks and whites most attrition by blacks was due to return migration to the rural eastern cape province the main sending region for blacks living in cape town attrition rates for whites were the result of both migration out of cape town and a significant number of refusals because of both high attrition rates and low initial response rates we excluded whites from our analyses presented below lam and colleagues provided a full description of the details of the caps study design response rates and attrition across the first four waves by wave 4 nearly 40 of women and 175 of men had had at least one child of those with at least one child women had on average 12 children and men had 11 children for our analyses we included all children reported by respondents yielding a total of 311 children reported by young fathers and 898 children reported by young mothers our primary analytic samples of children excluded two children with missing birth dates and 15 children who died before wave 4 moreover because we were interested in assessing parental involvement our samples also excluded 23 children who had lost a biological parent thus in total 3 of all reported children were excluded our analyses focused on three main outcomes whether children coreside with their young fathers whether children see their nonresidential fathers at least once a week and whether children receive financial assistance from their nonresidential fathers because previous research suggests that mothers and fathers may provide different assessments of fathers engagement all analyses were run separately for children reported by mothers and those reported by fathers young mothers and fathers were reporting different children both fathers and mothers provided reports about childrens residence and financial support whereas frequency of contact was reported only by fathers our first outcome indicated whether the child normally lives with the father at wave 4 the handful of young mothers or fathers who reported that their children sometimes reside with their father were coded as not coresiding for children who do not reside with their fathers we examined how often fathers see their child our second analytical outcome this categorical variable captured whether fathers see their child every day several times a week several times a month several times a year or never we considered fathers who see their children at least once a week as having regular contact and thus we collapsed these categories into a dummy variable for which 1 every day or several times a week and 0 less than once a week in our final set of analyses we assessed both mens and womens reports of fathers financial support to nonresidential children young fathers who do not reside with their child were asked do you provide any financial support to anyone to look after child and young mothers who do not reside with the childs father were asked does child other parent provide any financial support to you for childs name our two key independent variables focused on indicators of the type of the parents relationship to each other and the intergenerational ties between the young parent and his or her parents our primary measure of the parents relationship with each other used the question how would you describe your relationship with the childs other parent at the time the pregnancy occurred we coded these responses as 1 spousemarried 2 coresidential girlboyfriend 3 noncohabiting girlboyfriend and 4 exspouse former girlboyfriend or never a steady relationship we focused on relationship status during pregnancy to establish temporal order and reduce the potential for reverse causality to assess the quality of the parentgrandmother relationship we relied on an indicator of the closeness of the parentgrandmother bond specifically young adults were asked over the past 12 months how often has your biological mother had conversations with you about personal matters we preferred this measure of intergenerational ties to a more common indicator of whether the parent coresided with the grandmother because it better captures emotional closeness unfortunately however this question was asked only in wave 1 when one third of children had already been born in additional analyses we tested the effects of coresidence at the time of pregnancy and draw very similar conclusions even though the correlation coefficient between coresidence at pregnancy and having personal conversations at wave 1 was less than3 we also accounted for whether parents spoke with their fathers about personal matters in our models but this relationship never had a significant impact on our outcomes and is not shown in our tables all models include indicators for parents race and economic status unless otherwise indicated in tables 4 and5 our indicators of employment status and household economic status were measured at wave 1 or at the wave immediately preceding the childs birth other important factors such as parents age at childbirth parents education and the childs age and gender were included in all of our models but are not shown in the tables all of our multivariate analyses used logistic regression and clustered by mother or father to account for the correlations between children with the same parent results the data in table 1 describe the living arrangements and characteristics of children of young mothers and fathers only 264 of children reported by young fathers and 321 of children reported by young mothers coresided with their biological fathers in wave 4 two thirds of nonresidential fathers however reported that they see their child at least once a week and over 60 reported providing financial support young mothers reported that only about half of nonresidential fathers provided economic support these differences between mothers and fathers reports about financial support are consistent with previous research in the united states suggesting that mothers underestimate nonresidential fathers contributions and involvement these differences however may reflect real differences between our samples of young fathers and young mothers because these are not matched couples in fact the male partners of young mothers tended to be older on average than the young fathers in our sample the relationship status of young fathers and mothers at the time of pregnancy however was not significantly different at the time of pregnancy 180 of women and 125 of men reported being married about 13 of both men and women reported having a coresidential girlfriend or boyfriend whereas the largest proportion reported being in a relationship with the other parent but not living together a mere 61 of men and 54 of women reported that they were not in a relationship at the time of pregnancy young mens and womens relationship status and residency patterns changed considerably between the time of pregnancy and wave 4 many romantic relationships ended regardless of whether the couple lived together at the time of pregnancy a small but nonnegligible proportion of both cohabiting and noncohabiting relationships transitioned into marriage young fathers and mothers were similarly likely to live with their parents at the time of pregnancy both young fathers and young mothers were significantly more likely to speak about personal matters with their mothers than their fathers our sample was divided roughly equally between black and coloured fathers and mothers only about onefifth of our respondents had graduated from secondary school by the time of the pregnancy householdlevel poverty rates of young mothers and fathers were roughly comparable with over one third describing their economic status as poor or very poor twice as many young fathers as young mothers however were working at the time of pregnancy turning to our multivariate logistic regressions table 3 summarizes the results of our examinations of fathers and mothers reports about fatherchild coresidence the type of the motherfather relationship at the time of the pregnancy was strongly correlated with whether young fathers lived with their young children in wave 4 compared to married young fathers those who cohabited with their partners during the pregnancy experienced a roughly 80 decline in the odds that they would be living with their child at wave 4 young mothers reported a nearly 90 difference in the likelihood of fatherchild coresidence between married and cohabiting partners at the time of pregnancy both men and women reported that if fathers and mothers were in a relationship but did not live together at the time of pregnancy fathers were unlikely to live with the child at wave 4 the data in table 3 also focus on whether parents relationships with their mothers was associated with where fathers live whether fathers talk about personal matters with their mothers had little impact on whether young fathers live with their children in contrast when mothers have a close relationship with their mothers the odds that fathers coreside with their children falls by half both mothers and fathers reported that the odds of a coloured father living with his child are over two times higher than those of an african father last there were no significant relationships between mens or womens employment at the time of pregnancy and whether fathers subsequently live with their children fathers reports of how often they see their nonresidential children are summarized in table 4 in contrast to the findings given in table 3 we found that fathers relationship to the childs mother was not significantly related to whether he maintains regular contact with his child furthermore no contrasting sets of comparisons by parents relationship status at the time of pregnancy were significant fathers with closer relationships with their own mothers however are more than three times as likely to maintain regular contact with their nonresidential child interestingly we found that mens work status education and householdlevel poverty at the time of pregnancy or currently were not correlated with how often they saw their nonresidential children at wave 4 consistent with residency patterns table 4 shows that coloured fathers are more likely than african fathers to see their children regularly our final sets of models explored fathers and mothers reports of financial support from nonresidential fathers we found that the status of the parents relationship at pregnancy was not significantly related to whether fathers subsequently provide economic support for their children in fact none of the pairwise comparisons were significantly different except mothers report that fathers with whom they had no relationship at the time of pregnancy are significantly less likely to provide financial support than fathers with whom they had a noncohabiting romantic relationship there were no significant differences between fathers and mothers who cohabited and those who were in a noncohabiting romantic relationship at pregnancy the closeness of fathergrandmother relationships also had no significant effect on whether fathers subsequently give financial support to their nonresidential children in model 1 we found that none of fathers other characteristics such as their race employment status or household economic conditions when measured at the time of pregnancy were significantly related to whether fathers provide economic assistance to their nonresidential children in contrast fathers current economic conditions were strongly associated with whether he gives child support fathers who were currently working were more than seven times as likely to report that they financially support their children as fathers who are not currently working moreover fathers currently living in poor or very poor households were 82 less likely to provide economic support compared to fathers who lived in financially comfortable households it is interesting that after controlling for current economic status in model 2 we found that black fathers are significantly more likely than coloured fathers to give financial support to their nonresidential children even though coloured fathers see their nonresidential children more often than black fathers these differences most likely reflect different rates of labor migration and remittances among young black and coloured men in cape town mothers reports of child support shown in models 3 and 4 of table 5 provide a different perspective they show that mothergrandmother relationships have little impact on fathers financial support and that womens previous and current economic conditions are not related to whether they subsequently receive support from nonresidential fathers these results indicate that fathers are not more likely to give support to children with greater financial need discussion in our analyses we took a family systems approach to examine how fathermother and parentgrandmother relationships are related to young fathers engagement in their childrens lives in south africa prior research shows that there are important differences in fathers involvement by race and ethnicity in the united states interesting comparisons can also be made within the same race but across different social cultural and economic environments young black and coloured fathers in urban south africa share many characteristics and challenges with young african american fathers in us cities including high rates of poverty low employment limited educational opportunities and fragile relationships with their childs mother yet they live in the aftermath of different historical legacies follow different cultural practices and are more likely to migrate in search of work similar to studies among lowincome african american fathers we found that less than one third of young fathers in the cape town live with their children coresidence is closely related to the type of relationship fathers had with the childs mother at the time of pregnancy children whose parents were married at the time of pregnancy are significantly more likely to subsequently live with their fathers even compared to children whose parents were cohabiting consistent with studies in the united states this suggests that cohabiting unions are less stable environments for young children in addition children whose parents did not live together at the time of pregnancy regardless of whether their parents were in a committed relationship were much less likely to subsequently live with their fathers suggesting that although many noncohabiting young couples may ultimately hope to marry and move in together few do several studies in the united states also have shown that if teen mothers are not in a romantic relationship with the childs father they are likely to restrict his access to their children other research on black families in the united states however indicated that even when romantic relationships between parents had terminated or had never existed some young mothers encouraged the participation of fathers who pursued active parenting in order to ensure a place for the child in paternal kinship networks we found however no effect of the type of motherfather relationship at the time of pregnancy on whether nonresidential fathers regularly visit or provide financial support for their children this may indicate that such support from fathers is welcomed in order to legitimize the relationship between young fathers and their children providing the child with additional resources and kinship ties on which to draw interesting parallels can also be drawn between the roles of grandmothers in the united states and south africa in both places maternal grandmothers play a central and critical role in helping their unmarried daughters care for their grandchildren yet as kalil and colleagues argued this strong support from grandmothers may reduce young mothers desire and need for fathers involvement most studies in the united states suggest that high levels of support from maternal grandmothers or poor relationships between maternal grandmothers and fathers limit fathers involvement only one study found no significant relationship between highly involved grandmothers and fathers engagement consistent with these findings we showed that close ties between mothers and maternal grandmothers is negatively associated with fathers subsequent coresidence even after controlling for the type of relationship between mothers and fathers these findings reflect sentiments from qualitative interviews with young fathers in cape town who reported feeling intimidated and unwelcomed by the family of the childs mother close maternal ties did not seem to deter nonresidential fathers from seeing their children or providing economic support consistent with madhavans arguments that many young mothers welcome support from nonresidential fathers even if they are not in an ongoing relationship with them paternal grandmothers in cape town appear to play an important role in encouraging young fathers to maintain close contact with nonresidential children but they do not facilitate coresidence or economic support from fathers in qualitative interviews young fathers noted that their mothers helped them to be better fathers instructing them to stay in the relationship with the childs mother finish their schooling so they could secure a better job or quit using drugs young fathers in patrilineal societies may be encouraged by their mothers to activate their parental and kinship rights to children by socially recognizing their legitimacy as grandmothers seek to be a significant part of their grandchildrens lives even when romantic bonds with the childs mother have dissolved or were never present studies in the united states similarly have found that paternal grandmothers actively support young fathers in parenting their children good relationships between mothers and the childs paternal grandmothers predicts greater father involvement and one study found that if the fathers family provided economic support for the child nonresidential fathers were more likely to visit their children last as in the united states economics is a large factor in determining fathers involvement we found that fathers financial support of nonresidential children is primarily dependent on their current economic circumstances rather than their previous economic status or other family ties according to south africas maintenance act no 99 of 1998 parents are expected to provide payment for the maintenance for all their biological children that is consistent with the standard of living of the noncustodial parent given that most of the research on maintenance has focused on white fathers it is unclear whether this law is regularly enforced among nonresidential black fathers although we found a strong positive correlation between whether men are currently employed and whether they provide economic support for their children mens contributions are not responsive to mothers needs in light of the high rates of unemployment in south africa particularly among blacks young men may struggle to find and maintain employment that allows them to support their children regardless of whether fathers wish to provide financial support to their nonresidential children a lack of employment opportunities may prevent them from doing so fathers may face difficulties in engaging with children especially when they lack the financial capability to play the role of breadwinner given the economic insecurity many young men experience in south africa improving access to training and employment opportunities may prove to be an important means of increasing fathers engagement in their childrens lives despite the richness of these data there are several limitations of this study first all information came from relatively young fathers and mothers given the high rates of premarital childbearing and the relatively low median age at childbearing in south africa this is an important age group of parents to study but our findings do not necessarily reflect the situation of older parents in south africa who are more likely to live with their children and provide economic support second our data came from a particular urban environment in south africa which may reduce its generalizability to rural settings or even other urban areas of subsaharan africa third although we were able to compare and contrast reports on child coresidence and financial support from both young mothers and fathers these were not matched couples in fact the fathers reported by young mothers were on average slightly older than the young fathers we interviewed hence differences in the reported averages cannot necessarily be attributed to gender differences in reporting fourth in our analyses we moved beyond simple indicators of coresidence between parents and between parents and grandparents yet although our indicators of the type of parental relationship and willingness to talk about personal matters may better capture the closeness of these conjugal and consanguineous ties respectively they are not ideal more detailed questions about relationship quality could improve this study finally although we endeavored to minimize the potential for reverse causality by examining these conjugal ties at the time of pregnancy and consanguineous relationships at wave 1 we cannot exclude the possibility that some omitted factors such as unobserved personality traits about who selects into becoming an unmarried young parent may be influencing both the nature of these conjugal ties and the extent of fathers subsequent engagement with their children our results suggest that by examining broader kin relationships we can better understand the manner and extent of young fathers engagement with their children specifically viewing families as interconnected pairs of relationships that evolve over time and influence each other can help identify the complex factors that can encourage or discourage young men from being active participants in their childrens lives in societies like urban south africa where social cultural and economic conditions are rapidly changing the role of fathers is often ambiguous and young men have to navigate complexand at times even conflicting norms governing their responsibilities toward their children the legacy of apartheid coupled with poor current economic prospects undermines young fathers ability to form and sustain independent households with their children at the same time the traditional patriarchal family structures of the xhosa stand in contrast with a long history of strong maternal kin investment in raising children which may further marginalize the role of fathers nonetheless despite these factors young fathers in cape town appear to be carving out new roles for themselves which may draw on support for their families especially their mothers but which are also largely independent of their relationships with their childrens mothers

young south african fathers are often engaged in their childrens lives even if they do not live together using longitudinal data on children n 1209 from the cape town area the authors show that although only 26 of young fathers live with their children 66 of nonresidential fathers maintain regular contact and 61 provide financial support the fatherchild relationship however is embedded in broader family ties the type of fathermother relationship is strongly associated with whether fathers coreside with their children but not with fathers contact with nonresidential children close mother and maternal grandmother bonds reduce the likelihood that fathers live with their children whereas close ties between fathers and paternal grandmothers increase the chance that fathers visit nonresidential children family ties do not affect fathers financial contributions which are driven by mens current economic situation these findings illustrate that fatherchild relationships are best understood in the context of interacting family systemsafrican families father child relations intergenerational relations living arrangements nonresidential parents south africa has one of the lowest rates of fatherchild coresidence in the world with over 60 of children younger than age 14 living apart from their fathers posel devey 2006 although these fathers are absent from their childrens households they are often actively involved in their lives

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introduction the rate of diagnosis and prevalence of hypertension in children and adolescents appear to show a steady upward trend recent reports have shown that prevalence of primary hypertension in the under18 population varies from 5 to 20 worldwide 273884 and from 5 to 12 in poland 586076 persistent elevation of arterial blood pressure is an independent risk factor for myocardial infarction and heart failure stroke and endstage renal disease hypertension and specific morbid sequelae have emerged as leading causes of premature death among adults worldwide 1 although it is rare for the young to develop atherosclerotic cardiovascular disease the cumulative longterm effects of high bp may have multiple acute and chronic complications there is evidence that high bp in young age is associated with early markers of cardiovascular abnormalities such as left ventricular hypertrophy and atherosclerosis 3628 comorbid conditions include obesity high blood lipid levels learning and attention problems and type 2 diabetes 213 however the main complication of persistent high blood pressure in young age is its progress to adulthood making it the greatest cardiovascular disease risk 4 several lines of evidence suggest that young people who enter adulthood with higher bp parameters are more likely than their normotensive peers to be affected with htn and its morbidity sequelae 1936 thus earlier stages of life seem to be critical to htn 20 hypertension is a common condition of multifactorial determination it is suggested that htn develops from a complex interplay of genetic developmental environmental and behavioural factors 385761 heredity is a predisposing factor almost half of young people with primary htn have a positive family history of this condition but environmental and individual contextual conditions may also play an important role in the development of htn 6167 a number of factors have been identified as predictors of elevated blood pressure in children and adolescents they include maternal birth and earlylife characteristics such as maternal weight status smoking during pregnancy low birth weight breast feeding duration and childhood obesity 657084 life cycle approach indicates that adolescence and especially puberty is a critical stage for adult bp longitudinal data showed that during puberty bp may increase more than before it 81 rate of change in bp is likely to be synchronized with rapid somatic growth and adolescent growth spurt in height and weight 8186 moreover changes in stature during puberty are closely linked to tanner staging for sexual maturation gonadal hormones with possibly a preponderant effect of testosterone may affect bp levels and emergence of bp sexual dimorphism well manifest in adulthood 1729 additionally adolescence is marked by increasing involvement in health risk behaviours often continuing into adult life 32 unfavourable effects of sedentary lifestyle lack of vigorous or moderate physical activity obesity lack of a proper nutritionally balanced diet high salt intake low potassium and low calcium intake tobacco use alcohol intake and high stress may increase the risk for the development of adolescent hypertension 6263 furthermore many of these factors are additive such as unhealthy diet insufficient physical activity and obesity and vary in their propensity to contribute to the elevation of bp the literature on the potential confounders and mediators of childhood and adolescent hypertension has emphasized the role family level of socioeconomic status plays in the development of this condition 1555 the association between parental ses and their offsprings health outcomes has been well established 51625 these studies suggest that children of lowses families are likely to have worse health outcomes they are at a higher risk of cvd elevated bp metabolic syndrome greater bmi and other negative health outcomes 4345 they are also more likely to engage in riskforhealth behaviours than their betteroff peers 3452 unlike heredity ethnicity and geographic location parental ses and adolescents behavioural factors are potentially modifiable elucidating the pathways by which these factors influence bp levels and health consequences may help in understanding the health gaps between different social groups and in developing a public health programme to counteract the health inequality 41 in poland there is no data available for parental ses as a potent risk factor in adolescent hypertension although social differences in somatic growth development and maturation have been recorded since the 1980s 8109 this study aimed to fill that knowledge gap by focusing on ses differences in blood pressure levels among polish adolescents 1018 years old the specific aims for this study were to calculate prevalence of elevated blood pressure in relation to selected indicators of parental ses and to establish relative importance of sesrelated factors on the development of high blood pressure the study hypothesis was that adolescents living in lowses families might be at a higher relative risk of elevated bp than their betteroff counterparts materials and methods study design and sampling a crosssectional survey was carried out between february 2009 and september 2010 on a representative randomly selected sample of adolescents aged 1018 years participants in the adopolnor project a transdisciplinary study on adolescent health and quality of life it was an ethnically homogeneous group of students in grades 5 through 6 of primary school 1 through 3 of junior secondary and 1 to 2 of senior secondary schools in the wielkopolska province and its capital the city of poznań sample size was calculated using the formula for quantitative variable and a single crosssectional survey 66 the number of selected subjects was 5400 sampling procedure was a stratified twostage cluster sample design for the first sampling stage schools were sampled from the sampling frame provided by the ministry of education for the wielkopolska province via the poznań board of education sampling was stratified by rural and urban areas as provided by rogacki 79 and central statistical office of poland 2008 in this way 52 schools were selected the second sampling stage consisted of the selection of classes from the target grade of each participating school in this procedure if the number of classes was more than one the class was randomly selected in most villages however the students were assigned to only one class of each year level group the study design and study protocol were approved by the bioethics commission of the poznań university of medical sciences and the poznań board of education the survey was carried out in compliance with principles outlined in the helsinki declaration and subsequent amendments 90 schools headmasters received an invitation letter and an information brochure about the research project they approved the study protocol and gave permission to run the study in their schools furthermore in collaboration with them subjects parents were informed about the goals of the study and possibility of refusing the participation of their children in the study enrolled for the study were those students whose parents had given a written consent for them to participate in addition students who had attained the legal age for consent gave assent for their participation in the study almost all parents provided written informed consent for their children to participate in the adopolnor research project and 967 of young people aged between 16 and 18 gave us their written consent to be participants of the study complete data on parental characteristics and adolescent characteristics at time of investigation were obtained for 2451 male and 2490 female students the total of 4941 all examinations were performed in school nursery rooms during morning hours the study protocol included medical examination anthropometric measurements and parental and selfreported background data questionnaires detailed description of the adopolnor study is available elsewhere 51 general health status health status of each subject was assessed by general practitioners during general medical examinations via selfreport and proxy reports from parents anthropometric measurements body height and weight were measured by welltrained researchers according to standard procedures 56 the subject wearing light gym exercise clothes and without shoes was standing in an upright position with heels together arms to the side legs straight shoulders relaxed and the head positioned in the frankfurt plane the height was measured with a portable swissmade gneupel precision mechanics anthropometer to the nearest 1 mm from the highest point on the midline vault to the floor a subject was standing on body weight was measured to the nearest 01 kg on a calibrated electronic scale then bmi was calculated by taking a subjects weight and dividing it by hisher height squared following the iotf recommendation coles cutoff values were used to determine the weight status 2324 chronological age was calculated in decimal values by subtracting the date of examination from the date of birth the age groups were divided by years defined in terms of the whole year eg 10 years old group involved subjects between 1000 and 1099 years old blood pressure measurements blood pressure was measured by school nurses strictly following the guidelines of the fourth protocol of the american working group of high blood pressure in children and adolescents 74 a fully calibrated tech med tmz mercury gauge sphygmomanometer with sets of exchangeable cuffs and a clinical stethoscope was used for all bp measurements blood pressure systolic and diastolic was measured in duplicate on each of the three occasions separated by a 2day interval measurements were taken on the right arm with the subjects sitting for at least a 5min rest and the average of the two measurements was the final result for the given day as it was suggested in the seventh report for adults 22 the systolic and diastolic bp measurements corresponded to the reading on the sphygmomanometer at the first and fifth phases of the korotkoff sounds respectively the scale on the sphygmomanometer was graduated in 2mmhg divisions the readings were made to the nearest millimeter hg calculated intraobserver technical error equalled 13 mmhg and interobserver technical error equalled 23 mmhg 59 the bp classification was determined using the surveillance method for each participant the mean of measurements taken on three occasions was calculated the values of mean systolic blood pressure and diastolic blood pressure were adjusted by sex age and height percentile using current reference data for polish children and adolescents 59 normal bp was defined as systolic and diastolic bp less than 90th percentile prehypertension was defined as an average systolic or diastolic bp of greater than or equal to 90th percentile but less than 95th percentile and hypertension was defined as an average systolic or diastolic bp of greater than or equal to 95th percentile 39 socioeconomic status socioeconomic status was assessed through a selfreported family wealth using the family affluence scale ii and reports from parents using the adopolnorr survey instrument the ses indicators used in the study were the place of residence categorized according to the urbanization level 79 paternal and maternal educational attainment and occupation status family size family financerelated burden referred to as income adequacy indicative of the objective financial situation dwelling conditions and others the fas ii a fouritem measure of family wealth provided by students was reported by number of cars in family asking if the respondent have ones own bedroom number of familys vacation travels during the past 12 months and number of computers in the household the fas ii total score could range from 0 to 9 with higher scores indicating higher level of family wealth in the study it was scored as a composite score and classified into three categories low affluence middle affluence and high affluence data analysis the outcome of interest was demographic and parental socioeconomic factors associated with bp status in adolescent males and females after controlling for parental hypertension sex age and weight status at first multiple correspondence analysis was used to determine whether the explanatory variables for the bp status were associated to each other and which of them might potentially operate in an additive way 85 crude associations of bp status and all potential covariate variables were evaluated individually using the chisquare pearson test multiple multinomial logistic regression analyses were used to assess the association between bp status and the variables in question the dependent outcome variable was a dichotomous variable of bp status two models were evaluated model 1 involving normotensive vs prehypertensive bp status and model 2 involving normotensive vs hypertensive status after adjustment for all potentially confounding variables simultaneously the odds ratio was used as a measure of association a final explanatory model with a subset and relative odds ratio of the factors associated with bp status was obtained using a stepwise procedure with backward elimination and rejection criterion of the p value greater than 005 statistical analyses were performed using the stat istica 100 data analysis software system all significance tests comprised twoway determinations a value of p 005 was considered statistically significant results the social background of the sample is shown in table 1 the majority of families were urban residents of working parents fathers having fewer than 12 years of schooling and mothers with 12 years of schooling without financial strain ie with income adequacy family affluence level was selfrated by study participants and the majority of them rated it as medium families with two children accounted for almost a half of the sample three and more children were next in order of frequency structural relationships among indicators of parental socioeconomic statusexplanatory variables in the mca revealed that rural setting low parental educational attainment maternal economic inactivity large families with three and more children income inadequacy and low family wealth appeared to cluster closely together urban residence was associated with parental employment income adequacy medium family wealth and two children in family onechild families were related to large city settings the high affluent families markedly outlaid from other clusters indicating that the wealth was not associated with a specific setting or parental ses indicator these associations conform to the pattern of additive nature of urbanization and parental ses factors the ruralurban disparities in parental ses are shown in fig 1 proportion of parents with low education level was significantly higher for rural areas as it was for income inadequacy and low family wealth there was also a significant rural vs urban difference in the adolescent weight status prevalence of obese adolescents was higher in rural areas parental hypertension was equally distributed among inhabitants of rural and urban areas table 2 shows the prevalence of bp status in the study sample according to potential values are in percentage a economically active category includes employedown businessfarming covariate variables crude associations between bp status and covariates are expressed in terms of chisquare test in univariate analysis the sbp levels were associated with all but the family affluence factor like systolic diastolic bp was associated with all but sex and family affluence factors there was a clear gradient in socioeconomic factors with a tendency of the disadvantage to locate in rural areas parental low educational attainment unemployment or farming and in income inadequacy higher prevalence of sbp as well as dbp htn was found for participants with positive family history of hypertension being at older age and for male sex with obese weight status living in rural than urban areas having parents with low educational attainment and economically inactive with income inadequacy as compared to their betteroff peers at multivariate level only selected factors remained in their significance the adjusted odds ratios for parental sesrelated risk factors of prehtn and htn after controlling for fhh sex age and weight status are presented in table 3 the likelihood of developing prehtn and htn among adolescents from families with parental hypertension was almost twice as high as among those from families without fhh and systolic htn they were almost 4 times less likely to develop diastolic prehtn and almost 5 times to develop diastolic htn compared to adolescents whose mothers had low level of education peers having mothers with highacademic education level were 17 times less likely to develop systolic prehtn and 18 times less likely to develop systolic htn in addition they were 23 times less likely to develop diastolic prehtn and 28 times less likely to develop diastolic htn paternal occupation and income adequacy were two other factors associated with systolic prehtn using the employment status as reference category the adjusted odds ratio for systolic prehtn risk from unemployment was or153 using the betteroff financial situation as a reference category the adjusted odds ratio from income inadequacy for systolic prehtn risk was or140 using the normal bmi for age as reference category the adjusted odds ratios for systolic prehtn and htn risks from obesity were or8 42 discussion the present study provides the first data documenting social disparities in blood pressure levels among polish adolescents the findings revealed the multifactorial dependency of bp levels on geographic ie rural or urban dwelling and sesrelated familial influences at adolescence the clustering structure of all factors involved in the analysis indicated that residential location might be operating through differential parental ses the underlying pathways by which parental ses may influence their offspring bp levels include modifiable factors such as the level of maternal education status of paternal occupation and income interrelated to urbanization category of the place of residence after adjustment for fhh subjects sex age and weight status consistent ruraltourban and socioeconomic gradients were found in prevalence of elevated blood pressure which increased with continuous lines from large cities through smallto mediumsized cities to villages and from highses to lowses familial environments furthermore the adjusted likelihood of developing htn decreased with each step increase in maternal educational attainment and prehtn decreased with increased maternal education paternal employment status and income adequacy the relationship between parental ses and bp levels as a gradient confirms persistence of social gradients that have been observed in poland since the 1980s in other indicators of physical health 8109 adverse consequences of low ses on bp levels and cardiovascular functions have been widely demonstrated in adults 77 the findings of this study showed that social inequalities in bp levels manifest at adolescence this is in line with the adolescentemergent model which states that relationships between ses and health outcomes are rather weak earlier in life but strengthen during adolescence when young people begin to be influenced by peers in their health behaviour 203042 adolescence and especially puberty seems to be critical for the appearance of sexual dimorphism in bp which persists throughout adulthood this finding is also in line with aem and is most likely due to the activation of gonadal hormones with possibly a preponderant effect of testosterone involved during sexual maturation as well as acceleration in somatic growth during pubertal growth spurt 298186 the direct association of male sex with htn and inverse association with prehtn found in our study need further analysis of data from longitudinal study as expected elevated bp was independently associated with age the likelihood of developing systolic prehtn and htn increased twice with each year increase slightly weaker though significant association was observed between diastolic bp levels and age chronological age is a proxy for developmental trajectories its contribution varies in importance during each period prior to adulthood so it does for bp level 18 not unexpectedly our findings confirmed that parental htn would be a major determinant of adolescent prehtn and htn 5473 the contribution of genetic determinants in developing high bp is accounted for 27 of diastolic and 36 of systolic bp 11 environmental exposures to permissiveadverse conditions via parental ses can be targeted in order to improve community and individual health however ses per se does not directly impact the physical status and physiological and functional capacity of growing individuals 12 neither health outcomes and so cannot be regarded as a treatable risk factor of elevated bp there are several causal pathways that have been hypothesized for understanding the mechanisms that transfer geographical location and social and economic environment to health disparities at the community and individual levels rural communities are likely to be socially disadvantaged facing job and neighbourhood strain having low educational attainment limited access to culture and the internet and in consequence limited health literacy which drive them to unhealthy behaviours ultimately resulting in chronic ill health which in turn coupled with limited access to health care and low education level may limit job opportunities this is a vicious circle living in urban areas typically offers opportunities for better education employment better accessibility to health care services and adherence to medical treatment on the other hand rapid urban growth may generate numerous stressors resulting from population density pollution noise unemployment and poverty 3553 in poland disparities in somatic growth and selected health outcomes in the young age due to place of residence is a wellknown phenomenon that has been reported by numerous studies despite inconsistencies as to the benefits of either environment previous studies have shown that young people from urban areas are likely to be taller thinner and earlier maturing as well as of better general health status as compared to their peers living in rural areas 8344875 adverse effects of rural environment and its social structure on health outcomes found in our study are consistent with the results from the cbos august 2013 report bprofile of the rural population 78 according to this report the population living in rural areas showed that the better demographic situation characterized by positive demographic balance is accompanied by worse economic situationa disposable per capita income of urban residents was twice as high as that of rural residents importantly maternal education parental occupation income adequacy and adolescent obesity remained significant when adjusted for all other relevant parentrelated risk factors and place of residence all these variables appear to act synergistically on adolescent bp levels via the acquisition of knowledge and skills that promote health associated with a higher level of schooling and the indirect effects of education on earnings and employment prospects 2687 wilson and colleagues in their study on 76 black adolescents revealed that adolescents who lived in poorer neighbourhoods had lower diastolic bps if their mothers were more educated and their family had a higher annual income 89 the association between adolescent bp and maternal educational level has been demonstrated extensively 6883 in our study however maternal occupational status interrelated with education and paternal occupation had no effect on blood pressure neither had family size this finding is inconsistent with previous studies showing an independent effect of family size on offspring somatic growth 104849 at present study parental educational attainment and earnings become more important for offspring bp than number of children at home the prevalence of elevated bp that has been reported in paediatrics recently varies substantially across countries 273171 the regionalwide variation in elevated bp prevalence is largely attributed to differences in geographic location age range and methodology 39 the overall prevalence of elevated bp was 66 for prehtn and 89 for htn these data indicate that the prevalence of systemic hypertension in the juvenile population in poland has doubled over the last decade krzyżaniak and colleagues in the national study of bp conducted in 2000 among polish school children reported the prevalence rate of htn ∼4 58 similar figures 49 for htn and 111 for prehtn were found in a large sample study of children and adolescents aged 7 to 19 years in the city of lodz poland 76 this upward trend in htn is attributed at least in part to the rapid increase in adolescent overweight and obesity 4450 and the high prevalence of sedentary behaviours physical inactivity and unhealthy dietary habits 37 according to recent data from the national survey in poland the prevalence of overweight and obesity in 619yearold children and adolescents is 164 and underweight120 total 44 the findings of the present study showed similar figures 168 of overweightobese adolescents in total sample prevalence of obesity was found to be twice higher in boys than in girls and in rural than in urban residence areas although these figures are not top ranked among european adolescents predictions based on the worldwide trends suggest that it may change in the near future resulting in increasing risk of developing elevated bp and undesirable cardiovascular consequences 2772 brummett and colleagues revealed obesity and increased heart rate as key modifiable correlates of higher sbp and lower ses 15 in the present study weight status appeared to be an independent most significant risk factor suggesting its major role in mediating effects of parental ses on their offspring bp levels in addition it was found that higher parental ses was associated with lower bmi as it was claimed by brummett and colleagues there are many other studies identifying overweight and obesity as an independent significant factor of increased bp 213337468082 this study is not without its limitations a crosssectional design makes it difficult to assess the direction and causality this design however was methodologically appropriate for solving the research question ie evaluating the association between bp levels and exposures 69 there is also a possibility that confounding factors operating earlier in life and not included to this analysis introduced bias into the study results however studies of the association between prenatal factors and offspring bp have yielded mixed results indicating direct or inverse associations and null results as well 764 an example of maternal smoking during pregnancy may prove that bias of present results if any can be neglected smoking during pregnancy is more common among women with low ses 47 therefore it was argued that the relation between smoking during pregnancy and offspring bp is due to ses confounding rather than a true intrauterine effect 1447 another bias may be produced by errors in recall of the exposure and possible outcome it would have been useful to have longitudinal prospective information the reliability of selfreported data has widely been discussed in the literature and involved in the premises of this study 40 finally ses indicators do not include disposable per capita income but we share the opinion that income adequacy reflects more adequately the families purchasing power 88 the strengths of this study include a populationbased cohort study of healthy adolescents the clustering structure of parental ses reflecting that of the general population a multivariate approach and integration of multiple factors hypothesized as to be associated with the outcome variableadolescent arterial bp level conclusions the findings of the present study confirmed socioeconomic inequalities in blood pressure levels among adolescents young people living in rural areas are likely to be at a higher risk to develop elevated blood pressure than their betteroff peers from urban areas weight status appeared to be the strongest confounder of adolescent blood pressure level and at the same time a mediator between their blood pressure and parental ses this calls for regularly performed bp assessment and monitoring in this population effective strategies aimed at reducing global cvd risk should focus on obesity prevention and socioeconomic health inequalities as early as at adolescence by further trying to improve living and working conditions in rural areas

in poland there is no data on parental socioeconomic status ses as a potent risk factor in adolescent elevated blood pressure although social differences in somatic growth and maturation of children and adolescents have been recorded since the 1980s this study aimed to evaluate the association between parental ses and blood pressure levels of their adolescent offspring a crosssectional survey was carried out between 2009 and 2010 on a sample of 4941 students 2451 boys and 2490 girls aged 1018 participants in the adopolnor study the depended outcome variable was the level of blood pressure optimal preand hypertension and explanatory variables included place of residence and indicators of parental ses family size parental educational attainments and occupation status income adequacy and family wealth the final selected model of the multiple multinomial logistic regression analysis mlra with backward elimination procedure revealed the multifactorial dependency of blood pressure levels on maternal educational attainment paternal occupation and income adequacy interrelated to urbanization category of the place of residence after controlling for family history of hypertension an adolescents sex age and weight status consistent ruraltourban and socioeconomic gradients were found in prevalence of elevated blood pressure which increased with continuous lines from large cities through smallto mediumsized cities to villages and from highses to lowses familial environments the adjusted likelihood of developing systolic and diastolic hypertension decreased with each step increase in maternal educational attainment and increased urbanization category the likelihood of developing prehypertension decreased with increased urbanization category maternal education paternal employment status and income adequacy weight status appeared to be the strongest confounder of adolescent blood pressure level and at the same time a mediator between their blood pressure and parental sesthe findings of the present study confirmed socioeconomic disparities in blood pressure levels among adolescents this calls for regularly performed blood pressure assessment and monitoring in the adolescent population it is recommended to focus on obesity prevention and socioeconomic health inequalities by further trying to improve living and working conditions in adverse rural environments

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the concept of animal practices to better understand human relations with companion animals namely cats by addressing the ways nonhuman animals and humananimal boundaries are done and undone in the context of social media and digital media practices in this way i expect to make a contribution to a sociology for nonhuman animals and for humans alike by increasing our awareness of the ways humans socially categorize and relate to nonhuman animals sociological thinking may play an important part in the improvement of interspecies relations and hence in the life conditions of both humans and nonhumans let us then enter daphnes story by responding to two main questions how is a companion animal defined in digital discursive practices performed in social media how does this kind of digital interaction contribute to the renegotiation of humananimal boundaries the specific condition of cats as companion animals drawing on literature from the field of animal studies the discussion that the topic sparks links to the fact that daphne is in fact a cat that is to say that she is not really an animal but rather a companion animal getting attention due to this specific condition she has a personal name she shares the domestic space with humans often viewed as a member of the family as sharing a status of affective proximity to humans she is inedible and therefore will never be eaten and she is viewed and referred to as an individual with a personality of her own rather than simply a member of a species in this case felines like most companion animals she is deemed family the blurred boundaries between humans and nonhumans thus contributing to the definition of what a contemporary family is relational based on emotions and affects and individualistic where the individual is expected to flourish with the help of the family group be that individual human or nonhuman she therefore occupies like most companion animals a liminal condition that makes her status and position ambiguous she lies somewhere inbetween humans and animals she is neither completely an animal nor is she completely human either this liminality is intensified by her gender condition being a female she is expected to behave with docility and tenderness developing with her human guardians an affectionate relationship she is thus criticised for not complying to gender norms and behaviours her animality being built alongside her gender moreover due to her condition as a companion animal she gains much more visibility than other animals such as cattle who are edible and therefore eaten including by companion animals thus she participates in the visibleinvisible conundrum whereby the fact that some animals gain increasing visibility may paradoxically result in the invisibility of others moreover because she is a cat daphne certainly occupies a better position than other animals in the hierarchy of pets as cats and dogs are rated as closer to humans than other companion species however despite all the attention she seems to get from the facebook community of animallovers gathering around the animal shelters facebook page daphne is also subject to a somewhat unstable subjectification she is made a subject with a personality of her own and rights attached to it but only under certain conditions adaptation to human lifestyles not being aggressive being friendly and adjusting to the home and its inhabitants this instability and conditionality of her definition as a member of a preferred species deemed as closer to humans than other species results in conflicting versions of her and in the varied moral judgments passed on her story and its protagonists the particular timespace of social media and facebook critical animal scholars argue that the ways animals are depicted in mainstream media reproduce and legitimize dominant ideologies of antroparchy and speciesism playing a role in maintaining nonhuman animals under human domination this implies a critique of legitimated categories such as meat pet or even animal exposed as social and political constructs of a hegemonic order working as part of the machine without a centre of anthropocentrism although these approaches sometimes overlook other aspects of humananimal relations such as the agency of nonhuman animals or the more webbased unstable nature of power relations between species some of their questions can be extended to social media the narrativization of daphnes story takes place in a very particular setting the official facebook page of a portuguese animal shelter this means that we have to consider the specific features of this social media platform and the mediated interactions it enables as a social media platform facebook constitutes a tool with inbuilt communication features frequently used to communicate with other users networked through specific technological properties it presents particular technological features that are appropriated by individuals who transform them as social resources to better connect with others these affordances such as the timeline the like button the public display of the network and interactions or the opportunity to post multimedia messages make it a particular timespace where interactions and experiences acquire a specific nature the ways in which these technological features are used is key to understand their impact as many have documented thriving on emotions and the affective engagement of users with the contents displayed social media also rely on the active involvement of users who become both producers and consumers of such emotions and affective states such uses are rooted in the ebb and flow of personal life in particular the need to build a lifetime family or friendship memory to produce a meaning for their own existence or to be constantly in contact with others thus adhering to a social norm of being in a permanent relational continuum as such the ways users engage in the discussion around daphnes story will resort to a certain extent to elements of their own personal experience and daily life with companion animals both used to construct specific worldviews and positioning towards the story and the topics involved i argue that these features contribute to extend humananimal practices in time and place in specific ways thus making social media distinctive in their production in the following section i try to define animal practices as comprising the virtual media landscapes produced by its users such a capacity relates in particular with two features reach and mobility other features are also critical such as interactivity and replicability animal practices on facebook critical to understand how social media practices contribute to defining what an animal is is the notion of animal practices drawing on science and technology studies and following a theory of practice approach law and miele propose that animals do not preexist the practices they are involved in rather they are the relational effects of those practices in which they too participate they are being done in the unfolding of actions as well as all other participants in those practices and contextshumans and other nonhumans i argue that the legacy of ant helps to shed light into the ways companion animals participate in wider networks of relations and assemblages that enable them to become what they are these animals participate in practices with other humans and nonhumans some of which extend beyond the physical scene they inhabit here technology and social media become particularly relevant as the animals participation in such entanglements is reproduced and expanded in time and space through a range of social media practices they extend themselves beyond the scenes in which the flesh and blood animal participates hence the animal becomes who he is through complex and extensive webs of relations in some of these networks he participates directly in others he is evoked all of them concur to the emergent definition either of a particular individual or of the species to which he belongs this definition and its multiple versions reflect and impact on the ways humans relate to these animals and thus on their lives and welfare it also contributes to build a story as much of conflict as of wilderness and resistanceversions of less domesticated animals who resist human dominion according to this perspective animals are beings constantly in the making relationally becoming with the humans and nonhumans around them social media practices are one type of social practices among others that contribute to this constant making of the animals as parts of the networks and assemblages to which they belong it could be argued that because daphne has a body materiality would impose itself as preexistent and stable however her body is also affected and shaped by her interactions with her environment other animals and material elements it is also the result of all these fluctuating elements that change in time place and power as a result of these ever changing specific practices different and sometimes conflicting versions of the same animal can be enacted for example at the veterinary surgery the same animal infected with a contagious disease may emerge both as a sentientbeing demanding special care and attention to their wellbeing and as an infectiousagent an animal that must be put in quarantine to avoid contamination of other animals humans and nonhumans therefore far from being an ontological and static reality an animal is better described as a contingent unstable and ongoing becoming with humans other nonhuman animals spaces and objects other natural environmental and contextual elements from this perspective the authors talk about relationally emergent versions of the animal animals are the heterogeneous material and relational consequences of specific and patterned ordering practices that extend beyond local scenes to include more or less distant times and places animal practices in relation to daphne encompass a wide range of contexts and actors those described in the versions of her story but also the digital discursive practices that evolve from the narrativization of her life in the following section i will explain the methodological options that structured the approach to the empirical data i will then proceed to explore the discourses made public on facebook posts investigating how animal practices can be identified in the opposite narratives about the case eventually leading to the emergence of different versions of the same cat research methodology this article draws on the analysis of one particular case study the story of the cat daphne as described in one post of the official facebook page of a portuguese animal shelter published in 2017 both human and nonhuman participants in the digital story are fully anonymized the animal shelter is not identified nor is the human or the cat named with the pseudonym daphne these standard anonymization procedures have as a main purpose to preserve the participants identities and privacy despite the fact that the facebook page is public and therefore so is its content for the same reasons verbatim quotes from participants were avoided and the contents of their discourses paraphrased in order to avoid identification analysis of public content published on facebook also followed the principle of fair use the first post of the animal shelter gathered a voluminous and prolonged stream of responses from facebook users at the time of writing the post and its subsequent comments had gathered around 37k reactions more than 900 comments and around 700 shares in a 200word text it sets the tone of the discussion that followed a post from the adopter followed it gathering around 400 reactions from facebook users and around 170 comments because these were the first posts and the adopters post immediately followed the initial one from the shelter they gathered important comments both in length and in content many were comments about these comments and not about the original messages the subsequent interpretations draw on a qualitative analysis of this subsample of 170 comments on the adopters post which include reactions to the initial post from the shelter the article draws on two different types of analysis in order to explore the latent categories contributing to define and therefore construct nonhuman animals on these digital landscapes firstly narrative analysis enabled for each one of the two main posts the identification of the plot line its main characters and tones of discourse the analysis aimed primarily at practices rather than discourses a turn documented as privileging a focus on interaction at a local level an emphasis on the contextualizing power of narratives and a commitment to socialtheoretical concerns this practicebased approach oriented towards the capture of how small stories are embedded in everyday life and are part of the fabric of social practices that ordinary people engage in has been later applied to social media and online contexts atypical features of small stories emerge from digital platforms and practices such as fragmentation openendedness or multiple authoring of a post enhancing their proliferation the practices of storytelling in social media are also often anchored in reporting events from the posters daily life elements that can be found in the making of daphnes story both directly in the posts of the shelter and the adopter and indirectly in the posts where users describe details of their own daily lives with animal companions secondly content analysis using qualitative data analysis software nvivo 10 enabled the extraction of the main thematic categories in the posts of both the shelter and the adopter as well as of the users that subsequently commented on them the analysis followed an inductive grounded procedure privileging a logic of discovery without a previous set of predetermined categories it produced 41 principal nodes of which 7 included childnodes some verbatim expressions were captured as invivo categories that suggested insights into the way daphne in particular or companion animals in general were being depicted in the online exchanges besides the verbal text in the posts and comments the analysis also took into account the formal content of the social media affordances enacted by users as they contributed to the making of the story this included the consideration in context of the number and type of emotional reactions to others posts emoticons or posting of visual content although both these types of discourse analysis may be less common in ant their use is justified by the fact that social media offer a particular landscape for storytelling as part of wider social practices which they also contribute to outline the following section explores precisely the power of social media stories as told by their users to perform humananimal practices animal practices on facebook and the emergent versions of daphne the characters involved in the storyline are not always easy to identify one could begin by saying that the leading role belongs obviously to daphne the cat however that is not always the case nevertheless it is daphne who opens up the storyline even if only indirectly other leading characters are the animal shelter who discloses daphnes story and the adopter mainly in secondary roles we find all facebook users nearly all of them presented as female identities who react to and post comments about daphnes story finally there are all the other animals mentioned in the stories told by these facebook users in their posts but who just like daphne will become shadowed by the human narratives around them the plot unfolds in two main narratives the one presented by the animal shelter what we call the triggernarrative as it triggers all the subsequent discussion on the shelters facebook page and the counternarrative from the adopter in which he presents his own version of daphnes story the triggernarrative the triggernarrative is the first one to be put forward and in that sense leads the way to the construction of daphnes story in this virtual arena of facebook we can call it the hegemonic version not only because it was posted by the institution that runs the facebook page but also because most posts and comments of the users will follow and expand it this account is built around a tone of accusation of the adopters decision and behavior and more subtly of the adopter himself as a wrongdoer lacking the moral qualities to be a proper guardian of a companion animal in a 200word text the shelter builds daphnes story upon two main types of language a juridical language evokes a judicial process in which a defendant is already on trial initially it is used to describe the behavior of the adopter toward daphne who was immediately accused and judged without being given the right of defense and was immediately sentenced to return to the shelter then the direction of the storyline shifts using the same juridical terms to refer to the adopter but combined with psychological reasoning expressions such as moral crime sentence or trial are combined with more psychological and existential ones such as human emptiness lack of interiority absence of humanity or existential void claiming the role of a court of justice committed to restoring the truth the text declares daphne innocent and her sentence unfair and out of proportion the text closes with an open emotionally charged articulation of a moral judgment on the adopters behavior and on the dynamics of private and intimate life hence it becomes a double moral judgment the counternarrative in contrast the counternarrative of the adopter is based much more on a description of facts and is less emotionally charged published after the initial post from the shelter its tone is mainly one of complaint and selfdefense in a much longer text the adopter begins by coming out as a male so we learn that his gender had been changed in an attempt to conceal his identity then his discourse is built up around four different types of language to convey his version of the story factual professional selfdefensive and animalfocused the first distinctive feature is the factual tone of the narrative it focuses mainly on the description of facts and events in an attempt to produce an objective and dispassionate account this is in clear contrast to the post from the shelter which takes a highly emotive tone in conveying its message here rather than focusing on emotional states the narrative presents facts in detail following a temporal order it reconstitutes the timeline of the adoption as a joint experience of both the adopter and the animal starting from the point when he decided to adopt proceeding through the contact with the shelter the act of taking the animal home the first times together and the period in which the animal began to be perceived as problematic and ending with the decision to return her to the shelter the story is thus presented with a higher degree of complexity and emotions are not openly displayed the descriptive and factual tone of the text suggests a distinction between rationalityemotionality in which the rational remain mostly on the side of the narrator this is not the same as saying that emotions are absent instead they are managed with parsimony in what can also be interpreted as a form of gender performance privileging and enacting a masculinised rationality over feminised emotionality they remain subtly suggested by the way the factual argumentation proceeds this is true mainly concerning the evaluation of the shelters behavior which the adopter accuses of misconduct and lack of professionalism this is the second distinctive feature of the counternarrative of the adopter the insistence on a professional dimension of the events rather than on exclusively personal and emotional ones the adopter accuses the shelter of breach of confidentiality and of lying in order to achieve their goals thus producing false declarations the topic of the lie namely about daphnes age becomes particularly central to the storyline as age emerges as an important feature of the adoption process and hence of its success moreover the lie prompts from the adopter a question about the shelters honesty and professional integrity therefore an intention of public complaint and exposure of the shelters professional misconduct flows alongside that of selfdefense the same thing happens with the shelters triggernarrative in which this same intention of public exposure of the adopters misconduct accompanies the juridical tone of accusation and trial this narrative is also animalfocused in the sense that it explicitly talks about daphneher features as an animal as a member of a specific species and her particular personality it draws on the characteristics of her personality to describe her as problematic and therefore to build a version of daphne as disruptive thus justifying the need to return her to the shelter it depicts daphne as a nondocile cat who lacked social skills and could not socialize either with the other cat or with the humans living in the house she fled from all attempts at assimilation and could never adapt herself to her new home and family finally the text describes how she displayed less affectionate attitudes toward her human guardians namely by huffing snorting and most of all urinating deliberately over her guardians clothes the lack of docility emerges as a particularly important trait to define her one can argue that this is also linked to her gender being a female daphne fails to accomplish human expectations on both her animality and her gender viewed as a nondocile female animal she crosses the thin line between domestication and wilderness impossible to control through ownership this is how the description of daphnes behavior builds up toward justification of the need to return her to the shelter consequently the discourse evolves toward a selfdefensive tone which is where the counternarrative gets more emotional on the one hand due to the pervasive presence of feelings of injustice the adopter declares his sense of being unreasonably accused and convicted and his urge to restore justice by presenting the truth about the facts on the other hand the decision to return is presented as a result of longterm weighing and deliberation just like the decision to adopt a situation felt as unsustainable and unhealthy for both parties involved pushes the humans first toward a dilemma and then toward a decision felt as an emotional burden evolution of the storyline how a tale of adoption becomes a tale of abandonment the vast majority of the comments triggered by the counternarrative are from users with feminine identities and echo the triggerversion as told by the shelter the space to post a comment a particular affordance of social media platforms is also used by commenters to tell their own stories of their companion animals often problematic and pierced by conflict the content analysis showed that the most frequently repeated themes were the behavior and personality of the animal the return andor abandonment of the animal affects and emotions kinship bonding and mutual adaptation other frequent categories were the comments to the shelter metacomments ie comments without a proper content related to the topic but just commenting on the tone or existence of a previous comment and open insults two relevant categories for the construction of the thread of the narrative were the topic of the moral intention of animals behavior references to the adopters private and family life defense of the adopter and the age of the animal as the comments progress the storyline evolves to become a tale of abandonment all distinction between return and abandonment is erased the two behaviors are equated with all consequent moral assumptions namely in regard to the moral character of the adopter and the adopters behavior toward daphne namely returning her to the shelter intense emotions arise around the topic but the main issue is always the appropriate behavior of a good guardian the moral good qualities required to adopt a pet the implications of the act of adopting and the social and psychological conditions needed to do so what about daphne how is she portrayed and what does that tell about the ways in which the boundaries between humans and companion animals are built the twofold cat emergent versions of daphne the cat the discursive practices around daphnes lifeher behavior her moral intentions her life with her human guardians her disgrace in being returned to the shelterevolve to produce two different and emergent versions of this particular companion animal these practices are discursive rely mostly on verbal language and take place in the digital timespace of social media because these discourses elaborate upon daphnes behavior at home first and in the shelter afterwards daphne participates in them indirectly nevertheless and quite paradoxically not only is she unaware of all the discussion taking place around her but also of its possible impact on her future daphne is thus at the same time a participant and an absent element in this process empowered and disempowered or an absent referent to adapt carol adamss expression just as the death of the animal who lies on the plate to be eaten remains absent to the meateater so daphne remains absent from these discursive practices in which her story is being remade this absence cloaks the human dominion over her nonhuman condition present in each act in which humans make decisions about her life just as the absence of animal death hides the violence contained in the act of meateating hence the disappearance of daphne ends by protecting the conscience of the humans involved in the story all committed in their own way to her wellbeing and good fortune through such social media interactions the reverberation and reinvention of the animal practices in which she participates produce different and emergent versions of daphne as a cat she becomes the effect of these performative consequences of sets of somewhat choreographed but largely unknowable practices this radically challenges essentialist assumptions about the ontological nature of nonhuman animals as a real preexistent essentialist property of beings rather the real daphne is a being in the making emergent from the web of relations that involve her here social media practices add to other social practices in which daphne participates and through which she is redefined animal practices are heterogenous relational extended in time and spaces and quite specific emerging from momentbymoment patterns and flows they are heterogenous because they are composed of different kinds of elements persons objects technologies and devices buildings and material arrangements in the complete presentation of daphnes story the whole environment in which she is depicted is critical to the development of events the other cat in the house the desk underneath which she hides the clothes in which she urinates the cat litter in which she was supposed to urinate always all these play an important part in how the story unfolds through a bodily choreography which follows a pattern they are thus a patterned set of relations relating all relevant components together in a specifically ordered manner that is why they are relational the many components of daphnes story only assume their exact form their exact role inside this relational frame in which all bodies move according to each other in bodily choreographies inside the house daphne stuck underneath a desk daphne and the other cat quarrelling humans trying to feed her daphne huffing to the other cats and to her human guardians animal practices are also extended in time and space which means that they depend on distant relations and contexts including information technologies or transport systems the patterns of these extended relations also need to be ordered they are relational patterns of ordering that reach beyond the scene and this is particularly relevant to the case of daphne as it continues to be constructed beyond the material world in which she moves in the digital dimension of social media the relational patterns of ordered interactions between daphne and all other elements are resignified and extended in meaning through its retelling on social media finally these practices are very specific they are anchored in momentbymoment patterns such as the guardians description of trying over the months to reach daphne who kept resisting common patterns of socializing with humans and other cats this specificity enables us to understand and find our way through the messiness of a world where humans and animals live together and share common spaces and times sometimes fluidly sometimes in conflicting ways they make it possible to catch how practices may be inconsistent contradictory and conflictual therefore animal practices are performative they do different things and animals are the effects of those practices in the sense that they are being done in the unfolding of actions they are a consequence of the action as it unfolds as a result of different complex and uncertainly related logics of materially heterogenous practice hence the same animal may be enacted as different animals in different versions depending on the articulation of elements that compose specific practices this is how two different versions of daphne emerge from these animal practices performed by humans on social media which bear the specificity despite referring to animals behaviors and lives of animals themselves being unable to directly participate in them on the one hand there is the version of the animalvictim triggered by the animal shelter narrative and amplified by all facebook users who support it here daphne is presented as a disempowered victim of human mean conduct and lack of commitment a passive subject of multiple and sequential forms of maltreatment ending in tragic abandonment this version claims to protect animals rights and daphnes in particular namely the right to a home and a proper guardian the animal is compared to a child or to a member of the kinship network whose care is represented as a lifetime commitment excluding all possibility of interruption let alone abandonment this is actually where the argumentation based on kinship ties becomes more powerful a set of normative representations about contemporary kinship and family come to the surface in which bonding ties are seen as unbreakable at odds with the diversity of experiences of real families when facing several forms of rupture and reorganization from divorce remarriage couples living apart together lone parenthood singlehood etc such normative representations are used to perform a version of animals in which they remain under the eternal stewardship of humans in particular the animal is compared to a child as someone who lacks the full competences of the adults but while children grow up and become adults themselves this is not the case with this emergent version of animals as victims who seem to remain indefinitely in a childlike stage which claims full protection from humans in this sense the boundary between human and nonhuman animals is reinforced undermining our thinking of companion animals as autonomous subjects on the other hand the counternarrative from the adopter and his very few defenders produce a version of daphne as the animalmaladjusted this is a version in which she is depicted as unable to adapt to her human guardian and to a common life with him with all that it entails the other humans the space in the house the other animals living there in this version the core argumentation comes mainly from the description of the interaction between daphne and her surrounding environment during the year in which she lived with the adopter hence it highlights the heterogeneity and relationality of animal practices how they are composed of different types of elements organized in specifically ordered categories persons objects buildings and material arrangements other animals however even though all these elements play an important part in the way the story unfolds in this version of daphne she more than the other elements involved is held responsible for the crucial failure of the adoption process the description of their bodily choreography follows a pattern of estrangement that will eventually lead to her being returned to the shelter and that pattern of estrangement is mainly built over the features of her personality and her emotional states she is depicted as unsociable rejecting human approaches and eventually aggressive it is as if all emotions are placed on the side of daphne the animal while humans are depicted as trying to deal rationally with daphnetheproblem moreover this highlights how animal practices show up the contingency and messiness of the common worlds of humans and animals their latent inconsistencies contradictions and conflicts from an animal expected to be friendly and a member of the group these practices render her a problematic animal whom humans eventually felt it was impossible to live with therefore the same animal daphne a cat is differently enacted by these performative practices daphne as an animalvictim is mainly depicted as an element of a particular species felines represented as having behaviors specific to her species and possibly problematic daphne as an animalmaladjusted on the other hand is mostly described as an individual with a problematic personality when compared to other members of her species such as the other cat in the house other cats the adopter has owned and his own representations of felines this doubleedged representation of daphne highlights the contingent and relational identity of animals how they are done and undone in the unfolding of actions in which they participate to a certain extent it challenges conceptions of the animal as an ontological entity preexisting its encounters with the world nature humans material and technological objects it illustrates how flesh and blood nonhuman animals are not fixed ontologies rather they are contingent ever changing emergent entities they are constant becomings emerging from their entanglements with the world around them their ontological condition being radically relational this is not the same as saying that the animal is not a singular being with her own and unique point of view which remains in great part inaccessible to us as derrida put it in fact it is possible that it is precisely this condition of radical alterity of absolute otherness that brings about the discomfort expressed in the humans attitudes and narratives about her like derridas cat daphne triggers an uncomfortable questioning among the humans in this case about what it means to be a good human and a good guardian also made of feelings of shame mainly enacted in the public shaming of the adopter and his decision to return her to the shelter in addition daphnes unsubstitutable singularity becomes celebrated through the way she is depicted on social media as singularity resonates well with contemporary media language in search of a silver lining where is daphne the cat this article reflected upon the ways we build and blur our ideas about companion animals and humananimal boundaries in our daily lives and in our exchanges over social mediaand what effects that may have on the animals that are constantly being kept at a distance as an unsurmountable otherness despite all blurring of boundaries drawing on a case study of a story about a rescued cat in an animal shelter the article explored the construction of multiple and conflicting versions of this same cat both versions are the result of human interactions on social media and therefore do not reflect reality as it is but rather constitute a metareality a reality built over other realities summoned to support ones beliefs values and views of the world in this particular case of what it means to adopt a companion animal specifically a cat and what we can assume about humans from their behavior in this situation challenging essentialist views and assumptions about feline nature the concept of animal practices enabled us to observe how the animality of companion animals is configured in relation to humans their expectations and experiences as well as nonhumans technology becomes particularly relevant as daphnes participation in these entanglements is reproduced and expanded in time and space through a range of social media practices as such technology participates decisively in the definition of daphnes practices that depend on distant relations and contexts furthermore as a capacity to cause an impact or affect a network of actants daphnes agency is not only circumscribed to the practices in which she physically participates but also to the ones that are extended in time and place and in which she no longer directly participates paradoxically daphne the cat herself becomes invisible as her story unfolds along the thread of exchanges around her life her story is only told thoroughly in the first two posts from the shelter and from the adopter then it either is distorted or simply fades away leaving room for the particular storyies each facebook user brings to the discussion stories about their own pets their own processes of adoption and mutual adaptation stories of conflict and having to deal with problematic behavior however even in these stories the protagonists are seldom the animals themselves but rather their human keepers in particular the good deeds of humans around the act of adopting of resisting returning the animal despite the problems of mutual adaptation of struggling to build a life in which the rescued animals and all their possible problematic conduct may be accommodated hence daphnes existence is approached from a humanized perspective in two ways in relation to what has been called here the triggernarrative that of the animal shelter and its defenders she is compared to kinship categories mostly children and a member of the family this comparison blurs the line between her and her human fellows and is used to contend that once an animal is taken under human guardianship under no conditions is it justifiable to dispose of himher as one does not return a child to its birthplace likewise one never returns an adopted animal the return of an animal is thus equated with an abandonment and all interactions around this produce a version of daphne as the animalvictim paradoxically this withdraws from her a kind of agency that would enable the interpretation of her behavior as a message concerning her needs by contrast the counternarrative of the adopter and his few followers compares daphne to assumptions about the sociable behavior expected of an ideal feminised human to be gregarious docile caring kind she is therefore defined as an animalmaladjusted who has failed in the endeavor of adapting to the humans who gave her shelter therefore daphne the cat becomes an effect of these animal practices performed by humans and nonhumans during the adoption period after her return to the shelter and in the digital spacetime of social media the exchanges and interactions through the thread of posts telling and commenting on her story both humans and nonhumans participate in these animal practices the adopter the shelter keepers daphne other cat animals and the wider cultural context in which cats are constructed including the rescued animals of the facebook users the space of the house and of the shelter food and drink and the technological tools and environment of social media including its specific affordances hence different practices including discursive practices performed on social media construct different versions of the same animal the animalvictim and the animalmaladjusted through these practices there is a kind of pendular movement between erasing and reinstalling differences between animals and humans erasing as when daphne cats and companion animals in general are equated with children or members of the kinship network that one can never relinquish from a moral point of view reinstalling as when daphne is denied morality and intentional behavior declared incapable of doing any harm by means of belonging to a different species both versions represent humananimal boundaries as insurmountable highlighting the ambivalence that crosscuts the attitudes of humans towards nonhuman animals finally in these digital discursive practices that intend to have the animal question at their core animals remain paradoxically invisible despite their apparent extreme visibility so where is daphne the cat either she disappears or is redefined as a caricature i have advanced the idea that being at the same time present and absent nonhuman animals may form a new kind of absentreferent a relevant question thus is whether sociology can contribute to restore animals and daphne in this particular case from their digital absentreferent condition i argue that sociology may play a role in this matter and i have tried to show how its contribution may unfold in two ways by deconstructing the ways animals are defined in the course of humananimal practices in spite of being repeatedly put on the side of nature and through this uncovering the naturalization of animals by identifying the processes through which certain ideas of nonhuman animals are constructed and reproduced in order to preserve the status quo based on species gender or other form of social and political order trying to find daphne the cat herself thus raises important questions first drawing exclusively on discourses about daphne is certainly a limitation of this research as i did not engage directly with the animal excluding her from my field of attention such methodological circumstances also contributed somewhat to the invisibility of daphne and hence to reproduce the general invisibility of nonhuman animals in humananimal relations second it raises questions about power relations between humans and nonhumans and the anthropocentric distribution of resources in which nonhuman animals always occupy a disadvantaged position it is true that as ant defends power within these webs of relations is also contingent subject to constant change it does not exclusively run topdown humans exert their power over daphne in different ways as described previously however these are unstable balances and ones that daphne is also able to affect when she urinates outside her litter box for example she affects her human guardians and has the power to change the family equilibrium when she refuses to eat she affects the shelters staff their decisions their time their practices and behaviours their beliefs however in the end of the day the fact that she is being held in captivity makes her more vulnerable than the humans involved in the long term in this sense the life of daphne as all nonhuman animals is affected by her location within a humancentred distribution of resources in which she occupies a disadvantaged position her agential conditions are modified beyond her will as when the humans decide where she is supposed to live moreover her choices when exercised are already circumscribed she may choose not to eat but she is under technical and medical surveillance to secure her survival the story of daphne has triggered a reflection on whether animals are the effects of social practices in which they too participate rather than entities that preexist any kind of interaction with the world around them several elements human and nonhuman contributed to these animal practices extended in time and place beyond the specific contexts in which they were triggered these practices gained new breadth in the digital timeplace of social media whose particular affordances augmented the intensity of the exchanges involved in all this daphne remains the weakest link the least powerful part in this relation between human and nonhuman

daphne is a female cat whose story was publicly unveiled on the facebook page of a portuguese animal shelter an official post describes how she was returned to the shelter one year after being taken into the guardianship of the very same female adopter who was now returning her daphne is described as being deeply sad and even depressed as shown by her behavior of almost permanent stillness lack of appetite and voluntary starvation refusing to eat what she is given the shelters post reports that she was accused by the former adopter of urinating outside her sandbox and of disturbing the conjugal relationship between the adopter and the latters partner the post proceeds to announce that daphne is again available for adoption and to regret attitudes that cause animals to be relinquished on behalf of personal life issues however this is not the only version of daphnes story on the very day of its publication daphnes former guardian hereafter called the adopter posted a long comment correcting his gender identity male and not female and explaining his own version of the events in their various stages the decision to adopt and the route leading to it involving the shelter the phase in which daphne shared his life and home and her return to the shelter he describes daphnes adaptation to her new home as a very difficult process during which she could not get along with the other cat or with the humans living in the house she is described as being unsociable always hiding and avoiding contact and finally engaging in certain behaviors intentionally such as urinating on her guardians clothes or huffing and snorting in this version she was not happy and returning her to the shelter was a painful act which was reckoned the better way to find her another family and home where she could be happier some of these problems are attributed to daphnes age which made it more difficult for her to adjust to her new home this version as one might expect differs considerably from the shelters both in language and in tone this article explores the construction of multiple versions of daphne as an individual cats as a species and companion animals in general and the role that the particular time and space of social media play in this process its innovative contribute to the scholarship on humananimal studies is twofold by using actornetwork theory in particular

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background compared to nonindigenous australians aboriginal australians experience a significant level of disadvantage in health life expectancy education employment and living standards 1 2 3 4 5 6 7 8 these disparities are evident when considering maternal and infant health outcomes with higher rates of gestational diabetes and smoking during pregnancy among aboriginal women rates of preterm birth and low birth weight nearly double among aboriginal babies perinatal mortality rates of aboriginal infants 50 higher than those of nonaboriginal infants and maternal mortality rates of aboriginal women nearly three times higher compared to their nonaboriginal counterparts 1 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 maternal and infant health outcomes worsen with increasing remoteness due to challenges in health service provision and delivery 6 this disproportionately affects aboriginal women and their infants as 26 of aboriginal births occur in areas classified as remote or very remote compared to only 2 of nonaboriginal births 1101213 the factors contributing to the observed disparities are complex and include poor access to culturally appropriate health services sustained institutional racism lower educational attainment poverty and the continuing effects of colonisation 710132122 healthcare services can contribute to the reduction in existing health disparities between aboriginal and nonaboriginal women and their infants through the provision of timely effective and appropriate maternal and child healthcare 91117192324 health services delivered by a suitably trained and qualified professional throughout pregnancy birth and the postpartum period can reduce maternal and infant morbidity and mortality particularly among women whose health status is poor 25 among australian aboriginal women poor uptake of health services is associated with geographic isolation cost language barriers lack of trust previous negative experiences and culturally inappropriate or unsafe delivery and practices 9202627 aboriginal women are less likely than their nonaboriginal counterparts to attend mainstream health services commence antenatal care at the recommended time and attend the recommended number of antenatal visits 101928 this is in part due to maternal and infant healthcare in remote communities being logistically complex and fragmented involving multiple transfers of care among multiple providers and sectors of the health system resulting in a lack of continuity of care poor service coordination and inefficient communication between service providers 529 furthermore aboriginal women frequently perceived available services as culturally unsafe a biomedical model of care underpins most mainstream health services in australia which can be at odds with traditional aboriginal ways of giving birth 511202230 healthcare professionals are often inadequately trained and underprepared to work crossculturally further compounding the situation 30 consequently accessing maternal and infant healthcare services often results in high levels of fear and anxiety and low attendance at subsequent appointments among aboriginal women 1127 continuity of care is a phrase identified primarily in midwifery practice that refers to service models that incorporate continuity of services andor continuity of carer across antenatal labour birthing and postnatal care continuity of care is reportedly experienced as more culturally safe than siloed care and can result in greater uptake in health care during the perinatal period 3132 where health disparities continue to exist for aboriginal women and infants it is essential to explore the factors that contribute to extensions of this continuity to include the first 1000 days of life this literature review explored factors that contribute to continuity of care as aboriginal families transition from antenatal care through to child and family health care across the first 1000 days of life further it explored service features that contribute to positive care experiences and satisfaction with care methods search strategy the purpose of this integrative literature review was to review evaluate and synthesise what is known around continuity of care for aboriginal families in child and table 1 steps of nvivo guided thematic analysis inspired by jackson and bazeley 37 family health services in australia an integrative literature review systematically searches critiques and summarises relevant literature 33 the review was performed according to the prisma statement and checklist and a fourphase flow diagram the aim of the prisma statement is to help authors improve the reporting of systematic reviews and metaanalyses 34 searches were performed on scopus and pubmed and were limited to articles published from 2008 onwards the search terms included in the search are detailed below scopus search reproductive health services or maternalchild health or prenatal care or antenatal care or postnatal care or infant or continuity of care or indigenous health service and aboriginal additional articles were identified through initial background searches on google scholar as well as handsearching the reference lists of included articles these searches yielded a total of 2935 results excluded studies identified articles were excluded if they were duplicates or did not focus on maternal and child health services used by aboriginal people in australia based on an initial scan of each articles title and abstract the remaining 97 fulltext articles were examined to assess their suitability for inclusion in the review articles were excluded if they were study protocols policy perspectives and position papers discussions of the risk factors for specific diseases or practices descriptions or evaluations of specific programs or interventions or reports of pregnancy or birth outcome trends and statistics the remaining 67 articles were individually assessed by the authors to determine if continuity of care was explored at any point across the first 1000 days following discussion the authors agreed on exclusion of a further 39 articles that did not discuss continuity of care or continuity of care provision at any period across the first 1000 days in total 28 articles were included in the review included studies included studies employed a range of methods with the majority using mixed methods incorporating qualitative analysis of interview data and quantitative analysis of clinical data also included were qualitative studies with interview focus group and questionnaire data a small number of included studies were quantitative including cohort studies and crosssectional audits of existing data the remaining studies were reviews of the literature and descriptions of programs or interventions that included background performance and outcome data review process articles and data were initially analysed by authors ns oa and jg separately using the six steps of thematic analysis by braun and clarke 35 to identify broad concepts and themes this individual analysis was followed by computerassisted qualitative data analysis using nvivo 12 to enable teambased coding and collaboration 36 jackson and bazeleys framework for nvivoguided thematic analysis was applied to reanalyse the article data as outlined in below 37 the collaborative data analysis processes resulted in five key themes lack of continuity of care impact of lack of continuity of care continuity of care interventions impact of continuity of care interventions and strategies to improve continuity of care results study settings of the studies included in the review most were conducted in remote aboriginal communities in the top end of the northern territory or across both metropolitan and rural and remote settings in australia 156810131419202426272930 38 39 40 41 42 43 the studies conducted in the top end of australia predominantly focused on aboriginal communitycontrolled health services and remote health centres 15610192940 and in some instances also included a regional hospital where aboriginal women relocated for birth 5 the studies that were conducted across multiple locations usually included a metropolitan or regional hospital as well as a number of remote health centres and explored whether there were links or established referral pathways between these services 15681319242944 the remaining studies were conducted exclusively in metropolitan settings 112639 44 45 46 or rural towns in new south wales and queensland 142738 these studies were predominantly focused on specific aboriginal birthing or midwifery group practice programs within hospitals which provided antenatal care to aboriginal women within a culturally safe environment and were typically staffed by female obstetricians aboriginal midwives and aboriginal liaison officers a further five studies were review articles examining continuity of maternal health services among aboriginal women and their infants in australia 47121930 one explicitly included maternal and well child health services 4 key themes lack of continuity of care across the first 1000 days studies included in this review reported a general lack of continuity of care and continuity of carer within maternal and infant health services available to aboriginal mothers and their babies 1 46 13 19 29 30 42 43 45 47 lack of continuity of care and carer were especially common in healthcare services without dedicated aboriginal antenatal and birthing programs and interventions 14610132729304245 and were more commonly observed within hospitals than remote health centres 1045 aboriginal women were particularly disappointed with a lack of continuity of care during labour and birth as well as postnatally 44 similarly continuity of care was compromised for aboriginal women who presented to health centres with nonpregnancy related concerns during their pregnancies as they were treated by a different clinician 10 this lack of continuity of carer in some cases after experiencing continuity of carer antenatally contributed to aboriginal women feeling abandoned and uncared for 44 conversely one study reported that some aboriginal women who had been offered a continuity of care model of care delivered by an aboriginal maternal infant care worker declined the service stating that they did not wish to be treated by a known health care provider 45 the decision to opt out of a continuity of care model was primarily motivated by privacy and confidentiality concerns 45 midwives highlighted a lack of continuity of care within hospitals especially in large organisations where midwives were particularly time poor and hospital policies and procedures were inflexible 45 health care providers expressed concerns about the lack of continuity of care in early childhood services particularly with regard to access to a maternal and child health nurse to support a coordinated culturally responsive approach to service delivery 42 the observed lack of continuity of care and carer was attributed to inappropriate or inadequate resourcing of remote health services poor care coordination poor discharge documentation and communication between hospitals and remote health centres lack of aboriginal leadership a focus on a western model of care provision attitudes and practices of clinicians time constraints placed on midwives and other health care providers staff turnover and rotation and inflexible hospital policies and procedures 168104445 impact of lack of continuity of care lack of continuity of care and carer impacted aboriginal womens experiences of and satisfaction with the care they received and influenced their and their infants health outcomes lack of care continuity was viewed by midwives as a key barrier to effective care provision within the mainstream health system 45 a lack of continuity of care has been shown to affect communication and quality of care in antenatal and postnatal services for aboriginal women 4 this can in turn influence health outcomes with fragmented care being shown to increase medical risks and compromise patient safety leading to adverse outcomes for aboriginal women and their infants 4 continuity of care interventions a number of the included studies described interventions or programs that have been implemented in hospitals and other health care settings to improve continuity of care and carer for aboriginal mothers and their infants these programs typically focused on improving continuity of care through ongoing contact throughout pregnancy and birth with a primary midwife an aboriginal midwifery student a district medical officer or amic worker 5 8 10 11 14 20 24 26 3841 44 46 features of these programs that were most highly valued by aboriginal women were having a single known care provider throughout their pregnancy strong community links and being controlled by aboriginal communities 5121439 continuity of care following birth was not discussed in detail and did not feature as a component of most continuity of care programs a small number of studies specifically focused on programs that sought to improve continuity of care postnatally 3839 for example the malabar community link service in metropolitan sydney provided continuity of care for aboriginal women and their infants postnatally by referral to child health services following discharge after birth and access to a known care provider who aboriginal women could call with their queries 39 impact of continuity of care interventions continuity of care and continuity of carer were highly valued by aboriginal women having both facetoface and telephone access to a single care provider who was well known to the woman and who knew their story and could act as their advocate was very important to aboriginal women 51439444748 in particular aboriginal women valued care provided by another aboriginal woman such as an aboriginal midwifery student or amic worker which had a positive impact on cultural appropriateness 814 programs that offered continuity of care through antenatal and birthing services resulted in greater acceptability of care among aboriginal women and greater satisfaction with the quality of maternity care they received 527434449 continuity of care programs appeared to have a positive impact on maternal and infant health outcomes including improvements in antenatal attendance better monitoring and management of risk factors lower rates of preterm birth higher infant birth weight and lower perinatal morbidity and mortality 1924264144 47 48 49 however the methodological quality of studies reporting improvements in maternal and infant health outcomes has previously been assessed as weak and therefore these findings should be interpreted with caution 4 strategies to improve continuity of care included studies put forward numerous strategies to improve continuity of care for aboriginal women and their infants including in mainstream healthcare settings that do not have dedicated aboriginal maternal and child health programs the importance of establishing and maintaining designated leadership positions such as discharge coordinators was viewed as a means to improve communication and handover processes between hospitals and remote health services 29 in order to expand the role of aboriginal health care providers in mainstream health services partnerships should be established with universities and aboriginal communities to improve education and encourage employment of aboriginal staff in caseload midwifery models of care 14 health services should focus on improving communication and building stronger and more trusting working relationships between midwives aboriginal health workers and aboriginal families 45 47 48 49 this can be supported through ongoing cultural competency training for staff and greater flexibility in the application of hospital rules and regulations to support culturally safe care provision 11 aboriginal women should be actively engaged in the design and delivery of maternity care and programs designed to improve continuity of care should work with aboriginal women on identified needs to strengthen outcomes 46 efforts should be made to ensure that appropriate maternity care is available as close to aboriginal womens homes as possible where this is not practicable aboriginal women from regional and remote areas should have access to amic workers to improve continuity of carer particularly in instance where women relocate to a large metropolitan hospital for birth 11 discussion most of the studies included in this review focused on health centres in rural or remote aboriginal communities or programs targeting continuity of midwifery care for aboriginal women between their remote or regional homes and metropolitan and regional hospitals overall this review illuminates that there is a lack of documented evidence of continuity of care for women birthing in both regional and metropolitan areas in which they also live of note the majority of studies focussed explicitly on continuity of care during the antenatal birthing and immediate postnatal period there were only two studies incorporating research regarding experiences of continuity during an infants first 1000 days 3839 there was an absence of research identifying service usage and transitions throughout this period this includes access and engagement with culturally focussed andor mainstream health education and welfare services this review also found that the inclusion of the first 1000 days are imperative to demonstrate that successful family care must have continuity through pregnancy before during and after birth up until child is well into toddlerhood and cannot be isolated into separate stages of antenatal perior postnatal care the first 1000 days movement was established to facilitate change to improve global undernutrition 50 drawing on evidence for nutrition and support of neonates to women of reproductive age 51 the movement promotes development across four domains these include nutrition for brain development better health and equity for reaching potential and economic prosperity 50 while nutrition is vitally important aboriginal and torres strait islander leaders in australia have identified that broader holistic and cultural perspectives of health and wellbeing are required to facilitate change for aboriginal children 52 this is more important now than ever given that the infant mortality rate for aboriginal children in 2018 was double that of nonaboriginal children and the gap between the two rates has widened 53 studies included in this review focused primarily on maternity services in remote areas and their links to regional areas approximately 80 of aboriginal birthing mothers do not live in remote or very remote areas 54 this means that they are living in and accessing health services in regional areas or major cities 54 very little is known about how mainstream birthing units and aboriginal community controlled health organisations are connected during the birthing period in these areas even less is known about how these are linked with well child health services either acchos or mainstream services supporting critical growth and development until an infants second birthday the nurturing care framework was launched in 2018 through collaboration between the world health organisation the united nations childrens fund the world bank group the partnership between maternal newborn and child health and the early childhood development action network 55 it identified pregnancy to age three as a critical period for growth and development the life course is shaped by early childhood experiences that directly shape the structure and functioning of the infants brain 56 these experiences include the nature of care and enrichment the research is clear that negative experiences including poor maternal attribution abuse and environmental insult cause maladaptive structural changes that persist into adulthood 57 health outcomes in these early years have long been known to shape adult health and wellbeing educational outcomes employment and life expectancy 58 parental capacity to provide nurturing care is strongly linked to the social determinants of health and experiences of health inequity and poverty 5960 recent australian data indicate that 46 of aboriginal birthing mothers live in the lowest socioeconomic areas 52 are aged below 24 years and are 8 times as likely as nonaboriginal mothers to be teenagers 54 to enact the ncf and 1000 days australia 6162 these families require targeted interventions that are experienced as culturally safe and continue after the neonatal period this review identified that continuity of care in the provision of maternity services appeared to have a positive impact on maternal and infant health outcomes including improvements in antenatal attendance better monitoring and management of risk factors lower rates of preterm birth higher infant birth weight and lower perinatal morbidity and mortality and was the preferred approach for aboriginal families to meet the recommendations of the ncf the same lens on continuity needs to be applied to ongoing care through to the early years it is known that disadvantage is cumulative further research is needed to identify how to disrupt this accumulation across the critical early years 54 specifically the part that continuity of care and carer must play in this period of the first 1000 days of beginning life this study identified that continuity was hampered by structural issues such as inadequate resourcing inflexible policies and procedures time constraints provision of care from a western biomedical position and individual factors such as poor communication and unhelpful attitudes and practices of clinicians even though much of the research was conducted with aboriginal and communitycontrolled health services these services remain situated within national and jurisdictional biomedical systems of care these systems are fragmented with services across the first 1000 days being siloed and subject to disciplinary scopes of practice western biomedical models of care provision do not support or maintain an approach to equity in care 63 aboriginal perspectives are often relegated to the margins of health care systems and policies and there is a call for twoeyed seeing 64 which would mean that aboriginal and western world views of health illness and child wellbeing including health care systems need to come together and collaborate a twoeyed way of seeing means that one learns to see from one eye the strengths of aboriginal knowledges and from the other eye the strengths of western knowledges but most importantly to use both eyes together for the benefit of all twoeyed seeing honours multiple perspectives and realities as a gift acknowledged by many aboriginal peoples 6566 twoeyed seeing can be applied in the australian maternal and well child health services for example by implementing health navigators contributing to continuity of care for aboriginal families journeying the beginning life the ncf calls for systemic and policy change for health care equity with targeted approaches for infants and children most in need actions for change are clearly articulated in both the national framework for health services for aboriginal and torres strait islander children and families and the national safety and quality health service standards user guide for aboriginal and torres strait islander health 6768 key elements of service delivery include continuity of care and a placebased model for collaboration and integration of services 67 further it identifies multidisciplinary collaborative teambased approaches wellresourced highly skilled and competent workforce holistic care and flexible service delivery 67 a call to strengthen links between primary care and the acute sector to enable continuity of care is reiterated in the nsqhss user guide for aboriginal and torres strait islander health in addition to explicit directions to work in partnership address the specific health needs of aboriginal and torres strait islander peoples implement and monitor targeted strategies including the allocation of resources and improving cultural competency at system structure and individual levels 68 if these directions have existed since 2016 the results of this review indicate an urgent need for research into continuity of care and approaches to care that support optimal growth and development in the early years policymakers must step up here is an opportunity to invest in future health care says professor kerry arabena the first 1000 days between a womans pregnancy and her childs second birthday offers a unique window of opportunity to shape healthier and more prosperous futures 69 arabena talks about a first nations model aimed at strengthening all families so they can give their children the best start in life 5261 although elders community members and early childhood program developers work to provide coordinated comprehensive culturally informed interventions to support families 62 looking at health care holistically we need to examine the health care systems and workforce structureat present even though we know best practice from research health care systems structure and workforce are not providing optimum health care outcomes without a focus on continuity of care beyond the perinatal period limitations this review was limited by the available published literature and therefore does not reflect the scope of the problem that lack of continuity of care presents due to the sparse data and the lack of data from mainstream health services the outcomes of the retrieved studies may not be generalisable to the entire aboriginal and torres strait islander populations in australia the authors are aware of much work being undertaken at community and service level for practice improvement that is not represented in formal research literature conclusions this literature review provides a picture of continuity of care or lack thereof for aboriginal families with infants accessing care through pregnancy and after birth during the window to life from conception to age two within health services in australia the main themes of lack of continuity of care the impacts of this and strategies for achieving continuity of care all have implications for communities members of communities and the ability of healthcare services to provide appropriate and culturally safe care this review contributes to inform decision makers around best practice and models of care for aboriginal families and their babies this literature review highlights the importance of incorporating continuity of care for successful outcomes this is an important focus area for future research supplementary information supplementary information accompanies this paper at 1186s1291302005673w competing interests the authors declare that they have no competing interests

background aboriginal women and their infants experience significant disadvantage in health outcomes compared to their nonaboriginal counterparts access to timely effective and appropriate maternal and child healthcare can contribute to reducing these existing health disparities however accessing mainstream healthcare services often results in high levels of fear and anxiety and low attendance at subsequent appointments among aboriginal women due to inefficient communication poor service coordination and a lack of continuity of care methods this integrative literature review sought to explore factors that contribute to continuity of care and consider service features that contribute to positive care experiences and satisfaction with care received by aboriginal women and their infants in total 28 studies were included in the review and were thematically analysed using braun and clarkes six steps of thematic analysis this was followed by a collaborative computerassisted qualitative analysis which resulted in the emergence of five key themes lack of continuity of care impact of lack of continuity of care continuity of care interventions impact of continuity of care interventions and strategies to improve continuity of care results most studies focused on health services in rural or remote aboriginal communities and there was a lack of documented evidence of continuity of care or lack thereof for aboriginal women living and birthing in regional and metropolitan areas the majority of studies focused explicitly on continuity of care during the antenatal birthing and immediate postnatal period with only two studies considering continuity through to an infants first 1000 daysthe review highlights a lack of studies exploring continuity of care for aboriginal families from the antenatal period through to an infants first 1000 days of life included studies identified a lack of continuity in the antenatal periand postnatal periods in both regional and metropolitan settings this along with identified strategies for enhancing continuity have implications for communities and healthcare services to provide appropriate and culturally safe care it also marks an urgent need to incorporate and extend continuity of care and carer through to the first 1000 days for successful maternal and infant health outcomes for aboriginal peoples

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introduction selfrevolution is the second answer for us to jump out of the periodic law of history it is the fundamental driving force to maintain our advanced nature and purity and realize our longterm governance the ultimate goal of understanding the world is to transform the world and theory serves practice how to transform the theory of selfrevolution into effective practice is a realistic appeal twenty should effectively respond to this appeal put forward to improve the standard system of selfrevolution system promote practice implementation with institutional guarantee and highlight the systematic system of system standard system of selfrevolution the system of selfrevolution adheres to the principle of system integrity structure hierarchy and openness and under the guidance of system thinking as methods and constantly builds a more complete system so as to build an institutional fortress for promoting selfrevolution overview of the social systems research methods everything in the world exists in the form of systems which are the expression of both the universal connection of things and the relative independence of things 1 84 in the study of a certain object we oppose the analysis of research objects with isolated and onesided view abandon the metaphysical research and interpretation and analyze the research objects with the help of social system research methods which is conducive to the comprehensive grasp of the research object any research object can be regarded as a system most of the research objects of modern science are complex systems coupled by many factors with a complex structure traditional research methods cannot realize the multidimensional interpretation of the research objects and social system research methods have effectively overcome this defect social system research method refers to the use of integrity structural hierarchy openness based on the perspective of system thinking the system and system system and elements analyze the relationship between the elements and elements in order to realize the understanding of the research object from single to multidimensional from closed to open from low to high order realize space and time vertical and horizontal multidimensional combination self revolution system specification system is composed of various components coupling of complex system with the traditional research method of self revolution system specification system has certain limitations to build on the system science of social system research method of self revolution system of threedimensional research can effectively overcome the limitations of traditional research methods and provide theoretical guidance for the optimization of self revolution system system selfrevolution system standard system highlights the system principles since the past 18 years we have formed a system of institutional norms featuring selfpurification selfimprovement selfimprovement selfinnovation and selfimprovement the system of selfrevolution is a complex system that has been formed in great practice the top 20 proposal proposes to continue to improve the system of selfrevolution interpret the system of selfrevolution through social system research methods and examine the integrity structure hierarchy and openness of the system of selfrevolution the normative system of selfrevolution reveals the principle of integrity the socalled system is a unified whole composed of several interrelated and interacting seriousness in a certain way 1 84 among them the relationship between the elements is restricted by the whole the normative system of selfrevolution is a system coupled by multiple components each internal component has a strict internal logic with organizations at all levels as the main body from the macro level the selfrevolution system standard system consists of three parts leadership system standard system regulation system and supervision system from the micro point of view the leadership system standard system consists of the central centralized and unified leadership system standard system and the local leadership system at all levels among them the supervision system is coupled by the supervision system within the organization the supervision system outside the organization and the supervision system inside and outside the organization at all levels self revolution system specification system both from the macro level or micro level reveal system integrity characteristics which is not isolated between the elements is not a simple addition but mutual contact interaction requires us to improve the overall revolution system specification system handle the relationship between the elements pay attention to the overall coordination break the fragmentation system construction way form the system integration collaborative and efficient system specification system make the self revolution system specification system overall function fully emerge the principle of system integrity requires us to analyze and solve problems from the whole of the system and to deal with the relationship between the whole and the part on the one hand we must promote the improvement of the selfrevolutionary system and norms from a holistic perspective on the other hand we must focus on breakthroughs grasp the main contradictions and the main aspects of the main contradictions and realize the selfrevolution with breakthroughs in key areas anticorruption is the most thorough selfrevolution and the biggest cancer that threatens our advanced nature and purity is corruption we need to improve anticorruption systems and mechanisms so that we do not dare cannot and do not want to corrupt the normative system of selfrevolution follows structural principles structure is a certain way in which the elements of the system interact with each other including the proportion arrangement and combination of the elements 1 84the constitutive relationship of hierarchy is the vertical relationship between systems and the coherent relationship in hierarchy is the horizontal relationship between systems of systems which leads to the stromal differences between vertical levels there is no separation from the part and the vertical relationship is based on the horizontal existence structure is the key to the orderly operation of the system and it is a key factor to determine the overall function of the system for the nature and function of the system if there is no structure the system will lose its activity and the system will be difficult to operate reasonably and orderly therefore a reasonable factor structure can make the function of the system become more perfect and the unbalanced factor structure will cause the imbalance of the overall internal function of the system in a whole the excessively large proportion of a certain factor may lead to the overall system imbalance which can lead to very serious consequences the internal elements of the selfrevolutionary system have a close logical relationship in the horizontal and vertical aspects clarifying the logical relations among the elements in the selfrevolutionary system norm system is helpful for us to clarify the mutual relations among the elements in the system and provide theoretical basis for dealing with the complicated relations among the elements it helps us to build a reasonable and stable institutional structure so that each subsystem can cooperate and complement each other it will help to prevent the imbalance of system functions caused by unreasonable structure construction within the system build a strong institutional fortress for selfrevolution and ultimately achieve the purpose of highquality operation of the selfrevolution institutional regulation system from the horizontal point of view in the selfrevolution system standard system the leadership system standard system is the fundamental guarantee the regulation system within the organization is the regulation mechanism the supervision system is the supervision mechanism the three constitute an organic whole closely linked according to the structural principle of the system to realize the self revolution system specification system orderly and reasonable operation will deal with the leadership system system organization within the relationship between the regulation system and supervision system realize the benign interaction coordination not lead to the system internal function imbalance from a vertical perspective first of all we should properly handle the relationship between the central government local organizations and grassroots organizations and realize the upper middle and lower coordination local organizations and grassroots organizations should strictly implement the decisions and arrangements of the central government and the central government should ensure correct policies and provide effective guidance for lower organizations second the laws and regulations within the organization system through regulations system implementation disciplinary mechanism evaluation mechanism to form longitudinal regulation system completes the organization regulations planning drafting review cleaning filing execution interpretation evaluation work of the whole chain cut weaken advanced nature damage the factors of purity in order to effectively promote self revolution again under the leadership of the centralized and unified central do real and stronger organizations at all levels comprehensive supervision strengthen the leadership of all kinds of supervision subject and as a whole build supervision mechanism coordination mechanism patrol mechanism of propulsion system pattern make the supervision in the decision deployment command resource integration measures using more collaborative promote leadership and supervision has always been the end build a chess system supervision pattern at the same time to grasp the key seize the key link to drive the reasonable and effective operation of the overall system to clear the head and leadership supervision is the key to the implementation of the central decision deployment through superior supervision supervision supervision of the supervision system of coordination of the head and leadership supervision at the same time play the supervision of the superior organization of lower organization form hierarchical layers of interactive work system therefore the status and interrelations of the internal elements of the system are clarified horizontally and vertically and overall arrangements are made on this basis so as to grasp the overall situation and take into account the local optimize the internal structure of the system and realize the reasonable and orderly operation of the system the normative system of selfrevolution highlights the principle of hierarchy hierarchy refers to the hierarchical affiliation of the different components in the system 1 84 hierarchy refers to a number of systems composed of coherent elements and then through the new coherent relationship to constitute a new system step by step the elements of the system involved in the formation of a new system are called a lowlevel system and the system after the composition is called a highlevel system the bottom layer has a constructive relationship to the high level and the high level is based on the low level system 2 as a system with strict logic the normative system follows the principle of hierarchy and is coupled by multiple subsystems there is a hierarchical order between the levels from the bottom to the top and then to the whole forming a multilevel threedimensional structure and each level has its own special laws the standard system of selfrevolution has the central local and grassroots system vertically including the leadership system and organization the internal regulation system and the supervision system subsystem and there is a corresponding relationship between each vertical system and the horizontal system 3 among them the central government is the highlevel system and the local and grassroots organizations are the lowlevel system a multilevel logical chain is formed according to the internal logical structure the central government plays a leading role and based on the local and grassroots organizations the three are progressive closely linked and inseparable therefore we need to improve the self revolution specification system on the relationship between organizations at all levels coordinate the relationship between the system the implementation of the local central policy deployment propulsion grassroots concrete practice at the horizontal level to achieve the leadership system specification system organization laws and regulations system supervision system of benign interaction to form the optimal pattern of mutual cooperation and complement each other selfrevolution the normative system upholds the principle of openness the socalled openness refers to the internal and external elements of the system and the information can be optimized through interaction to realize the orderly development and functional optimization of the system it is necessary to adhere to the principle of openness the normative system of selfrevolution adheres to the principle of openness focuses on the twoway interaction inside and outside the organization and builds a mechanism and supervision system to adhere to truth correct mistakes find problems and correct deviations and maintains advanced nature and purity through internal forces at the same time we should pay attention to external supervision of the organization and play a role from the inside out through external forces to promote selfrevolution and achieve longterm governance under the guidance of the orientation of supervision within the organization all kinds of supervision should be promoted not only to play their effectiveness according to their own responsibilities but also to strengthen related interaction and system integration so as to form a joint force of answering the same questions and normal longterm supervision 4 we will continue to build a system of combining selfsupervision with supervision by the people form internal and external synergy and ensure that the organization will always be the strong leadership core for the great rejuvenation of the chinese nation in short the systembased and standard system of selfrevolution is a complex system following the principle of integrity structural principle hierarchy principle and openness of the system based on social system research method analyzes the self revolution system specification system which makes the understanding of self revolution from single to multidimensional from closed to open from simple to complex to provide theoretical support to improve the self revolution system to self revolution to promote social revolution to promote the great rejuvenation of the chinese nation

selfrevolution is the fundamental driving force to maintain advanced nature and purity and realize longterm governance the selfrevolution system standard system boosts the transformation of selfrevolution theory into concrete practice and constructs the system fortress for the realization of selfrevolution based on the research method of social system this paper expounds and studies the system of selfrevolution from the perspective of the four principles of integrity structure hierarchy and openness so as to realize the multidimensional understanding of the system of selfrevolution and then leads the social revolution with selfrevolution

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female 22 having poor balance 85 having limits in doing vigorous physical activity 71 having limits in performing moderate physical activity and 635 having pain interfere with normal activities about half had financial problems sometimes and 68 reported living with a spouse and children 30 had hypertension and took antihypertensive medication 16 felt tired most of the time and 11 felt nervous all the time we found that urban older adults had a higher fall rate than rural older adults urban older adults also had a higher level of fear of falling than rural older adults additionally urban older adults had significantly worse general health than rural older adults there were no significant differences in balance performance and fall selfefficacy scores it is important to recognize and identify fall risk factors among urban older adults and provide access to systematic communitybased fall prevention programs incorporating screening and tailored interventions based on those risk factors session 2390 abstract citation id igad1040786 engaging in artistic and creative opportunities to help understand the aging experience chair alexander bishop cochair melinda heinz discussant victor fung this symposium provides an overview of artistic and creative engagement methodologies to understand aging experiences the first presentation examines a collaborative effort involving a researcher and filmmaker to film edit and produce a documentary about irish mens sheds to increase awareness of diversity within the dissemination of narrative stories the second presentation focuses on drawing investigating how young children socially and cognitively represent perceptions of human longevity and of the concept of what constitutes old children were asked questions regarding what it means to be old and what they might look like at 100 years and to draw a selfportrait image findings demonstrating internal working models consistent with sociallylearned attitudes beliefs and stereotypes of aging the third presentation explains digital narrative gerontology and a life story project of the older adults life created by younger and older adults thematic analysis revealed improved wellbeing reduced generational stereotypes and feelings of loneliness and isolation the fourth presentation details an intergenerational project involving university students and older adults with cognitive impairment participants engaged in a sixweek telephonebased reminiscence experience and then cocreated a storyboardscript to create a digital story thematic analysis demonstrated six themes family religion and purpose in life loves and hates careerwork stresscoping and major life turning points the final presentation details music as a therapeutic intervention to improve older adults quality of life and foster social connections selfunderstanding and expression observations from working with older adults in a variety of environments and preferred music styles will also be discussed creating a documentary capturing the narratives of men attending irish mens sheds melinda heinz 1 and laura gleissner 2 1 upper iowa university fayette iowa united states 2 university of northern iowa cedar falls iowa united states how do we engage more individuals to consider and care about issues impacting older adults diversifying the mediums of how older adult stories are told offers one solution filmmaking is one medium where the narratives of older adults can be captured seeing and hearing directly from older adults speak about the issues that affect them provides a distinct way to understand experiences of aging i interviewed men in county limerick about how mens sheds promoted purpose and meaning in the lives of older men after transcribing each interview i partnered with a filmmaker to help create a documentary to tell the story of how mens sheds create an inclusive atmosphere for older adult men to continue feeling useful in older adulthood this presentation will explain how researchers who conduct interviews with older adults are uniquely positioned to collaborate with filmmakers to help tell the stories of older adults the aim of this investigation was to understand how young children socially and cognitively perceive human longevity through drawing data for this study were collected from young children ages 3 to 6 enrolled in prek and kindergarten classrooms through a universitysupported early childhood education center investigators first conducted brief openended interviews to gauge participant understanding of the concept of being old participants were then asked to draw a selfportrait image of what might look like at 100 years of age finally participants were asked to describe their picture as well as share a story regarding the selfportrait image they had crafted images were decoded and analyzed relative to depicted content pattern and position and color preferences findings highlight reliance on internal working models which appear to highlight socially emergent and learned attitudes beliefs and stereotypes about growing old further discussion relative to underlying indication of emotional development will be highlighted abstract citation id igad1040789 digital narrative gerontology as bridges between generations to improve wellbeing learning and shared experiences béatrice crettenand pecorini and emmanuel duplàa university of ottawa ottawa ontario canada elders are an essential society component for the collective success of the demographic transition for social inclusion and the fight against ageism ageism discrimination by age is a very present concern one way to respond to this challenge is to build bridges between generations in society intergenerational programs can reduce the perception of stereotypes about other generations strengthen intergenerational solidarity and help develop capital and social cohesion based on the theories of lifelong learning and intergenerational learning our research engages digital narrative gerontology we have organized several meetings in pairs where each pair created a digital narrative from the oral narration of the elder life story supported by the multimedia skills that the young adult acquired during the workshop we have set up from individual and pairs semidirected interviews logbooks debriefings and digital narrative based on case study thematic analysis our preliminary results confirm the results obtained in 2019 improved general wellbeing reduction in the perception of generation stereotypes reduction in feelings of loneliness and isolation strengthening intergenerational solidarity satisfaction to rediscover ones life or the projection of ones life stimulated by example new knowledge acquisition as well as the pride of artifact creation and its sharing this innovative project can be applied in schools colleges and universities as well as in community centers and seniors residences reminiscence strategies combined with an intergenerational approach may yield social and mental health benefits for older adults with cognitive impairment there is also evidence to support the use of digital storytelling with persons with cognitive impairment combined with intergenerational programs dst typically involves the production of a twotofiveminute audiovisual clip combining text images music photographs voiceover narration and other audio however there are few studies that combine reminiscence dst and an intergenerational approach with persons with cognitive impairment the current study is a thematic analysis of dst products created by university students in collaboration with older adults with cognitive impairment as part of a larger project examining how intergenerational reminiscence using dst may improve the social and emotional wellbeing of persons with memory loss after the completion of a structured sixweek telephonebased reminiscence the younger and older adults cocreated a storyboard and script as well as selected photos and music to accompany the narrative in the dst an interactive team approach using the phases of thematic analysis of the dst products resulted in six themes 1 family 2 religion and purpose in life 3 loves and hates 4 careerwork 5 stress and coping and 6 major life turning points subthemes included childhood and early adulthood family legacy faith volunteering travel music and resilience findings from the study extend current research by examining intergenerational connections reminiscence and the use of dst with persons with memory impairment we close with recommendations for practice and research

this study aimed to examine the prevalence of falls fear of falling fof activities of daily living adl and quality of life qol in communitydwelling older adults in thailand a crosssectional survey of 433 communitydwelling older adults was conducted we used a simple random sampling method to recruit urban and rural adults aged 60 years and older from 23 districts in thailand the measurements included demographics fear of falling history of falls qol the modified barthel adl chronic diseases and medications data were analyzed by using both descriptive and inferential statistics among the participants 453 reported having at least one fall in the past year and 80 reported high level of fear of falling compared to nonfallers and persons without fear of falling fallers and persons with fear of falling were more likely to have at least one chronic disease hypertension and stroke fallers and persons with fear of falling were more likely to take more medications or antihypertensive drugs daily activities including eating bathing dressing toileting and walking differed significantly between nonfallers and fallers p 001 for all and between persons with and without fear of falling p 001 quality of life measures also differed significantly between fallers and nonfallers p 001 in conclusion fallers and persons with fear of falling were more likely to have poorer health more medications lower quality of life and different daily activity patterns future interventions should consider the differences between fallers and nonfallers and persons with and without fear of falling

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introduction a col lege edu ca tion has been hailed as a great equal izer one that sub stan tially reduces the influ ence of par ents socio eco nomic sta tus on their chil drens life chances multiple stud ies have shown that earning a col lege degree effec tively elim i na tes the inter gen er a tional asso ci a tion between a fathers and a sons occu pa tional sta tus more recently schol ars have found that col lege also reduces and some times elim i na tes the asso ci a tions between par ents and chil drens social class indi vid ual earn ings and total fam ily income the results from this body of research sug gest that col lege offers a path to m d king social mobil ity allowing chil dren the oppor tu nity to move up the social lad der rel ative to their par ents and pro vid ing an answer to the old ques tion about edu ca tions over com ing dis ad van taged ori gins a col lege degree can do it do the equal iz ing effects of col lege extend beyond the wellstud ied eco nomic out comes to other dimen sions where some one lives ones health sta tus and ones fam ily for ma tion expe ri ences are just a few non eco nomic out comes that may or may not be equal ized among col lege grad u ates even if occu pa tional sta tus or income dif fer ences are min i mal among col lege grad u ates if disparities remain along other strat i fy ing dimen sions then the extent of equal iza tion and social mobil ity implied by prior work may have been overstated whether and when one marries in par tic u lar have impor tant impli ca tions for economic and fam ily sta bil ity with mar riage act ing as a social safety net build ing trust that encour ages joint longterm invest ments and poten tially pro duc ing dualearner fam i lies marriage is increasingly con sid ered a sym bolic indi ca tor of suc cess par tially because many cou ples see finan cial secu rity as a pre req ui site for mar riage whom one marries also mat ters given high lev els of spou sal resem blance in edu ca tion and income advan tage is con cen trated within cou ples which has impor tant impli ca tions for social repro duc tion across gen er a tions many stud ies have documented var i a tion in mar riage pat terns by social back ground for exam ple research con sis tently shows that those from more dis ad van taged backgrounds marry at youn ger ages which is in turn related to mar i tal sta bil ity despite these find ings we know lit tle of whether this rela tion ship varies by chil drens own edu ca tion or even whether the rela tion ship holds when account ing for chil drens edu ca tion in treating col lege grad u ates as a uni form group when study ing mar riage most prior work has assumed that the rela tion ship between a col lege degree and mar riage is sim i lar for all col lege grad u atesan assump tion con sis tent with the great equal izer hypoth e sis however there is cur rently lit tle empir i cal evi dence to sup port this assump tion if an asso ci a tion between par ents social sta tus and their chil drens mar i tal outcomes exists among col lege grad u ates then col lege may not be as much of an equalizer as past work has suggested little prior research has inves ti gated this pos si bil ity despite the impor tance of whether when and whom one marries for eco nomic and social out comes in this study i use the national longitudinal survey of youth 1997 to exam ine het ero ge ne ity in mar riage out comes within col lege grad u ates by paren tal edu ca tion in par tic u lar i focus on dif fer ences in mar riage tim ing and assortative mat ing pat terns between firstgen er a tion col lege grad u atesthose who have earned a bach e lors degree but do not have at least one par ent with a bach e lors degreeand con tinu inggen er a tion grad u atesthose who have earned a bach e lors degree and also have at least one par ent with a bach e lors degree firstgen er a tion col lege stu dents are an increas ingly vis i ble pop u la tion receiving atten tion both from uni ver si ties in recruit ment and reten tion efforts as well as from research ers seek ing to under stand their unique edu ca tional expe ri ences a large lit er a ture doc u ments the edu ca tional out comes of firstgen er a tion col lege stu dents but few stud ies have explored their post col lege social expe ri ences such as college as a great equalizer marriage and assortative mating mar riage if col lege is a great equal izer for mar riage we would expect dif fer ences in mar riage pat terns by par ents socio eco nomic sta tus to be min i mal among college grad u ates in other words mar riage pat terns of firstand con tinu inggen er a tion col lege grad u ates would be indis tin guish able but recent research sug gests that col lege may not act as an equal izer for marriage as it does for socio eco nomic out comes instead a mar riage mar ket mis match may exist for col lege students from more dis ad van taged social back grounds such as firstgen er a tion col lege stu dents these stu dents may find them selves torn between their social ori gins and des ti na tionsnot quite fit ting in with their more advan taged con tinu inggen er a tion peers but also no lon ger fit ting in with their high school friends this lim i nal posi tion may result in dif fi culty find ing com pat i ble part ners from either group both dur ing and after college this mar riage mar ket mis match faced by firstgen er a tion col lege stu dents may result in delaying or for go ing mar riage and may influ ence whom they marry by chang ing their pref er ences for part ners in the face of mar riage mar ket con straints in par tic u lar firstgen er a tion col lege stu dents may be more likely to cast a wider net for part ners and marry down in terms of edu ca tional attain ment some research ers have found sup port for this argu ment among more dis advan taged col legegoers who strug gled to find ideal re la tion ship can di dates and some times viewed their upward mobil ity as com ing at the cost of seri ous rela tion ship com mit ments i make three pri mary con tri bu tions in this arti cle first i extend prior work on col lege as a great equal izer to one non eco nomic out come test ing the notion of col lege as a great equal izer for mar riage against alter na tive hypoth e ses by neglecting mar riage out comes pre vi ous work in this area has implied that a col lege degrees abil ity to level the playing field in terms of indi vid ual socio eco nomic sta tus out comes is the ulti mate indi ca tor of social mobil ity however if an asso ci a tion between social ori gins and mar riage pat terns exists among those who earn a col lege degree the social mobil ity implied by great equal izer argu ments might be overstated given that marriage is a key com po nent of eco nomic wellbeing espe cially for women second i con trib ute to recent research on classbased mar riage market mis match by inte grat ing it with work on firstgen er a tion col lege stu dents who provide an ideal case for study ing poten tial social ori gin and des ti na tion con flicts and by updating pre vi ous research with more recent data finally this arti cle con trib utes to the existing lit er a ture on firstgen er a tion col lege stu dentsa field dom i nated by research focused on their edu ca tional expe ri ences by exam in ing mar riage to under stand the broader con sequences of firstgen er a tion col lege stu dent sta tus for later life out comes is college a great equalizer moving beyond economic outcomes to marriage education is often rec og nized as both a sys tem that pro motes social repro duc tion and a site for social mobil ity on the one hand one of the stron gest pre dic tors of chil drens socioeco nomic sta tus is their fam ily back ground espe cially their par ents edu ca tion often lead ing to the repro duc tion of advan tage or dis ad van tage across gen er a tions on the other hand col lege pro vi des an oppor tu nity for mov ing up the social lad der as evidenced by ris ing edu cational attain ment and upward social mobil ity over the last 70 years par tic u larly among women stratification schol ars have been try ing to make sense of edu ca tions dual repro duction and mobil ity roles for decades until the 1980s research suggested that no amount of edu ca tion could over come the con se quences of dis ad van taged social ori gins however hout showed that the rela tion ship between par ents sta tus and chil drens out comes depends on childrens ulti mate edu ca tional attain ment more spe cifi cally his work showed that the link between fathers and sons occu pa tional sta tus was effec tively bro ken for sons who earned a col lege degree a phe nom e non that earned col lege the title of the great equal izer this find ing has not been lim ited to chil drens occu pa tional out comes as oth ers have found sim i lar results for edu ca tion out comes among those who earn a bache lors degree the link between paren tal socio eco nomic sta tus and the like li hood of con tinu ing on to a grad u ate degree is min i mal evidence of col lege as an equal izer has also been found using more recent data despite chang ing social con texts and the expan sion of higher edu ca tion this work shows that the asso ci a tions between fathers and chil drens social class indi vid ual earn ings and fam ily income are all sub stan tially reduced or elim i nated among chil dren who earn a col lege degree and although pre vi ous research on col lege as a great equal izer has tended to focus on the same measures of sta tus in both the par ent and child gen er a tions this need not be true at its core the great equal izer argu ment sug gests that par ents sta tus char ac ter is tics become less impor tant for chil drens out comes at each addi tional level of chil drens edu ca tional attain ment with the rela tion ship disappearing among those who earn a col lege degree it is impor tant to note that although the phrase great equal izer may imply a causal effect of a col lege degree the mech a nisms respon si ble for this find ing are not well under stood and most research ers are quick to acknowl edge that results may be due to selec tion recent attempts to quan tify the extent to which these find ings are driven by selec tion have pro duced mixed results even with out hav ing iden ti fied the mech a nisms respon si ble pre vi ous research pro vi des strong evi dence that among those who earn a col lege degree socio eco nomic sta tus as an adult is not strongly tied to their par ents socio eco nomic sta tus but despite con sis tency regard ing col lege as an equal izer for socio eco nomic out comes very lit tle is known about whether a college degree is also an equal izer for non eco nomic out comes like mar riage a sub stan tial body of research doc u ments the rela tion ship between par ents charac ter is tics and chil drens mar riage and fam ily for ma tion pat terns with few excep tions this lit er a ture shows that indi vid u als from more dis ad van taged back grounds form unions and mar riages ear lier than their more advan taged coun ter parts and are less likely to expe ri ence edu ca tional homog amy college as a great equalizer marriage and assortative mating these dif fer ences in mar riage out comes by par ents socio economic sta tus are anal o gous to the dif fer ences observed in income or occu pa tional status outcomes suggesting that mar riage expe ri ences may be a can di date for a sim i lar equal iza tion pro cess at the same time pre vi ous research has dem on strated that a per sons own edu cational attain ment is closely related to their mar riage pat terns those with higher lev els of edu ca tion are more likely to ever marry marry later and marry some one who also has a high level of edu ca tion however lit tle research has exam ined mar riage out comes while simul ta neously account ing for own edu ca tion as well as par ents educa tion this is crit i cal for under stand ing the equal iza tion hypoth e sis for two rea sons first with out looking at the inter ac tion between chil drens and par ents edu cations we can not deter mine whether there is var i a tion in the rela tion ship between mar riage and chil drens edu ca tion by par ents edu ca tion second most work documenting dif fer ences in mar riage out comes by par ents edu ca tion does not adjust for chil drens own edu ca tional attain ment in research that does include both par ents and chil drens edu ca tion in mod els of mar riage results are mixed regard ing whether a rela tion ship per sists between par ents edu ca tion and chil drens mar riage if par ents educa tion is not related to chil drens mar riage once chil drens edu ca tion is accounted for there may be noth ing to equal ize this neces si tates not only exam in ing firstand con tinu inggen er a tion grad u ates mar riage expe ri ences but also mak ing sim i lar com par i sons by paren tal edu ca tion among those with lower lev els of edu ca tion most prior work on the rela tion ship between mar riage and edu ca tion has not allowed for poten tial var i a tion in the rela tion ship by social back ground the implicit assump tion is that edu ca tion does act as a great equal izer and that the rela tion ship between hav ing a col lege degree and mar riage is con stant regard less of par ents socio eco nomic sta tus i directly test this assump tion in the form of the great equal izer hypoth e sis against alter na tives that sug gest dif fer ences may remain between firstand con tinu inggen er a tion grad u ates mar riage tim ing and edu ca tional homog amy the first alter na tive i exam ine is a related though weaker ver sion of equal iza tion in this weaker form it is pos si ble that any dif fer ences in mar riage out comes by parental edu ca tion are reduced but not com pletely elim i natedthat is dif fer ences may only be par tially equal ized under par tial equal iza tion firstgen er a tion grad u ates may be more sim i lar to other col lege grad u ates than they would be had they not earned a bache lors degree but dif fer ences impor tant to mar riage may still remain for instance though firstgen er a tion stu dents often increase social and cul tural cap i tal while in col lege they never reach par ity with their more advan taged peers in short firstgen er a tion grad u ates are dif fer ent from oth ers with sim i larly edu cated par ents in part because of their col lege expe ri ences but they still may not be equiv a lent to other col lege grad u ates in ways that influ ence mar riage an alternative to equalization marriage market mismatch although most past research has implic itly assumed that col lege acts as a great equalizer for mar riage there are mul ti ple rea sons to sug gest oth er wise one alter na tive m d king hypoth e sis is that mar riage mar ket con straints faced by firstgen er a tion col lege students pro duce dif fer ent mar riage expe ri ences than those of other col lege stu dents firstgen er a tion col lege stu dents occupy a unique posi tion in the social order and may find them selves torn between their social ori gins and desti na tions as they climb the social lad der despite their upward mobil ity firstgen er a tion stu dents often do not develop the same resources or lev els of social and cul tural cap i tal as con tinu inggen er a tion students and strug gle to con nect socially with their higher status peers both of these pro cesses can hin der oppor tu ni ties for crossclass dat ing dur ing col lege firstgen er a tion stu dents upward mobil ity can also strain rela tion ships with fam ily and friends from their social ori gin which may develop into incom pat i bil ity in the search for part ners from their social ori gins this con straint from both sides may result in a mar riage mar ket mis match for firstgen er a tion gradu ates and mar riage expe ri ences that are dif fer ent from those of their con tinu inggen er a tion coun ter parts some prior research has supported the mar riage mar ket mis match hypoth e sis musick and col leagues find dif fer ences in the like li hood and tim ing of marriage by social ori gins among those attend ing col lege specifically they show that more dis ad van taged students had a lower like li hood of mar riage at all ages than more advan taged stu dents both delaying mar riage and resulting in a reduced like li hood to marry at all one poten tial lim i ta tion of this approach how ever is its focus on col lege atten dance more dis ad van taged stu dents are more likely to drop out of col lege and may be sad dled with debt asso ci ated with col lege attendance with out the rewards asso ci ated with a col lege degree because of this it is dif fi cult to dis en tan gle the mar riage mar ket mis match expe riences of those who attend col lege but do not fin ish from those who attend and earn a bach e lors degree1 i expand prior work on mar riage mar ket mis match by pri mar ily focus ing on col lege grad u ates and leverag ing more recent data to speak to con tem porary mar riage expe ri ences summary of hypotheses and predictions the great equal izer and par tial equal iza tion hypoth e ses build upon conflicting predic tions for mar riage out comes on the basis of firstgen er a tion grad u ates par ents edu ca tion and firstgen er a tion grad u ates own edu ca tion in con sid er ing their parents edu ca tion we would expect firstgen er a tion grad u ates to have ear lier ages of first mar riage and lower lev els of edu ca tional homog amy however con sid er ing their own edu ca tion firstgen er a tion grad u ates should have later ages of first mar riage and higher lev els of edu ca tional homog amy if the great equal izer hypoth e sis holds i expect firstgen er a tion grad u ates to have later ages of mar riage and higher lev els of edu ca tional homog amy that are equiv a lent to those of their con tinu inggen er a tion coun ter parts in other words among col lege grad u ates parents edu ca tion should not be related to chil drens mar riage out comes if the par tial equal iza tion hypoth e sis holds though i expect firstgen er a tion gradu ates to have later ages of mar riage than oth ers with sim i larly edu cated par ents yet ear lier ages of mar riage than con tinu inggen er a tion grad u ates that is some of the dif fer ence in age at first mar riage predicted by par ents edu ca tion will be reduced but not com pletely elim i nated for assortative mat ing this would mean firstgen er a tion grad u ates would have a higher like li hood of mar ry ing some one with a bach e lors degree than would oth ers with sim i larly edu cated par ents though they would still have a lower like li hood of edu ca tional homog amy than their con tinu inggen er a tion coun ter parts for both equal iza tion hypoth e ses dif fer ences in mar riage out comes by par ents edu ca tion should be larger for those with less edu ca tion and get smaller with each addi tional level of edu ca tion under the mar riage mar ket mis match hypoth e sis conflicting social ori gin and desti na tion sta tuses may make it dif fi cult for firstgen er a tion grad u ates to find com pat i ble part ners if the mar riage mar ket mis match hypoth e sis holds i expect firstgen er a tion grad u ates will marry later than their con tinu inggen er a tion coun ter parts owing to diffi culty in find ing a part ner and in light of a prolonged part ner search i also expect to see a reduced like li hood of edu ca tional homog amy as firstgen er a tion grad u ates are forced to either forgo mar riage or broaden their search beyond col lege grad u ates finally though i make no gen derspe cific hypoth e ses or pre dic tions because of limited prior research i do exam ine men and women sep a rately given wellestablished gen der dif fer ences in mar riage pat terns and a small body of lit er a ture suggesting gender var i a tion in the impor tance of par ents sta tus for chil drens out comes i also assess the hypoth e ses for marriage tim ing and edu ca tional homog amy inde pen dently in other words results for mar riage tim ing may sup port one hypoth e sis while results for edu ca tional homog amy sup port a dif fer ent hypoth e sis data and methods data the nlsy97 is a nation ally rep re sen ta tive lon gi tu di nal sur vey in which a cohort of 12to 18yearolds in 1997 were sur veyed yearly from 1997 to 2011 and every other year since then i use data through 2015 when respon dents were between 30 and 36 years of age the nlsy97 col lects a detailed rela tion ship his tory from each respon dent mea sured at the month level which allows for pre ci sion in esti mat ing the tim ing of first mar riage the lon gi tu di nal nature of data col lec tion also allows for the inclu sion of detailed timevary ing covariates because respon dents are between m d king ages 30 and 36 in 2015 a non triv ial pro por tion have not yet entered their first mar riage at the time of the most recent data col lec tion and some may have not yet fin ished their edu ca tion however about three quarters of bach e lors degrees are earned prior to age 30 the youn gest age at the last inter view further there are suffi cient data avail able to com pare the ini tial mar riage pat terns of firstand con tinu inggen er a tion stu dents as they tran si tion through early adult hood for many respondents this amounts to at least 10 years of data after col lege com ple tion2 analytic strategy and measures i esti mate a dis cretetime com ple men tary loglog haz ard model for tim ing to first mar riage as shown in eq the data are in per sonmonth for mat with dura tion at risk of mar riage mea sured from the month and year of high school com ple tion to the month and year of first mar riage or cen sor ing and i include a squared term to allow for non lin e ar ity in the haz ard of mar riage 3 defining the risk of mar riage begin ning at the time of high school com ple tion allows for com par i sons across mul ti ple lev els of edu ca tional attain ment includ ing the com par i son of firstand con tinu inggen er a tion col lege grad u ates this spec i fi ca tion excludes those who mar ried prior to high school com ple tion or those who did not fin ish a high school degree though this is a rel atively small num ber of respon dents to assess the sen si tiv ity of the results to the point at which mar riage eli gi bil ity begins i use two addi tional risk param e ter i za tions as robust ness checks one begin ning mar riage risk at the time of col lege enroll ment and another at the time of bach e lors degree com ple tion the depen dent var i able in eq is equal to 1 if an indi vid ual is first mar ried in a given month and 0 if they are never mar ried or are cen sored censored cases are those who have not yet mar ried by the time of the last inter view or leave the sur vey owing to attri tion or death college as a great equalizer marriage and assortative mating i make no dis tinc tion between sameand dif fer entgen der unions in my ana ly ses samegen der part ner ships were not well iden ti fied in early waves of nlsy97 meaning they are dif fi cult to remove from the sam ple the more recent data that allow samegen der mar riages to be iden ti fied show that less than 1 of mar riages were same gen der to main tain a con sis tent sam ple through out the study period these couples are included however because their num bers are small their inclu sion in the anal y sis is unlikely to sub stan tively change the results the mar riage pat terns examined here may be dif fer ent for sameand dif fer entgen der cou ples though and would offer an inter est ing ave nue for future research the main inde pen dent var i ables of inter est are a crossclas si fi ca tion of respon dents paren tal edu ca tion and respon dents own ulti mate edu ca tion the com bined par ent and respon dent edu ca tion var iables form a sixcat e gory par entbychild edu ca tion group ing this com bined var i able rep re sents an explicit mea sure of gen er a tion sta tus along with other par entbychild edu ca tional categories though it is ana lyt i cally equiv a lent to an inter ac tion between par ent and respon dent edu ca tion parents edu ca tion is based on a com bi na tion of both child and par ent reports from the first inter view in 1997 i use highest bio log i cal parents edu ca tion in all ana ly ses recent work sug gests that non res i den tial fathers and step fa thers may con trib ute dif fer ently to inter gen era tional sta tus trans mis sion although these dif fer ences are small and vary by father involve ment despite this my results are robust to alter na tive spec i fi ca tions of paren tal edu ca tion respondents edu ca tion is based on the most recently avail able report of edu ca tional attain ment from the respon dent in the results presented below i focus pri mar ily on dif fer ences between firstgen er a tion and con tinu inggen er a tion col lege grad u ates however all mod els are esti mated using infor ma tion from all avail able groups this allows for alter na tive com par i sons as well as com pari sons of the rela tion ship between paren tal edu ca tion and mar riage across dif fer ent edu ca tional lev els to fully assess the equal iza tion hypoth e ses although using respon dents ulti mate edu ca tional attain ment lim its my abil ity to draw causal con clu sions about the effect of a col lege edu ca tion on mar riage tim ing it facil i tates a sim ple con stant defi ni tion of social mobil ity additionally uncovering descrip tive dif fer ences between these groups is a nec es sary step in under stand ing any rela tion ships between gen er a tion sta tus and mar riage alternatives such as using timevary ing edu ca tional attain ment are con cep tu ally prob lem atic par tic u larly in terms of inter pre ta tion for instance using timevary ing attain ment treats those who never fin ish col lege as indis tin guish able from those who do fin ish while both are in the some col lege attain ment level but those who even tu ally fin ish col lege have differ ent mar riage pat terns dur ing this impor tant time 4 and using ulti mate edu ca tional m d king attain ment allows me to account for these dif fer ences that said i pres ent alter na tive spec i fi ca tions in the online appen dix and results are sim i lar across the alter na tive attain ment mea sures the dura tion mea sures are interacted with the par entbychild edu cation categories to allow for nonproportionality in this rela tion ship it is well established that those with less edu ca tion marry ear lier than those with more but that the more edu cated even tu ally catch up this may also be true for the com par i son between firstand con tinu inggen er a tion stu dents given that mar riage tim ing also varies by gen der the time and par entbychild edu ca tion var i ables are fur ther interacted with gen der and results are presented sep a rately for men and women 5finally the mod els con trol for back ground fac tors related to mar riage tim ing and edu ca tional attain ment i include timevary ing con trols for geo graphic region and reli gious affil i a tion as well as timeinvari ant con trols for age at high school com ple tion raceethnic ity6 and fam ily struc ture while grow ing up missing data on con trol var i ables are filled using pre vi ously known val ues when avail able this helps reduce data loss to miss ing val ues and poses few prob lems since none of the mea sures used are highly var i able over time models includ ing addi tional back ground fac tors that may be endog e nous to mar riage pat terns such as par ent hood enroll ment pat terns cog ni tive skills and atti tudes toward self can be found in the online appen dix though results are con sis tent with those presented below the orig i nal nlsy97 sam ple included 8984 respon dents designed to be nationally rep re sen ta tive when used with the pro vided sam pling weights which i use in all ana ly ses presented here of the full nlsy97 sam ple i remove 1139 cases for which infor ma tion on high school grad u a tion date is unavail able i addi tion ally remove 372 cases reporting mar riage prior to high school grad u a tion and 345 cases that are miss ing infor ma tion on their own or their par ents edu ca tional attain ment finally i remove seven cases that are miss ing data on the remaining covariates this pro duces an ana lytic sam ple of 7121 respon dents who ever grad u ated from high school or earned an equiv a lent cre den tial of those who earned a high school cre den tial 5367 ever attended a post sec ond ary insti tu tion and 2232 earned a bach e lors degree in the results presented below i focus pri mar ily on those who earned a bach e lors degree although as men tioned ear lier addi tional groups are included in the mod els given the nonproportionality and non lin e ar ity of the mod els model coef ficients are dif fi cult to inter pret instead i pres ent predicted prob acollege as a great equalizer marriage and assortative mating bil i ties from the mod els to com pare the like li hood of hav ing mar ried at dif fer ent dura tions since high school com ple tion for dif fer ent sub groups because i am presenting predicted prob abil i ties i also pres ent bootstrapped con fi dence inter vals and sig nifi cance tests to assess the pre ci sion of my esti ma tes and make com par i sons across groups 7to exam ine assortative mat ing pat terns i extend the tim ing anal y sis to esti mate a com pet ing risk mul ti no mial logit model distinguishing whether a respon dent does not marry marries some one with less than a bach e lors degree or marries some one with a bach e lors degree or more this allows me to com pare the like li hood of firstgen er a tion grad u ates mar ry ing some one with a bache lors degree to the same like li hood for con tinu inggen er a tion grad u ates unlike the tim ing anal y sis i use a pro por tional haz ard model for the assortative mat ing anal y sis to max i mize par si mony log p j 1p j ⎛ ⎝ ⎜ ⎞ ⎠ ⎟ α j ∑β 1kj attain k β 2 j time β 3 j time 2 β 4 j gender ∑β 5kj attain k × gender β 6 j time × gender β 7 j time 2 × gender ∑β lj controls results descriptive findings table 1 pres ents weighted descrip tive sta tis tics for col lege grad u ates by gen er a tion sta tus and gen der 8 women outnumbered men among col lege grad u ates espe cially among firstgen er a tion stu dents which is con sis tent with the wid en ing gen der gap in col lege com ple tion in gen eral con tinu inggen er a tion stu dents were more likely to be white and have grown up with both bio log i cal parents than were firstgen er a tion stu dents there were rel a tively small dif fer ences by reli gion or region there were few dif fer ences in the median age at high school com ple tion suggesting that any observ able differ ences between groups in their mar riage pat terns were not a result of dif fer ences in when they fin ished high school relatively few dif fer ences were seen between groups in the prob a bil ity of being mar ried five 10 or 14 years after high school com ple tion the larg est dif fer ence was found 10 years after high school com ple tion among men although that gap nearly disappeared within four addi tional years of obser va tion this is con sis tent with the equal iza tion hypoth e ses m d king for mar riage tim ing however con di tional on mar riage firstgen er a tion respon dents were much more likely to have mar ried dur ing col lege than were con tinu inggen er a tion grad u ates given sim i lar mar riage tim ing pat terns this find ing is con sistent with firstgen er a tion stu dents lon ger time to earning a degree unlike the small dif fer ences in mar riage tim ing i found large dif fer ences in educa tional assortative mat ing pat terns between firstand con tinu inggen er a tion col lege grad u ates par tic u larly for women firstgen er a tion women were the least likely to notes ba bach e lors degree totals may not add to 1000 because of rounding a based on kaplanmeier esti ma tes roughly five 10 and 14 years after high school com ple tion b conditional on mar riage being observed in nlsy97 college as a great equalizer marriage and assortative mating have mar ried homogamously with about a quar ter mar ried to a part ner with at least a bach e lors degree the dif ferences in edu ca tional assortative mat ing were smaller among men where homog amy was the most com mon out come for both firstand con tinu inggen er a tion men these descrip tive results sug gest that col lege may not be uniformly equal iz ing for all out comes or all stu dents time to marriage from high school graduation figure 1 pres ents modelbased sur vival curves for firstand con tinu inggen er a tion col lege grad u ates sep a rately for women and men curves are based on a model that allows for nonproportional haz ards and con trols for race region reli gion fam ily struc ture while grow ing up and age at high school comple tion 9 panel a shows that dif fer ences in mar riage tim ing between firstand con tinu inggen er a tion women were small across the dura tion exam ined for both groups the predicted time it took for 50 to expe ri ence their first mar riage was approx i ma tely 10 years after high school grad u a tion or around age 28 as shown in panel b the dif fer ence between firstand con tinu inggen er a tion men was some what larger especially in the years imme di ately fol low ing high school com ple tion firstgen er a tion men appeared to be mar ry ing slightly ear lier although this gap closed by the time they were in their early 30s it took firstand con tinu inggen er a tion men approx i ma tely 105 and 115 years after high school com ple tion respec tively for 50 to expe ri ence their first mar riage for women the small dif fer ences between firstand con tinu inggen er a tion gradu ates in predicted mar riage tim ing pro vi des ini tial sup port for the great equal izer hypoth e sis suggesting that the notion may apply to non eco nomic out comes such as mar riage for men though firstgen er a tion grad u ates ear lier mar riage offers ini tial sup port for the par tial equal iza tion hypoth e sis for both gen ders there was no evidence of delayed mar riage for firstgen er a tion grad u ates com pared with con tinu inggen er a tion grad u ates thus offer ing no sup port for the mis match hypoth e sis upon closer exam i na tion how ever com par i sons across addi tional edu ca tion groups pro vided lit tle evi dence of equal iza tion either par tial or full for either equal iza tion hypoth e sis to be supported we would also expect larger dif fer ences by paren tal edu ca tion for chil dren with lower lev els of edu ca tion to assess this i com pared dif fer ences by paren tal edu ca tion across child edu ca tional attain ment lev els at three dif fer ent time points fol low ing high school com ple tion panel a of figure 2 shows that dif fer ences in mar riage tim ing by paren tal edu ca tion for women were not only small for those who earned a bach e lors degree but were small within each edu ca tion group for men dif fer ences by paren tal edu ca tion were some what larger but did not pres ent a pat tern con sis tent with an equal iza tion pro cess instead the tim ing gap between men with or with out col legeedu cated par ents was either con sis tent across edu ca tional attain ment lev els or grew with addi tional edu ca tion level offer ing no sup port for the equal iza tion hypoth e ses that dif fer ences in mar riage tim ing by par ents edu ca tion were small even for lower lev els of edu ca tional attain ment sug gests that par ents edu ca tion has lit tle relation ship with chil drens mar riage tim ing after adjusting for chil drens own edu ca tion fig 1 predicted marriage survival curves beginning at high school graduation by generation status and gender nlsy97 predictions are based on an individual with the following characteristics white protestant grew up with both biological parents northeast resident and graduated high school at age 18 bootstrapped confidence intervals college as a great equalizer marriage and assortative mating fig 2 predicted probabilities of marriage by years since high school graduation respondent education parental education and gender nlsy97 error bars represent 95 confidence intervals predictions are based on an individual with the following characteristics white protestant grew up with both biological parents northeast resident and graduated high school at age 18 p 05 p 01 p 001 college as a great equalizer marriage and assortative mating fig 4 predicted probabilities of marrying spouse with ba by age 32 by respondent education parental education and gender nlsy97 error bars represent 95 confidence intervals predictions are based on an individual with the following characteristics white protestant grew up with both biological parents northeast resident and graduated high school at age 18 p 05 p 01 p 001 bach e lors degree though firstgen er a tion men were more likely than their con tinu inggen er a tion coun ter parts to marry some one with less than a bach e lors degree for women assortative mat ing pat terns for firstand con tinu inggen er a tion gradu ates were notice ably dif fer ent the predicted prob a bil ity of firstgen er a tion women mar ry ing a part ner with at least a bach e lors degree was 17 per cent age points lower than that of con tinu inggen er a tion women continuinggen er a tion women expe ri enced lev els of edu ca tional homog amy sim i lar to those of men but firstgen er a tion women were much less likely to marry a col lege grad u ate furthermore the esti ma tes show that firstgen er a tion women were 12 per cent age points more likely to marry a part ner with less than a bach e lors degree than were con tinu inggen er a tion women the rel a tively small dif fer ences in edu ca tional homog amy between firstand con tinu inggen er a tion men are ini tial evi dence in favor of the great equal iza tion hypothe sis which predicted sim i lar lev els of edu ca tional homog amy as with the mar riage tim ing results though closer exam i na tion across addi tional edu ca tion groups reveals pat terns incon sis tent with equal iza tion in par tic u lar there is no evidence of a gap by paren tal edu ca tion that diminishes with each addi tional level of edu cation although firstand con tinu inggen er a tion men had sim i lar like li hoods of mar ry ing a part ner with a bach e lors degree the evi dence does not sup port the great equal izer m d king hypoth e sis given the lack of dif fer ences at lower lev els of edu ca tion furthermore simi lar lev els of homog amy among firstand con tinu inggen er a tion men also pro vide no sup port for either par tial equal iza tion or mar riage mar ket mis match hypoth e ses for women the much lower like li hood of edu ca tional homog amy among firstgen er a tion grad u ates did not sup port the great equal izer hypoth e sis but both par tial equal iza tion and mar riage mar ket mis match predicted lower lev els of homog amy among firstgen er a tion grad u ates comparisons in panel a of figure 4 show that the dif ference in the like li hood of mar ry ing some one with a bach e lors degree by paren tal edu cation grew with each addi tional level of edu ca tional attain ment this is fur ther evi dence against any form of equal iza tion and pro vi des the most sup port for some form of mar riage mar ket mis match for womens edu ca tional assortative mat ing i return to pos si ble expla na tions for gen der dif fer ences in the like li hood of edu ca tional homog amy in the discussion robustness checks the mar riage tim ing and assortative mat ing results presented earlier are based on analy ses con di tional on high school com ple tion examination of alter na tive defi ni tions of when the risk of mar riage begins allows me to explore whether the results are consis tent across sam ples and iden tify if there is a spe cific edu ca tional tran si tion where dif fer ences between firstand con tinu inggen er a tion stu dents emerge or dis ap pear to test whether the results are sen si tive to alter na tive risk set param e ter i za tions i esti mate two addi tional mod els the first begins the risk of mar riage at col lege enrollment and the sec ond at col lege com ple tion as with the model begin ning at high school com ple tion these mod els exclude those who marry prior to enroll ing or finishing col lege respec tively comparisons across mod els in table 2 show that the mar riage tim ing results from alter na tive risk defi ni tions are largely con sis tent in all three mod els the dif fer ences by paren tal edu ca tion in the pro por tion mar ried by a given time are min i mal for each edu ca tional attain ment level for instance approx i ma tely two thirds of firstgen er a tion women are predicted to be mar ried by their early 30s regard less of risk param e ter i za tion taken together this is evi dence that the sim i lar i ties between firstand con tinu inggen er a tion grad u ates are not a result of the ana lytic sam ples or mar riage risk param e ter i za tions the alter na tive mod els are also con sis tent with the main results when exam in ing dif fer ences for less edu cated groups by paren tal edu ca tion for exam ple the dif fer ences by par ents educa tion for some col lege women are nearly iden ti cal whether mar riage risk begins at high school com ple tion or col lege enroll ment i also assessed the sen si tiv ity of the assortative mat ing results to these dif fer ent ana lytic sam ples and mar riage risk param e ter i za tions regardless of when risk of mar riage begins firstand con tinu inggen er a tion men had sim i lar levels of edu ca tional homog amymore than 50 predicted prob a bil ity in all cases at the same time firstgen er a tion women were con sis tently less likely to marry some one with a bach e lors degree the con sis tency of these addi tional ana ly ses for both mar riage tim ing and edu ca tional college as a great equalizer marriage and assortative mating table 2 predicted prob a bil ity of mar riage at five 10 and 14 years after edu ca tional tran si tion by risk param e ter i za tion gen der paren tal edu ca tion and respon dent edu ca tion 32 50 nlsy97 discussion and conclusions is col lege a great equal izer of dif fer ences in mar riage tim ing and assortative mat ing by paren tal edu ca tion the evi dence presented in this arti cle sug gests that it is not first there appear to be few dif fer ences to equal ize in mar riage tim ing though the dif fer ences between firstand con tinu inggen er a tion col lege stu dents tim ing of marriage are small dif fer ences by paren tal edu ca tion among lower lev els of edu ca tion are also smalla find ing incon sis tent with any form of equal iza tion this is sur pris ing given prior research documenting the rela tion ship between par ents sta tus and childrens mar riage but it high lights the impor tance of account ing for chil drens own edu ca tion when exam in ing this rela tion ship research that includes both par ents and chil drens edu ca tion in mod els of chil drens mar riage is rel a tively rare and has pro duced mixed results depending on the con text and data more research should exam ine the con di tions under which par ents edu ca tion mat ters for chil drens mar riage net of chil drens own edu ca tion and whether this rela tion ship has evolved over time the sim i lar i ties in mar riage tim ing also do not sup port the mar riage mar ket mismatch hypoth e sis which predicted that firstgen er a tion col lege grad u ates may delay mar riage more than their con tinu inggen er a tion coun ter parts this incon sis tency with prior work does not appear to be solely due to dif fer ences in analytic sam ples although the data used here fol low respon dents only into their early 30s it is unlikely that the mar riage tim ing pat terns presented earlier will diverge enough to sup port the mis match hypoth e sis with a lon ger period of obser va tion it is pos sible how ever that period or cohort dif fer ences between the two pop u la tions stud ied may explain the incon sis tency in find ings future work should con tinue to inves ti gate this classbased mar riage mar ket mis match the con di tions under which it applies and how it may have changed over time second the pat terns of assortative mat ing presented here also do not sup port the great equal izer hypoth e sis differences between firstand con tinu inggen er a tion gradu ates were large for women with firstgen er a tion women being nearly 20 per centage points less likely to marry a col lege grad u ate than their con tinu inggen er a tion coun ter parts additionally there was no evi dence of declin ing dif fer ences by paren tal edu ca tion at higher lev els of respon dents edu ca tion given that dif fer ences in womens like li hood of mar ry ing a col lege grad u ate by paren tal edu ca tion were actu ally smaller for lower lev els of edu ca tion the assortative mat ing results for women pro vide more sup port for the mis match hypoth e sis than for the par tial equal iza tion hypoth e sis the small assortative mat ing dif fer ences observed between firstand con tinu inggen er a tion men paired with small dif fer ences by paren tal edu ca tion among other edu ca tional attain ment lev els do not sup port either equal iza tion hypoth e sis thus the assortative mat ing results for men are sim i lar to the null results for tim ing which sug gest that paren tal edu ca tion for men in this cohort is not strongly related to educa tional assortative mat ing once con trol ling for respon dents own edu ca tion these gen derspe cific assortative mat ing find ings are also incon sis tent with musick and college as a great equalizer marriage and assortative mating col leagues brief exam i na tion of mis match and homog amy fur ther high lighting poten tial period or cohort dif fer ences in these pro cesses the large dif fer ence observed between firstand con tinu inggen er a tion women is in line with prior work suggesting that par ents sta tus may be more impor tant for daughters than for sons out comes it also mir rors recent qual i ta tive work documenting the mar riage expe ri ences of less and more priv i leged col legeedu cated women the higher like li hood of mar ry ing a less edu cated part ner sug gests that firstgen er a tion women may not be real iz ing the full poten tial of their upward social mobil ity a find ing pre vi ously masked by research focus ing on eco nomic out comes for instance firstgen er a tion womens lower prob a bil ity of mar ry ing a col lege grad u ate has impli ca tions for their house hold income and their chil drens devel op ment and out comes analyses iden ti fy ing the rea sons for the gen der dif fer ences in edu ca tional assortative mat ing between firstand con tinu inggen er a tion col lege grad u ates are out side the scope of this study but these dif fer ences may result from a num ber of pro cesses that should be explored in future research one pos si ble expla na tion is that gen der dif ferences in edu ca tional homog amy are the result of dif fer ences in the kinds of schools that firstgen er a tion women attend for instance part ner choice may be linked to the dis tance between home and col lege the gender and socio eco nomic com po si tion of a school and col lege selec tiv ity all of which vary by gen er a tion sta tus and can shape the devel op ment of networks and avail abil ity of part ners dur ing and after col lege a sec ond pos si bil ity is that the increased impor tance of womens eco nomic sta tus on the mar riage mar ket com bined with the grow ing female advan tage in col lege com ple tion has resulted in a sup plyside con straint of eli gi ble part ners which dis ad van tages par tic u lar women high lev els of edu ca tional homog amy among men regard less of gen er a tion sta tus sug gest that they are not as constrained as women in find ing col legeedu cated part ners if men also pre fer women with highly edu cated par ents firstgen er a tion women may face a short age of avail able col legeedu cated partners forc ing them to either forgo mar riage or adjust their pref er ences the results presented here sug gest the lat ter since firstgen er a tion women do not have a higher like li hood of for go ing mar riage at least by their early 30s but do have a higher like li hood of mar ry ing less edu cated part ners a third related pos si ble expla na tion for firstgen er a tion womens lower like li hood of mar ry ing a col lege grad u ate is part ner pref er ences womens chang ing eco nomic pros pects may have altered their will ing ness to select part ners for non eco nomic reasons in con junction with a rise in indi vid u al i za tion and the dein sti tu tion al iza tion of mar riage there are now fewer nor ma tive pres sures regard ing mar riage and more room for per sonal devel op ment and choice to the extent that firstgen er a tion women pri or i tize non eco nomic fac tors in searching for a part ner this may help explain their higher like li hood of mar ry ing a less edu cated part ner it should be noted though that m d king exchange may also be occur ring such that firstgen er a tion women may pair with part ners in the higher end of the income dis tri bu tion even if those part ners have lower lev els of edu ca tion more work is nec es sary to iden tify the sources and con se quences of the observed gen der dif fer ences in assortative mat ing finally it is impor tant to acknowl edge that this research focuses on mar riage outcomes of firstgen er a tion col lege grad u ates but dif fer ences in other impor tant social out comes may also tem per social mobil ity pros pects to the extent that firstgen er a tion grad u ates are dif fer ent in terms of other strat i fy ing dimen sions such as health or where they live the abil ity of col lege to equal ize later life out comes may have been overstated by prior work future research that identifies the mech a nisms respon si ble for the findings presented here and explores other poten tial strat i fy ing out comes will help us bet ter under stand the per sis tence of inequal ity across gen er a tions par tic u larly among those who appear upwardly mobile on the basis of tra di tional mea sures such as edu ca tional attain ment or occu pa tional sta tus ■ competing risk models for assortative mating differences in mar riage tim ing are one mea sure of whether a col lege degree acts as an equal izer for mar riage another is whom one marries figure 3 plots the cumu la tive predicted prob a bil i ties of each of the three pos si ble mar riage out comes through 14 years after high school com ple tion never mar ry ing mar ry ing some one without a bach e lors degree and mar ry ing some one with a bach e lors degree or more these predicted prob a bil i ties are presented by gen der and gen er a tion sta tus and are based on mod els that con trol for race region reli gion fam ily struc ture grow ing up and age when com plet ing high school 10 the predicted prob a bil i ties show that three of the four groups of col lege grad u ates were substan tially more likely to marry some one with at least a bach e lors degree than some one with less than a bach e lors degree this is con sis tent with work documenting high lev els of edu ca tional homog amy among col lege grad u ates for men firstand con tinu inggen er a tion grad u ates had sim i lar predicted prob a bil i ties of mar ry ing a part ner with a 10 table a3 in the online appen dix pres ents full model results fig 3 predicted probabilities of first marriage type by age 32 by generation status and gender nlsy97 error bars represent 95 confidence intervals predictions are based on an individual with the following characteristics white protestant grew up with both biological parents northeast resident and graduated high school at age 18 p 001

college has been hailed as a great equal izer that can sub stan tially reduce the influ ence of par ents socio eco nomic sta tus on their chil drens sub se quent life chances do the equal iz ing effects of col lege extend beyond the wellstud ied economic out comes to other dimen sions in par tic u lar mar riage when and whom one marries have impor tant impli ca tions for eco nomic and fam ily sta bil ity with mar riage act ing as a social safety net encour ag ing joint longterm invest ments and poten tially pro duc ing dualearner fam i lies i focus on the mar riage tim ing and assortative mat ing pat terns of firstand con tinu inggen er a tion col lege grad u ates to test whether col lege acts as an equal izer for mar riage against alter na tive hypoth e ses using dis cretetime eventhis tory meth ods and data from the national longitudinal survey of youth 1997 i find small dif fer ences between firstand con tinu inggen er a tion grad u ates in marriage tim ing but larger dif fer ences in assortative mat ing par tic u larly for women firstgen er a tion women have a sub stan tially lower like li hood of mar ry ing another col lege grad u ate than do con tinu inggen er a tion women and a higher like li hood of mar ry ing a non col lege grad u ate these find ings high light the impor tance of exam in ing non economic out comes when study ing social mobil ity and offer insight into how inequal ity may per sist across gen er a tions espe cially for women despite appar ent upward mobil ity

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introduction this article concerns recognition and compensation of the intimate gendered and unremunerated work of caring in this case for relatives of mine workers who became ill as a result of silicosis and tuberculosis in south african gold mines in its decision in nkala and others v harmony gold mining company limited and others 2016 a court took the unusual step of acknowledging this care work and attempting to compensate it partially albeit via the legal backdoor the article combines insights from political economy and law within a feminist frame to develop an argument about compensation for social reproductive work to address the harm experienced by the carers of mineworkers using the theory of depletion through social reproduction the article examines how we understand the costs of care in order to fully compensate the harms suffered by the carers we do this by examining a series of photographs and accompanying descriptions by thom pierce called the price of gold taken in the mineworkers homes after their discharge from work due to illness i in so doing we tease out some of the complexities of the calculation of loss for economic and legal measurement that should inform any consideration of compensation of people engaged in caring for those who are injured or ill in a range of reparatory contexts we link this discussion to feminist critiques of the law of damages that expose the way in which traditional legal categories ignore and exclude womens unpaid work by using a feminist approach that unpacks and acknowledges care in its many dimensions we challenge the structural devaluation of intimate labour in may 2016 the south african high court granted an order in the case of nkala and others v harmony gold mining company limited and others 2016certifying a consolidated class action against 32 mining companies by mineworkers and their dependents who contracted silicosis and tb the litigation that led to this decision began in 2012 with efforts dating back to 2009 by some of the lawyers involved in the case the case concerns the contraction since 1965 of silicosis by miners breathing in silica dust generated during mining the disease can take many years to manifest is incurable debilitating and often fatal the mineworkers argued that exposure to silica dust also increases the risk of tb a lung disease caused by bacterial infection once miners became too ill to work they returned to their families who became tasked with their care the nkala decision a landmark judgment in the development of class action law in south africa authorises the commencement of the largest class action litigation ever to occur in the country with almost half a million possible claimants ii the article focuses on the aspect of the decision that concerns the access of dependents of the miners to parts of the compensatory damages potentially arising from this claim it then discusses the issue of unpaid care work by the families of the miners using the theory of depletion through social reproduction it goes on to apply this theoretical frame in analysing some of the photographs taken by thom pierce to consider the complex and varied dimensions of harm suffered by the family members of the miners following this it looks at legal responses to compensation for unpaid care and how social reproduction and its depletion should be built into the laws approach to remedying this harm whether through damages reparations or other means i the nkala case background the case against the mines and their complicity in the illness and death of possibly hundreds of thousands of mine workers should be understood within the history of the symbiotic relationship between mining capital and the colonial postcolonial and apartheid states in south africa over the past 130 years since gold was first discovered in the witwatersrand iii the state colluded with the mining industry to ensure its supply of cheap black labour and the mines funded the development of the apartheid state the migrant labour system was central to this collusion in providing a pool of cheap labour workers were legally prevented from living in areas close to the mines and were housed in poor conditions in mine compounds for part of the year they returned to families for brief visits in the rural labour reserves or bantustans racially designated areas with limited land services or infrastructure to which communities were removed coercively and lived in poverty by removing black peoples access to their land and livelihood they were effectively forced to become migrant labourers many mine workers also came from neighbouring countries particularly lesotho mozambique and malawi at its peak in the mid1980s half a million black workers were employed in the mines this has been declining steadily since then to around 120 000 workers in 2016 with the slowing of production when workers returned to their homes they encountered limited access to health care and social security family members usually women were left to provide the bulk of the care for these workers on an unpaid basis this caring work which is deeply gendered further entrenched womens poverty and inequality which was already severe in areas which supplied labour to the mines the litigation is significant in shining the spotlight on the historical legacy of a system of state and private sector complicity leading to structural violence against mineworkers and their families the development of class action law in the judgment is not however the focus of our discussion of interest here is a less prominent feature of the courts decision dealing with the legal question of whether certain personal claims for compensation are transmissible to the heirs of mineworkers who die before the claim officially commences the next section will discuss this dimension of the nkala judgment which has resulted in progressive development of the law in south africa and a noteworthy finding on the issue of unpaid care work transmissibility of damages the south african law of delict allows for claims for damages for monetary loss caused by wrongful injuries to a person known as special damages it also allows claims for wrongful injuries to a persons body leading to pain and suffering loss of amenities of life and disfigurement that is not readily calculable but which can be given a monetary value by the courts as a form of compensation known as general damages the law has refused to allow general damages as a claim arising only from the personal experience of suffering from being transmitted to a persons estate the dependents are however still able to claim loss of support and the estate can claim damage to property while both can claim medical and funeral expenses the exception to this based on roman law is that once litis contestatio has been reached the executor of the estate is allowed to effectively assume the role of the deceased and can pursue all pleaded claims including those for general damages the reason behind this is that a claim made by a person before death is effectively frozen once litis contestatio is reached and the executor is simply stepping into the shoes of the deceased rather than bringing a claim in herhis own right mojapelo djp and vally j the majority of a full bench of the provincial high court in the nkala case noted that reaching litis contestatio in roman times was quite straightforward but under current south african court procedure is a much more complicated and uncertain issue iv pleadings may appear to be closed but an amendment to pleadings at a late stage can change this status including if made by a defendant attempting to prolong close of pleadings or litigation as a whole the failure of the common law of damages to keep pace with the changes to the law of procedure led the mineworkers to claim that the common law required development to avoid causing injustice or infringing south africas bill of rights they asked the court to develop the common law to allow all claims in the class action including those for general damages to be counted from the date of the launch of the certification application the court accepted this challenge mindful of its obligation to ensure that the common law is responsive to changing social conditions and remains relevant and appropriate this judicial role is accepted across common law systems the additional dimension in the south african context is the existence of a constitutional mandate to the courts to develop the common law consistent with the spirit purport and objects of the bill of rights and s39 the mineworkers argued that by disallowing the transmission of the general damages claims to their estates the law violated a number of their rights including to equality dignity life access to the courts and freedom and security of the person which includes a right to bodily integrity they claimed that their right to compensation for damages suffered as a result of the mining companies actions should be able to benefit their dependents even if they do not survive the litigation process to benefit from it themselves this implicated their right to equality since those who survive their illnesses for the duration of the action and their dependents would be in a better position than those who do not the latter group suffering discrimination as a result the court found that there had been legislative developments in the united kingdom australia and the united states to address the issue of damages for personal injury reaching the estates of people wrongfully injured who later died as a result the court also noted that since the first applications that preceded the class action a significant number of mineworker claimants had died and others might succumb before the matter was finalised it thus found that failure to develop the law would result in a huge injustice that would benefit the mining companies as a result of the very harm they caused the deceased class member the court noted that the harm resulting from the loss of the general damages would impact on the widows and children of the deceased mineworkers the indigent weak and vulnerable in our society while benefiting powerful corporates significantly the court added the following point it has to be borne in mind that while the mineworker experienced pain and suffering from the loss of amenities of life prior to his death his widow and children too bore some hardship by virtue of the care they were required to give to him as a result of his loss of amenities of life the gender bias inherent in the common law rule under consideration by the court was raised by the amici curiae in this case in prior proceedings two amici curiae were admitted to the certification case these nongovernmental organisations are the treatment action campaign representing users of the public healthcare system in south africa and sonke gender justice working on issues of gender equality both organisations raised arguments in support of certification of the class action by the mineworkers an affidavit by dean peacock the executive director of sonke gender justice was admitted as additional evidence in the case peacocks evidence concerned the gendered implications of occupational lung disease focusing on the disproportionate care burden carried by women v the major argument that emerged from his evidence is that ill mineworkers are primarily dependent on home and communitybased care which is largely provided by women and girls due to the lack of access to state provided compensation social security and medical care referring to the literature on the impact of care in the context of hivaids in south africa he detailed some of the effects on the carers minds bodies and finances the court accepted the evidence of the amici curiae that ill mineworkers in rural areas depended on homebased care provided by wives and daughters it noted the following impact of the provision of this care the carework is demanding and includes efforts such as carrying lifting and bathing the mineworkers monitoring their medication and staying up at night to attend to their needs these women and in some cases girls are often anxious about the physical deterioration of their loved ones the mineworkers and as a result have reported experiencing tearfulness nightmares insomnia worry anxiety fear despair and despondency … trauma … headaches body aches and physical exhaustion in short they too bear a heavy burden as a result of the mineworkers contracting silicosis and tb often the care work requires fulltime attention effectively compelling many women and girls to forego incomegenerating educational and other opportunities vi the court noted that general damages would benefit these carers by reducing their carework and would indirectly compensate them for the carework they have already provided based on these arguments the court found that the common law had to be developed to allow for general damages claims to be transmitted to the estate of a deceased plaintiff who dies prior to litis contestatio and ordered that the date of the launch of the application for certification august 2012 be regarded as the date on which claims by members of the class would be transmissible aside from the import of the decision in overturning a longstanding legal rule the judgment is highly significant in recognising the issue of unpaid care work in the law of delict this significance is twofold first the judgment gives attention to the many dimensions of caring and the varied impacts of this work on the carer in so doing it acknowledges these tasks as work and their impacts as harms both of which are unusual in law which tends to overlook unpaid caring work second the judgment attempts to compensate the carers for the harms they have suffered it is notable that the judges refer to indirect compensation for this work is this compensation by stealth through the legal back door that is normally closed to carers the law does not usually allow carers to bring damages claims for their unpaid caring work which is treated as gratuitous this article argues that while the judges in nkala attempted to develop the law some way towards addressing the unfair position of carers within the constraints of what they felt was possible this does not take the law far enough it suggests that unpaid caring work and the depletion that arises from it should be fully compensated directly to the dependent carer the article now looks at the first issue raised by the judgment the nature of unpaid care its impact on the carer and how to understand and measure it for the purpose of compensating it in law unpaid care and depleted carers measuring uncounted work this section aims not only to highlight the harmful effects of the mining practices on the lives of the miners and those connected to them but also to disaggregate what human life means in the law although the court recognised the contribution that women make to caring for the miners and to the deleterious effects of this work like much of the law globally it did not recognise the value of domestic labour as labour with value this is largely because domestic work is placed outside the production boundary and is not seen to be contributing to the national gdp and therefore to the national economy much has been written about the importance of this anomaly of excluding most of the work within the home as unproductive labour and its harmful effects this literature challenges not only the domination of the marketwhat counts is what can be commodified and exchanged but also of gendered relations that reflect the world of men but not the world of womens labour while marx and polanyi see the effects of commodification of the first count as the source of instability and eventual crisis of the economy feminists have argued that there is a simultaneous crisis of reproduction that has its roots in the denial of the place of social reproduction in the economy and its commodification through the market fraser has argued that social protection in polanyian terms is being undermined within state policy structures and this in turn is affecting the boundaries of social reproduction as well as the development of human capabilities feminist economists have also argued that the restructuring of states and markets is leading to a situation where the subsidy provided by social reproduction is being increasingly relied upon to fill the gaps in the state provision of welfare rai et al argue that in order to identify the extent to which this is harmful we need to measure the costs of social reproduction which they term depletion through social reproduction in this article we think about social reproduction as both the fleshy messy and indeterminate stuff of everyday life and also a set of structured practices that unfold in dialectical relation with production with which it is mutually constitutive and in tension these practices include 1 biological reproduction this carries with it the provision of the sexual emotional and affective services that are required to maintain family and intimate relationships 2 unpaid production in the home of both goods and services this includes different forms of care social provisioning through unpaid work in subsistence farming family business as well as voluntary work directed at meeting needs in and of the community and 3 the reproduction of culture and ideology which stabilises dominant social relations rai et al define depletion through social reproduction as the level at which the resource outflows exceed resource inflows in carrying out social reproductive work over a threshold of sustainability making it harmful for those engaged in this unvalued work the harm through depletion is experienced not only by individuals involved in this work but also to the fabric of the household and those who inhabit it and to the communities within which households and individuals live their lives depletion through social reproductive work then continues to leach out from the labouring bodies households and communities unrecognised unmapped and unvalued and results in harm to those engaged in this work if unrecognized depletion erodes individual lives as well as social institutions which produces a crisis in society harm occurs when there is a measurable deterioration in the health and wellbeing of individuals and the sustainability of households and communities and when the inflows required to sustain social reproduction fall below a sustainable threshold in this context despite social reproductive work being carried out within consensual social relations the doing of this work may still remain harmful analysing depletion involves identifying indicators and forms of measurement as well as developing an appropriate terminology issues to do with harm and subsidy are relevant here as well as questions about the point at which depletion needs to be recognized accounted for and how in the end it can be reversed we also need to understand the scale of depletion and the rate at which it takes place this would allow us to understand and think through issues of compensation for depletion for the miners and their families the concept of depletion is valuable in understanding the everyday political economy it is not just useful for examining how depletion follows the reduction of state provided services due to economic crises but also aids in understanding the political economy of work and care in the global south it is particularly helpful in understanding care in the context of the south african mining industry and the states role in legislating for enforced racialised rural reproduction of labour in conditions of poverty elson has focused on the depletion of human capabilities in the context of economic crisis while rai et al build their theory on an analysis of everyday political economy which extends to include not only the public and the private sectors of the economy but also the domestic sectors of the economy which focuses not on statemarket relations alone but also on how the domestic sphere shapes and is shaped by these relations hassim and razavi have also argued that most social policy innovations in the global north look to reshaping the male bread winner model of employment to address the issue of increasing mobilisation of women into the labour market conditions of work taxation and provision of care services by the state however they argue that informal work still forms a critical part of the labour landscape in countries of the global south such as south africa and that this requires a different approach to provision of care social policy and the work of women without this they argue job security and workrelated benefits remain privileges available to a relatively thin stratum of workers predominantly men as we will see below this is exactly what we are faced with in the case of miners who have been retrenched they remain the focus of compensation battles while their carers are overlooked the focus on the everyday labouring body in the domestic sphere that the depletion framework provides is important we believe because this everyday depletion leaves few resources for the poorest and the most vulnerable with which to negotiate and weather crises of social reproduction particularly in times of economic and social distress we now discuss the issues of social reproduction depletion and compensation through thom pierces beautiful photo essay the price of gold which illustrates the impact of illness on the lives of the miners widows other carers and their households the powerful pictures display the sadness physical vulnerability and poverty of the miners and their families we have chosen to unearth one of the less visible themes that serve as a background to the photographs the role of women as carers and as bearers of the burdens of social reproductive work without claiming expertise as visual researchers our analysis of these photographs builds on a critical approach to visual culture which in gillian roses words means that we take images seriously …think about the social conditions and effects of visual objects…and consider our own way of looking at images this means that looking carefully at images then entails among other things thinking about how they offer very particular visions of social categories such as class gender race sexuality ablebodiedness and so on critical visual studies have with berger worried about images in which men act and women appear the social construction of illness of silicosis acquired by black male bodies by working in white owned mines frames the social context of these photographs pierce aims to alert the audience to the pain and loss that these photographs reveal and to support the legal claims of the miners and their families pierce gives attention both to the male workers and in some cases to their relatives both groups are clearly affected by the mens illness and loss of employment the photographs speak to the issue of gendered roles and to gendered recognition of individual selves in most photographs the description is of male lives even when female bodies are present in the same frame there are women in kitchens situated in their homes with the accoutrements of everyday life their dwellings showing wear and tear but also careful maintenance in some images women are present as an absence where women are working to support the family sometimes far away from the home xolisile butus wife works in komani and earns the money for the household she only comes home once a month in another case retrenched miner mthuthuzeli mtshange is seen working as a gardener hundreds of kilometres from home to earn enough to support his 8 children who are presumably being cared for by his wife or other relatives women are not portrayed as secondary to the men but as subjects who suffer the effects of poverty most often they sit rather than stand as if weighed down by the burden of care shaped by their relationships with ill men we are able to deduce that these women are responsible for providing care in the face of poverty sickness and death in this context the depletion of the individual is easily imagined the long days combining caring for the husband children grandchildren and the home following his illness and retrenchment depletion can be physical as measured by the body mass index tiredness exhaustion sleeplessness health clothing heating and access to clean water etc it can also be mental the undermining of the self feelings of guilt and apprehension and insufficient time for oneself the enjoyment of family and friendships and to participate in community life all these factors can if they fall below the threshold of normal wear and tear deteriorate the wellbeing outcomes and reduce the capability of the individual to carry out social reproduction in the long run in certain circumstances they can even lead to increased morbidity the tiredness and anxiety on the face of the widow of a miner zwelakhe dala who passed away in 2015 is clearly evident she told pierce it is too painful if my husband was not working on the mines he would still be alive mrs dala writes pierce raised their five children on her own for the most part she is now left with no income except for a small pension ledwaba and sediki write of the miners aspirations when they left home usually as 18yearolds…they harboured dreams of earning good money on the mines to help them fulfil their dreams of building grand homes for their families…instead…they come back broke and broken it is not only the miners that are broke and broken their homes are too mncedisi dlisani shown in this picture with his family in his ruined house worked on the mines for 15 years after being diagnosed with tb he had to leave work and spend 9 months in hospital it is not only poverty that we witness in this portrait of deprivation but also the crumbling of the very fabric of homestead pierce notes that due to bad weather and poor building materials the walls of their main house collapsed and he has no money to repair it and that he now lives with his family in a rondavel whilst issues of compensation mean that the money for repair of the house is a critical concern it is also important to reflect upon issues of labour if dlisani is ill if his wife is looking after him and doing other social reproductive labour in bringing up their family then who is looking after the repairs of the house how can the space of the home not suffer and how can she properly care for him in these physical conditions as we have seen above depletion of households is reflected in a decrease in collective household resources which then adversely affects the rate of repair of household infrastructure including enough disposable income to carry out essential repairs to the fabric of the house improving the environment of the house to support the members of the household… depletion of the household could also be influenced by intangible factors such as the adverse effects of poverty and ruination on the standing of the household in the community looking at compensation claims in the mining class action using the lens of photography enables us to think about depletion and about which harms are recognized and which ones are not and the reasons for this it also leads us to ask who is compensated for which of the harms done to them and who is not and what effects does the denial of compensation for this depletion have on the lives of individuals households and communities understanding depletion as it manifests itself in the photographs points to the need for a deep and textured reconsideration of ideas of loss and injury as they are normally understood and quantified for the purpose of compensatory damages in law the article now turns to the second issue arising from the nkala case the legal recognition of caring labour as a loss deserving of damages caring depletion and harm issues for compensation this section sets out the current state of the law in south africa relating to compensation for unpaid care it then considers feminist critiques of tort law to expose the problems with existing legal formulations it goes on to consider feminist legal responses to international law that propose new approaches to harm in law drawing on these it argues for the broadening of legal definitions of harm that should include recognition and compensation of social reproduction and the depletion that may arise from this the south african law of delict has its roots in romandutch law which recognised that members of the family of the deceased had a right to enforce a claim for the loss of … support resulting from the death of the deceased caused by the unlawful acts of the defendant as noted above dependents actions are for patrimonial losses only and do not include claims for general damages based on the reasoning that the injury is suffered by the breadwinner rather than the dependent the law aims to put dependents in the same financial position in which they would have been had the breadwinner lived to compensate their out of pocket losses within this broad principle the courts have had to determine certain issues including who counts as a dependent and what constitutes a dependents patrimonial loss the basis of the dependents action is the existence of a legal duty of support the dependents action has been extended over many years to a range of situations not contemplated by the old authorities by elaborating on the categories of people regarded as dependents entitled to support in law wives and dependent children have always been entitled to claim loss of support where a male breadwinner was killed or injured and hence prevented from supporting them ix a century ago the court in union government v warneke extended this rule to apply to a husband claiming loss of support following the unlawful killing of his wife although the man did not depend on her income he counted on her looking after his seven children her death meant that he would now incur financial loss in paying for their care the law effectively acknowledged the need to compensate a man for the replacement costs of a wife who had provided unpaid caring functions rather than financial support as a valid form of the dependents action but this acknowledgement of unpaid care work by the law has not translated into compensating women who provide such care work to their injured partners since a damages claim rests with the injured man only he can be compensated for his loss were he to pay for care services these would be covered by his damages claim but his ability to rely on unpaid care services from family members means he does not suffer monetary loss and these services are thus noncompensable the family members through their voluntary assumption of caring responsibility carry the physical financial and emotional costs of this work even where they give up paid work to perform this function they are merely entitled to be maintained by him as they were before his accident but this maintenance obligation remains with him and for him to pursue as part of his own claim for lost income x should a breadwinner die the dependents are then able to claim in their own right for the loss of support they would have received had the man survived and provided for them xi it is this unsatisfactory state of the law that led the nkala court to consider ways of allowing the dependents to access the general damages that were meant for the mineworkers this indirect approach was needed because these women have no actual claim to compensation from the mining houses for their caring labour feminist legal scholars have for decades now raised a number of critical concerns with the law of delicttort including in south africa a broader feminist critique of law is that it is not only reflective of the social context in which it is located but also creates and maintains power inequalities judges are informed by their own race class and gender positions assumptions and biases based on their particular life experiences thus law including tort law while formally genderneutral tends to view the subject of law as male usually white and ablebodied where women do make an appearance they are often squeezed into legal or social categories such as the good wife the bad mother and similar unhelpful stereotypes a common assumption in tort law is that wives and other family members will assume responsibility for the care of injured men it is also assumed that women take on these responsibilities through the exercise of empowered rather than constrained choice feminist scholars have pointed to the consistent devaluation of womens work in their capacity both as victims of harm and as dependents they have noted that womens unpaid work in the home is frequently discounted in damages awards unless their male partners suffer financially as a result of this lost labour the approach taken in south african law to disregard unpaid caring work has been evident in other common law jurisdictions xii the feminist critiques of tort law also assist in understanding why the complexities of caring work and the depletion that may result from it are often absent in the law joanne conaghan points to the difficulty tort law faces in dealing with the relational nature of harm emotions and intimacy thus physical harm that results in economic loss is the easiest area for tort law to address it becomes less helpful in being able to appreciate the impact of harm on family members particularly where they experience mere grief as has been noted it also struggles to deal with the knockon effects of such harms on the family members of the injured person including those that result from the caring responsibilities they are forced to assume the focus on marketbased relations in tort law leads to a vigorous … eschew of intimacy in favour of a male notion of autonomy tort law aims to define the boundaries of personal freedom and limited responsibility for others that contrasts with ideas of relational interdependence xiii paradoxically tort law is focused on duties of care that people owe to each other yet it avoids acknowledging some of the key relationships that underpin this care in determining the legal scope of such duties a further feminist concern with tort law is that it focuses on individual rather than collective responsibility for harm as conaghan notes the focus of tort on individual responsibility in the context of injury and harm sits somewhat at odds with more progressive articulations of social or collective responsibility for misfortune this has particular resonance in the case of the miners who must pursue damages claims albeit as a class against the mining houses but not against the state that was complicit in the harmful treatment of black mine workers in south africa feminist legal work in international law and in the context of postconflict transition has also challenged traditional legal conceptions of harm and compensation these are critiqued as ungendered and individualized and where gendered frames have been adopted this has largely been in the context of sexual violence rather than socioeconomic violence this focus on the socioeconomic impact of conflict has some parallels with the depletion argument in this article while their arguments relate to the context of conflict our arguments refer to a comparable crisis the context of ill mine workers returning home that generates the depletion of their carers households and communities in the context of armed conflict diana sankey has alerted us to subsistence harms deprivations of subsistence needs as a discrete form of violence like depletion these socioeconomic deprivations can be seen as structural harms and as a gendered form of violence that is underpinned by gendered roles and inequalities that harm women more than men other legal scholars have argued that these socioeconomic harms are cumulative and social location plays a role in determining the incidence and distribution of particular harms the violent disruption of life can lead not only to erosion of wellbeing but also to the narrowing of the coping strategies available to women resilience therefore is not a given the nonrecognition of harm can lead to disruption of households and communities as the individuals affected both physically and mentally lose capacity to cope further ni aolain argues that individual violations create communities of harm which include not only the victim herself but also those people who are closely tied to her emotionally or who are in a relationship of codependency with her this resonates with depletion which sees harm taking many forms material and nonmaterial subsistence discursive emotional and citizenship harms the lack of recognition of these harms erodes the capabilities of women to cope emotionally it challenges their place in society and their right to frame claims against the state as entitlements rather than as the needs of subjects requiring rescue the amicus arguments in the nkala case challenge current legal frameworks to address the contributions and costs of social reproductive work by the families of the mine workers they aim to advance the law more generally towards recognition of the intimate gendered work of care and its effects that has historically been rendered invisible and devalued in the cases this article has suggested that the concept of depletion would give greater conceptual depth to the notion of harm occasioned by caring for the ill mine workers in their development of the concept rai et al outline three ways of reversing depletion mitigation replenishment and transformation while theorised separately this is of course a heuristic device to focus on different aspects of reversing depletion so for example replenishment through increased welfare provision through monetary credit may result in buying in more care rather than shifting the gendered patterns of care responsibility however considering them separately does allow us to explore the distinct elements of different strategies for reversing depletion within the depletion framework the strategy of mitigation allows individuals engaged in social reproductive work to lean on monetary buyin of labour or on relational labour this can however lead to passing on the costs of depletion to these others a depletionchain in effect in terms of transformation they argue that depletion would be reversed where society fully values unpaid domestic labour and gender relations are equalised however it is replenishment that seems to speak best to the miners case as this occurs where states or private bodies contribute to inflows it includes interventions by both state and voluntary associations and other nonstate actors to change policy or the law in the miners case compensation would contribute to inflows to offset depletion the argument here is that the state has a role to play in developing policies that address the harm attendant upon depletion nonstate actors like sonke also play a role in campaigning for legal change whether through legislation or the courts the opening up of the compensatory regime to enable not just the miners affected by silicosis and tb to be compensated for their loss of income livelihood and aspirations but also those affected by these illnesses as carers could serve as a bridge between the replenishment strategy and transformation strategy conclusion by reading thom pierces photographs through feminist legal and political economy perspectives we have argued that compensation for miners in the silicosis case in south africa can be better framed by employing the depletion through social reproduction theory this would allow the law to be more responsive to the gender relations of care of the miners it would ensure that compensatory responses would take fuller account of the individual miners social context by seeing them as situated within relationships families and communities in this way compensation would need to be broadened to include not only the cost of marketised care but also the cost of depletion through social reproductive work by the families households and communities this approach requires a twofold response first reform of tort law is needed to recognise and compensate unpaid care work and the depletion that results from this care work in the context of extreme poverty and lack of services in rural south africa and the harm this caused family members was arguably foreseeable and sufficiently related to the miners illnesses not to be considered remote carers would need to be allowed to make claims in their own right rather than as indirect recipients of damages just as dependents are able to do in a claim for lost support however quantifying the costs of this care is not necessarily straightforward if comparable care services in the market are used as the measure then payments may be small because the market tends to undervalue care work which is feminised and poorly remunerated in addition if women are compensated for the lost opportunities to work but these opportunities are very limited and low paid for unskilled black women in rural areas in south africa then again payments are likely to be very small compensating caring work even on a more generous measure that takes account of this context would not address the broader costs of depletion to the carer in relation to the costs of depletion lost opportunities to participate in communities and for rest and leisure for example would also pose challenges for quantification any reform of the law in this area would need to generate creative and appropriate measures of the costs of care and depletion of the carer the second response to addressing depletion particularly in cases where there has been widespread and systemic harm is through reparatory schemes these involving private actors andor the state could use similar innovative mechanisms for quantifying depletion as developed in tort law reform in addition they could provide more communityoriented responses such as infrastructure projects that create employment opportunities educational scholarships and so on designed to remedy the broader harms caused to communities by practices such as hazardous gold mining the arguments advanced in this paper for the recognition of care and depletion could inform any settlement scheme that may arise from the class action litigation in the silicosis case this would be of value to the miners and their families and would also stand as a valuable precedent for similar compensatory schemes in other countries and contexts the growing concerns with the issue of unpaid care are being expressed at the international level the recent un commission on the status of women stressed the need to recognize reduce and redistribute the disproportionate share of unpaid care and domestic work by promoting the equal sharing of responsibilities between women and men and by prioritizing inter alia social protection policies and infrastructure development at para 30 the recognition of unpaid care has also been articulated in human rights terms a report of the united nations special rapporteur on extreme poverty and human rights argued that heavy and unequal care responsibilities are a major barrier to gender equality and to womens equal enjoyment of human rights and in many cases condemn women to poverty therefore the failure of states to adequately provide fund support and regulate care contradicts their human rights commitments by creating and exacerbating inequalities and threatening womens enjoyment of their rights ideas of depletion of social reproduction should also inform the development of international law in responding to gendered harms south africas strong constitutional framework which requires the common law to be developed in line with constitutional values and rights could lead to greater recognition of care in law this too might serve as an example to other jurisdictions and also inform the development of international law several countries have supported household satellite accounts that sit alongside the gdp calculations and demonstrate the value of unpaid domestic work the latest being the uk in 2016 feminist economists have also developed statistical models methodologies such as timeuse surveys to calculate the value of this work the missing link is the political will to standardise inclusion of this work into country gdps forcing them to acknowledge the value of womens labour to the economy and therefore to compensate both individual miners who are suffering from the collapse of their everyday economies with retrenchment because of illness as well as the carers who look after the ill miners this momentum to recognise social reproductive work is of course stymied by the instabilities of capitalisms crises leading many to ask whether capitalism needs the reserve army of unpaid labour whether it is impossible for it to recognise and compensate for social reproductive work while acknowledging the small spaces for feminist intervention in developing the law the nkala decision although insufficiently farreaching provides an opportunity to rethink care in law to extend law effectively into the intimate spaces of the home and to compensate the invisible work that supports the world end notes i over a period of 20 days in september and october 2015 thom pierce travelled around south africas eastern cape into lesotho and up to johannesburg to find and photograph the 56 miners and widows named in the court documents this project was supported by the treatment action campaign and section 27 organisations working on the right to health in south africa the price of gold series can be viewed in full at we are grateful to thom pierce for allowing us to reproduce some of these photographs which are labelled here with the name of the applicant in the case ii in september 2016 the supreme court of appeal granted the mining houses leave to appeal against the decision the appeal has been set down for march 2018 as the lawyers for the mineworkers point out the appeal and any delay it causes to the resolution of this case is hugely problematic since significant numbers of plaintiffs are dying each year parallel to the appeal process there are discussions occurring between some of the parties regarding a possible settlement for a detailed discussion of the settlement efforts and appeal process see pete xi in such cases women are unlikely to be able to claim the replacement costs of mens noneconomic contributions such as caring for children since the law is likely to assume often correctly so that this work was done by women xii the australian high court addressed this issue in griffiths v kerkemayer 1977 139 clr 161 but subsequent court decisions and legislation have significantly undermined the decision for a discussion of the more progressive developments in canadian law regarding compensation of unpaid work in the home see brooks xiii conaghan draws on jennifer nedelskys work on a feminist conception of relational autonomy

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introduction indonesia is a diverse country with many cultural and religious traditions existing diversity however has the potential to lead to conflict religion intergroup relations and ethnicity are still very sensitive topics that can cause conflict there are numerous riots worldwide many motivated by religion and culture conflict is typically sparked by the prevalence of stereotypes pitting one group of people against another from different cultures and religions the worst effect of these disputes is the lack of tolerance between cultures and religions according to hasyim muzadi there are at least three reasons why there is a conflict between religious groups in indonesia a multicultural country a partial comprehension of religion political and economic causes and depictions of nonreligious issues the perspective of religion by placing religion as a source of conflict has led to various attempts at reinterpretation and then finding common ground at a certain level to reduce conflict between religious communities if there is mutual tolerance disparities in religious beliefs frequently cause conflicts this is because there are incorrect viewpoints and people or groups with a limited understanding of religion beginning with an excessive sense of zeal eliminates the likelihood of truth it moves on to asserting his truest faith denying stuttering and encouraging radical acts against other religions the foundation of religious life is the teaching and inviting in of goodness taught in every religion followed by mutual regard respect and tolerance in a religion that must be upheld to uphold human values an interesting fact is that one of the forms of approach to the essence of every religion is love the fundamental reason all religions teach love can be known as follows christianity is very attached to love1 buddhism is famous for maître2 khonghucu teachings are interpreted with jinn hinduism calls it tat twam asi3 and in islam it is interpreted as mahabah each religion has its concept of love and from that love each religion is taught to do good to each other in islam mahabah is the concept of sufism which is the actualization of love for allah toward his being as muslims indonesian muslims must incorporate the idea of mahabah into social interactions to eradicate division and intolerance in the countrys wide cultural and religious variety the author makes an effort to examine the idea of the mahabah according to kyai haji hasyim asyari because he is a prominent indonesian muslim who has influenced the countrys unity he is associated with the realization of interreligious tolerance it seems that the feature that sets this particular study apart from others is its focus on the implementation of mahabahs sufistic feature in the practice of unity in diversity specifically in the context of addressing religious diversity in indonesia this novel approach builds upon previous research such as abdul hakams study of kh hasyim asyaris teachings on sufism by applying the concept of mahabah to contemporary issues this study offers unique insights into how sufi practices can promote unity and understanding in diverse communities the author notes that this research is unique because it connects the idea of mahabah with sufism a mystical tradition within islam that emphasizes spiritual purification and enlightenment by doing so the author aims to show how the practice of mahabah can be grounded in a spiritual tradition and can help address contemporary issues such as religious divisions in indonesia overall the author is interested in exploring how islamic concepts and practices can promote social harmony and tolerance in indonesia and how traditional islamic scholarship can inform contemporary discussions on these issues methods it is not easy to determine the research method used without additional context about the research however if the data collected does not involve direct interaction with human participants it can be classified as a noninteractive research method noninteractive research methods usually involve gathering data from sources such as surveys observations or existing datasets without directly involving human subjects examples of noninteractive research methods include content analysis archival research and secondary data analysis based on the information provided the research method used in this study is document analysis document analysis involves collecting and analyzing data from various written sources such as books archives and written works instead of collecting data through direct interaction with human subjects in this case the researchers collect data by studying and analyzing literature related to kh hasyim asyaris concept of mahabah and its actualization of interfaith tolerance this research method can provide valuable insights into a particular phenomenon or topics historical cultural and social context however it is important to carefully evaluate the quality and reliability of the sources used in the document analysis to ensure the validity of the findings results and discussion sufistic life of kh hasyim asyari kh hasyim asyari was a prominent figure in indonesian history known for his contributions to the state as a great ulama and statesman kh hasyim asyari is the founder and supreme leader of a muslims organisation nahdlatul ulama which still exists and has many followers he was a great scholar from pesantren tebuireng in jombang and a national hero kh hasyim asyaris contributions to indonesian muslims progress include his academic work his struggle and educating the people and his thoughts on education his thinking was balanced between the inner and outer dimensions between traditionality and modernity kh hasyim asyari utilized anthropocentric theology to raise muslims awareness to fight the practices of colonialism and break free from its shackles while also fighting the ignorance of aqidah in his book almuqaddimah alqānūn alasāsī li jamiyyah nahḍatul ulama kh hasyim asyari emphasized the idea of unity which included national unity and religious unity he believed that the condition of the indonesian nation being colonized by the dutch was the most dominant social condition and his thought in this book was motivated by the social conditions that occurred at that time kh hasyim asyaris thoughts in the field of education included the significance of education the purpose of education the character of the teacher the duties and responsibilities of the student the education system the curriculum and the method he believed that education should instill nationalism and patriotism which evoke the courage to make sacrifices of soul body and property in conclusion kh hasyim asyari was a significant figure in indonesian history known for his contributions to the state his thoughts on education and his fight against colonialism kh hasyim asyaris thinking in sufism follows the orthodox sufism formulated by imam junaidi albaghdadi and imam alghazali the concept of sufi teachings written by kh hasyim asyari has taught that in sufi teachings one should not exaggerate anything but he advocates being mediocre the goal is that sufism in islam is not considered radical this type of sufi emphasizes increasing moral values and piety by carrying out the teachings brought by the prophet muhammad saw the notion of mahabah in sufism is the tendency of the heart to love god or obedience to gods commands staying away from his prohibitions and obeying all its provisions based on imam alghazalis book ihya ulumiddin mahabbah allah and his messenger are an obligation knowing the nature of love it must be preceded by marifah and idrak because man loves nothing but what he recognizes so it can be understood that the terminology of islamic mysticism is the tendency of a persons heart to only love allah empty the chambers of his heart from other than allah accompanied by obedience to carry out his commandments and stay away from his prohibitions mahabah according to kh hasyim asyari the word mahabah derives from the word ahabba yuhibbu mahabbatan which literally means to love deeply it can also mean alwadud which mean an ultimate love mahabbah can also means a true love that leads to the owner of the majesty namely allah swt love for anything will be fake if not framed by love for him sufism in islam has many figures with various concepts among them is the concept of love coined by rabiatul adawiyah mahabah is a concept in which a servant no longer loves fellow creatures but is solely given to the creator namely allah swt according to kh hasyim asyari mahabah is not just a feeling or emotion but an active embodiment of ones devotion and commitment towards god and his messengers in sufi terms mahabah can be seen as a form of spiritual love leading to greater obedience and submission to god there are also those who argue that mahabah comes from the word hubb which means four logs used to support a vessel like a lover who is willing to bear the burden he loves it is then etymologically understandable that he is omnipotent can be interpreted as the love of something very deep his heart is overwhelmed with his love and there is nothing to fill his heart except love mahabah is a concept in islamic thought that refers to the highest level of love and affection towards god and his creation from the perspective of kh hasyim asyari mahabah is an essential aspect of islamic education and character building his educational thought emphasizes the ethical aspects of learning and puts tasawuf as the foundation of education in shaping the character of learners mahabah is also relevant in forming a sakinah household which is peaceful harmonious and full of love contemporary sufism focuses on the concept of muhammadan love as the essence of the mahabah kh hasyim asyaris educational thought is based on the ethics of teaching and learning emphasizing characterbuildings importance in education in his book adab alâlim wa almutaallim kh hasyim asyari explains the duties and responsibilities of students in the teaching and learning process including their relationship with their teachers and fellow students that concept is also relevant in the context of nationalism he believed that islam and nationality are inseparable and that muslims should be loyal to their country and work towards its progress in conclusion mahabah is an essential concept in islamic thought particularly from the perspective of kh hasyim asyari it is relevant in islamic education character building forming a sakinah household and nationalism his ideas on the relationship between islam and nationality are also significant in contemporary indonesia the founder of nu also has a big enough thought and role in various ways including in islam and nationality in pertaining to the islamic thought kh hasyim asyari has formulated islamic thoughts patterned in traditional islam among the islamic thoughts namely in the field of tasawuf the field of kalam and the field of fiqh as is understood men must surely be social mixed with others for no one can be alone to meet all the needs he is inevitably forced into society gathering that brings goodness to his people and rejects the needs and threats of danger from him therefore unity the inner bond with one another helping each other to deal with one thing at the same age is the most important cause of happiness and the most powerful factor for creating brotherhood and affection how many countries became prosperous and servants became powerful leaders development was evenly distributed countries became developed governments were established and roads became smooth transportation became crowded and there were many other benefits of unity the greatest virtue and the most powerful causes and means ‫ﲜميع‬ ‫يستقل‬ ‫أن‬ ‫ﻻﳝكن‬ by those narratives kh hasyim asyari explained that unity in society could create brotherhood and affection and this is the basis for the moral and national thinking of him his thoughts on unity are also corroborated by his description which explains the dangers of breaking brotherhood and division it can be seen in his book attibyan fi nahyi an muqathaati alarham walaqrabin where he quotes many verses from the quran and the hadith about brotherhood and the danger of division through the nu organization kh hasyim asyari demonstrated the nature of moderation while laying the groundwork for the moderate movement which unites the concepts of country and community additionally nu has been at the forefront of defending pancasila and the republic of indonesias 1945 constitution until now in the meantime tasamuhreflecting behaviors of him have been captured in photographs by m sanusi kh hasyim asyari and nus efforts to promote moderation unity and defend democratic values are admirable and serve as an example for others human beings must realize that they need each other to fulfill their needs islam teaches humanity to be united and not divided and that is one of the proofs that islam is in harmony with human nature allah commands muslims to unite with the foundation of the mahabah actualization of god as hablun min allah means guarding a relationship with god always carrying out all his commands and leaving all his prohibitions as interpreted by the rope of allah namely the religion of allah namely islam which produces marifatullah then mahabah which is actualized to human which are interpreted by the ropes of fellow human beings namely socializing to society in the form of tolerance to nonmuslims and ukhuwah islamiyah to fellow muslims the author describes this as stated on the following figure 1 the growth of awareness builds harmony through everyday attitudes as mentioned above driven by several factors such as theological factors the actualization of mahabah in islam is included in the realm of sufism akhlâqî sufism akhlâqî is a sufism that concentrates on improving moralities and attitudes with certain methods formulated sufism concentrates on avoiding the despicable manners while realizing the praiseworthy ones in daily lives the urgency of mahabah in building a tolerant society in indonesia mahabah in kh hasyim asyari thought refers to love and affection towards fellow human beings regardless of their religious or ethnic backgrounds this concept is closely related to interfaith tolerance which emphasizes respecting and accepting differences among people of different faiths according to zuhri kh hasyim asyaris religious thinking was based on ahl alsunnah wa aljamâah discourse which emphasizes the importance of unity and cooperation among muslims nizar explains that kh hasyim asyaris thought about unity is reflected in the establishment of nahdlatul ulama an islamic organization that promotes the values of tolerance inclusivity and social justice bagaskara adds that kh hasyim asyaris ethics in the teaching and learning process act act muslim non muslim also emphasizes the importance of respect empathy and compassion towards students and fellow teachers finally his concept of mahabah has significant implications for creating interfaith tolerance according to rosyidin kh hasyim asyaris thought about the sakinah household which emphasizes the importance of love respect and harmony in family relationships can be extended to the broader society this idea aligns with the governments program specializing in character education to promote interfaith tolerance furthermore the concept of hubb alwathan min aliman which emphasizes the love for the homeland can also promote national unity and social cohesion in conclusion kh hasyim asyaris concept of mahabah emphasizes the importance of love respect and compassion towards fellow human beings regardless of their religious or ethnic backgrounds this concept has significant implications for creating interfaith tolerance and promoting social cohesion the prominent thoughts about unity ethics in the teaching and learning process and the sakinah household can be used to promote interfaith tolerance and character education in indonesia from the perspective of the founder of nu islam and nationalism are inseparable and muslims should be loyal to their country and work towards its progress indonesia is based on the principle of unity in diversity which emphasizes respecting and appreciating the diversity of indonesias cultures and religions he believed nationalism should be based on justice equality and human rights in the context of interfaith tolerance kh hasyim asyaris ideas on the relationship between islam and nationalism are significant his emphasis on unity in diversity and respect for other religions can be seen as a manifestation of the mahabah towards gods creation furthermore kh hasyim asyaris educational thought emphasizes the ethical aspects of learning and character building and can also contribute to developing interfaith tolerance by instilling the values of mahabah in learners they can learn to appreciate and respect the diversity of religions and cultures and work towards a more harmonious and peaceful society in conclusion mahabah is an essential concept in islamic thought particularly from this perspective mahabah can be actualized in interfaith tolerance by fostering religious tolerance and promoting unity in diversity kh hasyim asyaris ideas on the relationship between islam and nationalism which emphasize the importance of justice equality and human rights can also contribute to the development of interfaith tolerance by instilling the values of mahabah in learners they can learn to appreciate and respect the diversity of religions and cultures and work towards a more harmonious and peaceful society conclusion based on the description above it can be concluded that the actualization of mahabah in islam can give rise to interfaith tolerance mahabah according to kh hasyim asyari in the context of sufism is a servants faith in his god by working out his commands and knowing his prohibitions with the guidelines of the quran and hadith as for the social context namely the servant to god that will give rise to marifatullah servants of god and man with his fellowmen who will give rise to tolerance even among religious people finally the foundation of mahabah as the actualization of religious tolerance in islam is still in the realm of tasawuf akhlaqi while the realm of aqidah and sharia has its limitation

this study examines the concept of mahabah in the context of indonesian cultural and religious diversity and its potential for promoting religious tolerance the indonesian nation is diverse with multiple cultures and religions which can be a great strength or source of conflict the worst impact of conflicts between cultures and religions is the loss of tolerance between them to promote interfaith tolerance in indonesia it is important to imply the concept of mahabah in socializing which is interpreted as loveaffection in every religion kiai haji hasyim asyari is an indonesian muslim figure who has influenced the unity of the indonesian nation and this study explores his concept of mahabah and its actualization on religious tolerance the library research method collects data by studying various literature such as books archives and written works related to kh hasyim asyari according to kh hasyim asyari mahabah in the context of sufism is the faith of a servant in his god by following the quran and sunnah in the social context the servant of god will give rise to tolerance even between religious people by exploring the concept of mahabah in the context of indonesian cultural and religious diversity this study seeks to promote religious tolerance and social harmony in indonesia

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saint and slackers challenging discourses about the decline of domestic cooking the demise of cooking amidst growing concerns about nutrition and food safety anxiety about the impoverished state of domestic cooking has become a common part of public discourse whether reported in academia or the media or highlighted by an increasing number of celebrity chefs a perception of the erosion of skills held by previous generations has emerged over the last 1015 years suggested contributing factors include the breakdown of traditional domestic divisions of labour associated with increased labour market participation by women the wider availability of convenience foods and the effects of technologies culpable in both deskilling cooking in the kitchen and distracting children from being in the kitchen to absorb tacit cooking skills for steinberg the loss of culinary traditions and skills generally assumed to pass via a hierarchy of gerontocratic authority is a necessary part of becoming modern academic discourses of decline and deskilling find their parallels in policy concerns indeed these contributed to the social inclusion discourses which were to form the basis for social and public health policies of the labour government in the uk in the late 1990s during this period there was a proliferation of communitybased interventions aimed at reaching the most marginalised groups in society with advice concerning health exercise diet and nutrition with many professionals taking the view that possession of cooking skills and knowledge can improve diet however the emerging perception of cooking as a recreational lifestyle choice over the same period along with the concomitant rise in popularity of cookery programmes cookbooks and merchandising of an array of specialist cooking paraphernalia problematises discourses of deskilling and lack of interest suggesting that it is within particular constituencies that this is assumed to be the case indeed hollows and jones writing on the shifting image of jamie oliver from lifestyle expert to moral entrepreneur via jamies school dinners and jamies ministry of food highlight how the latter in particular works within a wider discourse of class pathologization appealing to populist discourses within which it is assumed that it is socially and economically excluded populations who are unable to cook this pathologisation of certain social groups is not however a recent phenomenon concerns about the dearth of cooking skills among the lower classes can be traced back at least 200 years when calls were first made for the poor to be educated in the basics of cooking in a related domain poor cooking and food hygiene knowledge have also been implicated in increased concerns regarding the incidence of indigenous foodborne disease in the uk improved safeguards in the productionsupply chain food safety legislation and the creation of the food standards agency are cited as having improved food safety however continuing high levels of foodborne illness and the dearth of knowledge regarding what happens to food beyond the point of purchase have led to the emergence of a particular understanding of consumer behaviour within the food industry and among food scientists this understanding is based on assumptions about consumer ignorance and poor food hygiene knowledge and cooking skills these assumptions are often accompanied by perceptions of a loss of commonsense´ understandings about the spoilage and storage characteristics of food supposedly characteristic of earlier generations jackson et als study of consumer anxieties regarding chicken production highlights that among producers there may exist a culture of blame through which discourses of deskilling in relation to food safety have been invoked consumers have been characterised as lacking in rudimentary cooking skills and as associating cooking with the assembly of several precooked components from cartons packets and tins similarly they are understood to be increasingly distanced from primary foodstuffs in their raw state because of the mediating role of the retail industry and because most consumers have little direct contact with agriculture also contributing to a narrative of deskilling is the impact of innovations these range from food supply systems to the technologies of the kitchen which have undeniably operated to reduce demands for certain sorts of skills on behalf of the people doing the cooking the effects of technological developments on the competencies skills meanings and practices of food provisioning have been explored over recent decades including around fridges cookers freezers and microwaves which have transformed the interior landscape of the domestic kitchen the articulation of the culpability of technologies within a narrative of deskilling is made clearly by giard who suggests that electromechanisation has transformed the cook into an unskilled spectator who watches the machine function in her place the emancipatory promise carried by new technologies and convenience to freeup time for typically female cooks has been thoroughly problematised since cowan identified the ironies of household technology increasingly technological developments are more likely to be associated with discourses of decline which threaten health family relationships and cultural identities these various discourses implicitly recognise cooking skills as complex their effective acquisition requiring childhood immersion in the complex of values routines and skills of a traditional family kitchen close to the apron strings of mother however the complexity of cooking skills and the range of innovations now available which contribute to the processes of meal preparation immediately invite closer attention to claims made through discourses of decline indeed both murcott and short have questioned what exactly is implied by the verb to cook and importantly who is it that does it female participants reported by both murcott and charles and kerr indicate that while they recognise that men are involved in food preparation their culinary creations are more likely to be characterised by these women as snacks as opposed to proper meals consequently we might ask what constitutes cooking for example does it require the application of heat to fresh raw ingredients prepared from scratch or is it simply any process that involves some level of transformation of foodstuffs such as the preparation of a sandwich beans on toast or heating up a ready meal in the microwave indeed short highlights the apparent failure among those lamenting the deskilling of cooking to unpack the meaning of phrases such as cooking ability culinary knowledge traditional cooking skills and assembly skills and as silva points out the introduction of innovations such as ovens has not eliminated complex assessments and judgments required on the part of the cook knowing when a cake or joint of meat is done does not hinge on manual abilities but as short observes on cognitive perceptual skills that prompt the appropriate action a further consideration is that advice on how to cook meat in particular does not remain static and consumers are presented with different and often contradictory sources of information the packaging in which a chicken is wrapped will tell us to cook the bird for xnumber of minutes per kilogramme and ynumber of additional minutes thereafter the advice given by mrs beetons cookbook might differ to that suggested by delia smith or jamie oliver our mothers or grandmothers injunction might have been to cook it until the juices run clear while food safety experts now inform us that the only way to safely check meat for doneness is by testing the internal temperature with a meat probe thus while food scientists and producers may bemoan lost understandings of the storage and spoilage characteristics of food and knowledge about how to cook safely and thoroughly knowledge understood as previously having been passed down from generation to generation there is little acknowledgement that the everyday act of preparing a meal is now fraught with an awareness of microbiological concerns which our grandmothers may not have faced cooking has certainly been simplified and deskilled in significant respects through the availability of convenience foods and innovations which speed up the process simultaneously it has also become more complex in terms of the volume of information available about how to cook safely healthily tastily on a budget for a family for guests for oneself and in terms of the range of knowledge and skills necessary to negotiate contemporary technologies of food provisioning from useby dates to microwave defrost programmes an implicit assumption embedded within discourses of decline in relation to cooking knowledge and skill is that at some point in the past our mothers and grandmothers did know how to cook and that they had acquired their knowledge via embodied experience and a form of cooking apprenticeship through observation and an engagement in the kitchens of their own childhoods these scripts of the past clearly reflect a valorisation of traditional cooking practices associated with a golden era of cooking during which the family meal was the cornerstone of family life but when was this era and for whom was it a reality shapiro reporting on the us at the turn of the twentieth century documents the emergence of the domestic science movement which saw traditional approaches to cooking displaced by science and technology the latter having gained the aura of divinity indeed exponents of this approach specifically eschewed tradition including the intrafamilial intergenerational transfer of cooking knowledge s they saw it domestic science would recast womens lives in terms of the future and haul the sentimental ignorant ways of mothers kitchen into the scientific age it would seem thatin the us at least early twentieth century modernity brought to cooking practices a rejection of those tacit understandings of food and taste invoked in the discourses previously described of the current era in favour of something more precise more reliant on instruction and guidance and less judgement from the individual or based on experience shapiro suggests that by the 1950s domestic science had not only brought with it culinary regimentation but also intellectual and imaginative collapse the model housewife now being little more than a clinical and efficient assembler of processed foods selected on the basis of optimal nutrition digestion and hygiene also implicit within discussions regarding the intergenerational transfer of cooking skills is the assumption that knowledge is passed between women grandmother mother daughter reminding us that responsibility for family feeding continues to lie firmly with women indeed with the exception of adler who discusses cooking practices passed from father to son and swinbank in her analyses of the influence of mothers domestic cooking on the culinary practices of haute cuisine chefs grandfathers fathers and sons remain largely invisible in the literature these arguments highlight the need to problematise claims regarding a historically recent death of traditional cooking skills such narratives rest upon a simplistic framing of the complex processes knowledges and skills involved in accomplishing the provision of a meal in any historical situation and contestable assumptions about the dynamics of generational transfer of those attributes clearly there are grounds for empirical interrogation methods this article draws upon early findings from a current qualitative research project 1 which focuses on patterns of continuity and change in families domestic kitchen practices over the last 100 years exploring domestic food provisioning practices in context as people interact with food and other objects both at the points of purchase storage preparation consumption and disposal the project draws on current theories of practice to explore the ways in which differingand often competingdiscourses and sources of knowledge regarding cooking and food safety practice have been negotiated into everyday routines it investigates also the role of a variety of innovations ranging from useby´ dates and antibacterial sprays to fridges freezers and cookers in transforming everyday kitchen practices which according to some viewpoints have deskilled consumers the study aims to make visible both memories of cooking as well as the meanings behind individuals actual practices as they interact with food and other objects both in the shop and in their own kitchens from pursuit of this aim findings emerge which are pertinent to questions arising from the problemetisation of discourses of decline in skills in addition to a series of seven completed focus groups with people segmented by age and different household types a household study is also being carried out this combines foodfocused life history interviews with ethnographic work in the form of provisioning goalongs and videoed kitchen tours and meal preparation2 although recruitment is ongoing twenty participants from seven families have been interviewed to date the objective of exploring patterns of continuity and change in families´ kitchen practices is being achieved by speaking with representatives of at least two generations from each family one of which must be aged 55 fieldwork is based predominantly in south yorkshire and derbyshire families recruited to date largely reflect a highly motivated middleclass constituency although social mobility within these families particularly among the older generations is significant recruitment has been facilitated largely via snowballing through interpersonal networks but also through focus groups with existing community groups and leafleting in community centres more marginalised population groups have proved harder to reach and recruitment is now focussed on addressing this gap in the data while the research is ongoing at the time of writing the data collected to date provide robust empirical grounds for the job of critical engagement undertaken in this article informed consent was secured during every stage of the research process and where photographic images have been used this is with participants consent interviews were digitally recorded and transcribed verbatim each participant being assigned a pseudonym each author reviewed a selection of transcripts to ensure consistency in the interpretation of the data and a coding framework was subsequently developed which reflected an interactive engagement between the research questions and the data in what follows we first draw briefly upon data from the focus groups to begin to elucidate the dimensions of debate around ideas of intergenerational transfer and difference this sets the scene for the main body of discussion which draws largely on the data collected during the interviews in which participants were asked to speak not only about their own practices but also those of their partners and members of other generations including those who are now deceased we focus on two extended families the andersons and the faulkners both families were recruited from the first authors extended friendship networks the andersons were approached because in both the older and younger generations it is the men who are the everyday cooks by contrast hannah faulkner is an acquaintance who had expressed interest in the research and had agreed to both approach other members of her family as well as friends and colleagues in her place of work we focus on these particular families here because they specifically contest claims regarding the saintliness of women of earlier generations just like mother a range of insights are emerging from the data collected thus far regarding the dynamics of intergenerational transmission of cooking values and practices while focus group participants in particular have deployed generalising discourses of generational loss of skills foodbased lifehistory interviews combined with observations invariably reveal a more complex and nuanced picture at the individual level although small scale intensive qualitative work can neither prove nor disprove long term population level trends in cooking skills it is this sort of research that is needed to begin to disentangle the diverse influences and relationships which converge in cooking practices as a basis for critically exploring the validity of claims about declining cooking skills within those discourses purporting the decline of cooking there is imagined some past halcyon period characterised by innate cooking skill against which narratives of erosion are framed the same general discourse has also found expression in our research so far particularly in focus group discussions where participants are typically more likely to speak in general terms and about other people for example exploring issues of responsibility in relation to food safety 85year old bert who took part in a focus group with people aged 6389 argued that …all these ladies were taught food hygiene as girls this high today young children do not go in the kitchen they dont work with their mums their mums dont know hygiene the same so consequently that is where it starts with the housewife berts comment indicates the currency of ideas that people of an earlier generation possessed superior knowledge and skills that have somehow been lost to subsequent generations and that they were paragons of virtue in the domain of food hygiene however his views were challenged by his own wife who pointed out i dont think you can generalise like that bert because you know youre making us out to be saints with food hygiene and younger people not and i dont think thats true i think theyre equally as aware of food hygiene reinforcing nellies point focus group participants in their thirties highlight perceived limitations within their mothers practices these include chopping everything on the counter without a board overboil ing everything microwave cooking and a fascination with prepackaged foodperceived as a demonstration of progressing and moving with the times the focus groups were a space in which the complexities that lie behind generalising assumptions of superior competence and of generational transfer were initially problematised however while the use of focus groups did a good job of opening up the complexities inherent to these processes they could not lend themselves to the indepth exploration of practices which can be bound up with intensely personal stories the household study provided an opportunity to achieve a more nuanced understanding of how these issues may or may not be played out at the level of individual families while there are certainly examples within our data which reinforce generational stereotypes there were others which confound suggestions that younger people are feckless and wasteful while their predecessors were paragons of virtue in the kitchen here we focus on two families which highlight why linear historical narratives about the decline of cooking are simplistic and fail to account for the complexity of individual circumstances which are often time and context specific within these two families we present a range of similarities and contrasts there are women of a now dead generation who are perceived by their children as falling short of the domestic ideal in some respects but not in others among their children there is the retention of some of their values and concerns while others are consciously eschewed and knowing how to cook canat different moments in time also facilitate a choice not to cook we have an example of a mother equipping her teenage daughter for independence but also a father learning with and from his grownup son and in both families there are women and men whose interest in cooking has been inspired by the experiences of travel or exposure to other cultures andmore closely to homeby now ubiquitous cookery programmes and an abundance of cookbooks finally there is the acknowledgement that how parents want to cook and feed their children is not always consistent with what children are prepared to eat therefore requiring a lower level of skill than they would ideally like to deploy case studies the anderson family the anderson family consists of retired professionals laura and ted who have been married for 43 years both laura and ted agreed to take part in the study they have two children one of which also volunteered to take part along with his partner the younger couple have a threeyear old son and polly fell pregnant with their second child during their participation in the study in their interviews participants are being asked to reflect upon their earliest memories of food provisioning cooking and the distribution of roles and responsibilities in the kitchen both laura and ted discussed their mothers who had primary responsibility for feeding the family it is their reflections upon their mothers practices and the extent to which these have been embraced or rejected via their own practices that we focus on here ted is the eldest of five children born into a mining family his mother was married at 18 and had sole responsibility for raising her young family since her husband teds father wasnt around really confounding ideas that women of a particular generation were saints in the kitchen ted does not shy away from highlighting what he believes to be his mothers limitations he says i think i think we er later most of my brothers and i thought that we were lucky to get by with the way my mother cooked it was very sloppy although he suggests that exposure to this kind of slightly sloppy environmental control is probably a good thing arguing that the contemporary preoccupation with reproducing hermetically sealed environments reduces our immunity to everyday microbial threats ted also acknowledges that his mothers practices left much to be desired for example he reports how hygiene and ideas about crosscontamination were apparently beyond the scope of his mothers practice well she wasnt wasnt clean in the kitchen she used to used to wipe the surface of the of the the worktop with this cloth she used to be wiping the floor with… er or youd have bleach in your food or something or erm youd i think there was no real hygiene he also explains how she would drop food on the floor and then stick it straight back in the pan sometimes giving the potatoes a slightly bleachy flavoured quality while ted is not averse to putting fallen food back in his own pan he will give it a scrub first for him it is important to retain a sense of pragmatism and practicality about perceived environmental threats and he argues that we cant be expected to live up to the standards of the modern world in teds opinion his mothers principal limitation appears to be that she simply didnt know how to cook and lacked the knowledge and skill he now values in knowing how to combine ingredients to produce something really tasty here ted reflects on what he views as the limits of his mothers practice am was your mum a good cook ta no am laughs tell me about your mums cooking then ta well she didnt know how to cook and she had my grandmother was a very good cook am so how come your mum didnt learn from her ta i dont know shes much more casual i think i think she could but she wasnt a very conscientious or careful cook and she wasnt very adventurous am conscientious and careful about what ta erm about erm the kind of way she cooked things like for example she always overcooked vegetables as everyone did in those days really but always did erm she didnt have any er any real feeling for many foods i think she never never had good vegetables and indeed noone did in those days they were no worse than the ones from school school meals she wasnt a great cook but she she was quite enthusiastic in this excerpt teds narrative contests dominant discourses of how knowledge about how to cook passes through intergenerational transmission the skills his grandmother possessed are notin his view passed down to her daughter while his skills now appear to owe little to his mother importantly for ted his mothers perceived lacked of skill is offset by her enthusiasm now we move on to laura and her family of birth an only child born to less affluent middleclass parents in the south of england she describes living with her maternal grandfather until his death when she was nine although ted and laura are similar ages lauras mother did not marry until she was 29 meaning that she was an older housewife than was teds mother apparently in common with other women of this older generation the repertoire of food and meals that we had at home was very narrow and laura recalls how it wasnt until she was on a foreign exchange holiday in her late teens that she discovered that fried eggs could be anything other than dead brown and crispy while teds mother is described as being a poor but enthusiastic housekeeper this is contrasted by lauras mum who might also be seen as falling short of the ideal of the 1950s housewife but in very different ways she says although laura presents an image of her mum as being a somewhat begrudging housewife who would have preferred to have spent her time gardening or painting she is nonetheless scrupulous in the execution of her domestic responsibilities and laura recalls the rituals and routines which surrounded for example the sterilisation of milk jugs with boiling water mum didnt and unlike teds mother lauras mum is reported as being extremely particular about the use of cloths for different surfaces thereby minimising the potential for crosscontamination theres this thing which my auntie did as well like having these cloths these erm like plastic coated wires strung along the bottom of the cupboards up in the kitchen and then there would always be these cloths hanging up in the kitchen that they would use for wiping surfaces and it was always really important that you know you use a separate cloth for a specific thing you had to keep i cant remember the order of it but you know certainly food erm floor cloths and food surfaces were kind of separate additionally and in spite of her recollection that there was not a massive thing about food hygiene there was always a bottle of dettol in the cupboard patterns of continuity and change one of the principal concerns of the study is to explore patterns of continuity and change within families and here the andersons provide some useful insights although somewhat critical of his mothers casual approach to cooking and food hygiene ted does inherit some of his mothers pragmatism regarding microbial threats perhaps the most important continuity between ted and his mother is their approach to feeding of this he warmly says yeah well its nice to feed people i think its erm its i mean my mother would say she was a bit more casual about it bit bit more erm global in her intentions and less maybe less effective than she might be in her execution but she her intention was to give people a good feed and thats i think thats a great goal in life really and its erm theres nothing better you can do for people than give them a nice meal a decent meal every day its a great pleasure yes yes for laura one of the similarities between she and her mum is the fairly basic cooking which characterised the years in which her children were young this is commented on by lauras son jonathan who says that her meat and two veg approach to meals perhaps reflected the fact that she was probably at the outer reaches of her capabilities laura herself would not deny this deferring to her husband when it comes to the preparation of the evening meal which for her has to be a cooked dinner that said the household is not characterised by a complete reversal of the traditional gendered division of labour indeed maintaining her own mums concern with hygiene she says that her role within the kitchen reflects her concern that it is kept tidy but the preoccupation with cleaning does not end at mere tidiness making a distinction between anxiety and disgust which she recognises as being conceptually different laura explains her discomfort both with knowing that their cat might have been up on the dining where both mothers and laura are reported by their children as lacking skill and imagination in the kitchen ted and his son jonathan rupture ideas that cooking knowledge is something which is passed on either via processes of intergenerational transmission or through the female line unlike women of various ages who attest to learning how to cook by osmosis this did not occur for these men jonathan and ted developed an interest in cooking together while laura was working away and the family had taken in chinese lodgers intrigued by the simple way of cooking used by their houseguests ted and his teenage son attempted to replicate this approach while fending for themselves at different stages both went on to supplement their knowledge by reading mediterranean cookbooks in teds case while jonathan picked up ideas from european friends while working at eurocamp initially and later by watching ready steady cook years of reading observing others and experimentation has resulted in a knowledge and feel for food and an understanding of how ingredients work together enabling both men to enthusiastically produce a wider range of mealsthat will both satisfy and inspire than they believe their mothers had in the past figure 1 illustrates ted consulting one of his mediterranean cookbooks while figure 2 shows jonathan deploying his skills and expertise in the kitchen teds delight in being able to combine a selection of fresh and processed ingredients with the right seasoning and other bits from the cupboard is clear in the comment below for him the issue is not one of whether one can cook but an ability to understand the principles of taste there is something very er rewarding about starting up with some rather ancient vegetables stuck at the bottom of the fridge just a few old bits and pieces from the bottom of the fridge and thats thats an amazing thing to do and er people say theyve nothing to eat and oh this is stupid and a few wellchosen tins if necessary but you can just er you can always produce something very very nice if you know the principles of taste i think how to produce something from er ingredients how the ingredients go together our work with the anderson men in particular clearly contests the currency of narratives of erosion and ted and jonathan highlight that cooking and provisioning are more than merely constituent elements in the job of feeding the family indeed they demonstrate a shift toward cooking being an expressive lifestyle practice albeit one that men who live with women can engage with their own terms 3 while ted andersons mother worked hard to make the little money she had to feed a large family go far delighting in giving them a good feed kate faulkner paints quite a different picture of her childhood although she admits that her mothers nursing background meant that everything was scrubbed and cleaned she was quite into hygiene disinfecting things this was according to kate the limit of her saintliness in the kitchen indeed confounding stereotypes which purport family feeding to be an important marker of mothers caring roles from the outset kate reports that her mother didnt want to cook she hated cooking she hated anything to do with food she didnt really like food or eating insert images here where laura andersons mother is depicted as undertaking her domestic activities begrudgingly kate does not hold back in suggesting that her mother was neglectful and she complains that hunger was something which characterised her and her brothers childhoods perhaps to compensate for the dearth of nutritious food provided by his wife kate says that her father would set them up for the day with a cooked breakfast this proved important because school meals were also appalling and there would be little to look forward to when they came home for tea i used to have a cooked breakfast and then i went to a convent school in but the food was appalling like gristle stew you know a tiny portion so i was so thin and undernourished i think and erm and then id come home and thered be no food no mealthere wasnt an evening meal that just didnt happen so for an evening meal wed have perhaps an egg or something so i mean i was always ill while kate describes sugar butties and the absence of meals with any nutritional value she also reports that when old enough she had to step into the void wrought by her mothers disdain for cooking she recalls spending hours peeling potatoes and sunday mornings as the time to make all the food for the week including baking since there wasnt a lot of money while admitting that she felt resentful of her supporting role in the kitchen at the time she acknowledges that i ended up a really good cook cause of that kate could not really remember how it was that she learnt to become a good cook but she is clear that her skills were not acquired from her mother whom she suggests was not only a dreadful cook but lazy also anything for convenience my mother was a great one for anything for convenience laughs and tins and packets there was all the tins and packets she didnt believe in cooking things from scratch moreover kate also suggests that she was an arrogant cook who refused to engage with cookbooks or learn how to make certain dishes curry being an example figure 3 she also learnt from someone outside of the family sharing the family home and cooking space for kate this was the amma4 who lived with them while the family was based in the far east by the time her own children came along she was well prepared to implement the sort of parenting in their childhoods which she had longed for in her own however when her own young daughters turned out to be fussy eaters refusing to eat her lovingly prepared nutritious homecooked meals kate was distraught feeling that she was failing as a mother here we see that rather than deskilling hannah or being reflective of laziness on her part innovations such as the ricemaker and automatic oven along with the availability of frozen foods offer timepressed mothers important resources in the business of feeding young children who require constant care and observation i eight months after the interview the first author spent an afternoon with hannah during which she observed her making lunch writing her shopping list accompanied her shopping with beatrice now 22 months and collecting daisy from school before returning home to prepare the evening meal hannah felt that it was important to draw attention to the fact that her circumstances have changed since she was interviewed and the impact that this has had on her cooking routines and practices not only is daisy now at school but beatrice is no longer just tottering around meaning shes much easier now hannahs compromises around food and its preparation do not indicate that she has become deskilled in cooking is eschewing the values instilled in her by her own mother or that she is becoming like her grandmother extended engagement with the household highlights the complexity of the challenges faced by peoplewomen in particularbalancing work and family life in her view hannah has become neither deskilled nor lost interest her priorities have simply shifted to accommodate the needs of her young children indeed her continuing interest in and commitment to cooking in the way she had before having children along with her desire to nurture this interest in her daughters is reflected in figure 4 where we see hannah supervising her daughters creating their own pizza toppings to put onto prebought and rolled pizza dough an activity which hannah reportsis something the children really enjoy to the extent that the lack of particular food skills is a problem whether for public health particular ideals of family togetherness personal wellbeing or the support of some desired form of food supply and retailthe dynamics and causes of such deficiency cannot be tied down to any specific processes or easily aligned with any linear historical narrative of decline the findings presented above begin to expose the diversity of sources through which culinary competence is constituted they indicate too the specificity of appropriate levels of skills and competence in the changing landscape of household food provision as the systems of food provision and the spatial and technological configuration of kitchens and of eating responsibility and competence are inevitably redistributed insert image that the issues raised by the anderson and faulkner families are not simply isolated examples of older women who challenge the stereotypes of good oldfashioned cooks is reflected here by chef and food writer nigel slater whose understanding of the principles of taste like ted and kates apparently emerges in spite of not because of his mothers limited culinary competence mum was never much of a cook meals arrived on the table as much by happy accident as by domestic science she was a chopsandpeas sort of cook occasionally going so far as to make a rice pudding exasperated by the highs and lows of a temperamental creamandblack aga and a finicky little son she found it all a bit of an ordeal and wished she could have left the cooking like the washing ironing and dusting to mrs p her woman that does preliminary analyses of data from this ongoing study indicate that it is both simplistic and inappropriate to make assumptions about the knowledge and domestic practices of people of a particular generation assuming one to be paragons of virtue while another is demonised for its ignorance or laziness indeed what we have learned from the data thus far points toward the profound complexity of the ways in which individuals practices are socially and culturally embedded and emergent from a range of factors which include exposure to external influences time and space and a range of lifecourse transitions which might temporarily or permanently rupture existing patterns and behaviours amidst the many ways in which our participants have developed their own levels of competence as domestic cooks learning from parents is not necessarily a substantial identifiable source of cooking skills while understanding and abilities learnt as children at home undoubtedly can provide a firm foundation for future competence as an adult it seems to be neither necessary nor sufficient for people to competently accomplish the provision of food for themselves and others in a foodscape which has continuously changed in fundamental ways over recent generations cooking skills are learnt appropriated and reassessed from multiple sources and according to shifting life circumstances from major events of partnering separating or parenthood through a new tv cooking programme capturing someone somehow ready to engage anew with the challenges and pleasures of cooking it is the aim of this study to facilitate an understanding of peoples practices which accounts for the subtleties of their interactions with objects knowledge discourses and others as they move between different environments

amidst growing concern about both nutrition and food safety anxiety about a loss of everyday cooking skills is a common part of public discourse within both the media and academia it is widely perceived that there has been an erosion of the skills held by previous generations with the development of convenience foods and kitchen technologies cited as culpable in deskilling current and future generations these discourses are paralleled in policy concerns where the incidence of indigenous foodborne disease in the uk has led to the emergence of an understanding of consumer behaviour within the food industry and among food scientists based on assumptions about consumer ignorance and poor food hygiene knowledge and cooking skills these assumptions are accompanied by perceptions of a loss of commonsense´ understandings about the spoilage and storage characteristics of food supposedly characteristic of earlier generations the complexity of cooking skills immediately invites closer attention to discourses of their assumed decline this paper draws upon early findings from a current qualitative research project which focuses on patterns of continuity and change in families domestic kitchen practices across three generations drawing mainly upon two family case studies the data presented problematise assumptions that earlier generations were paragons of virtue in the context of both food hygiene and cooking in taking a broader lifecourse perspective we highlight the absence of linearity in participants engagement with cooking as they move between different transitional points throughout the lifecourse

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the ecuadorian study used the ncfas to assess 470 vulnerable preschoolers environments • high internal consistency and reliability were confirmed in this context • the adapted version with fewer items was validated through factor analysis • the results are pivotal for designing interventions in areas lacking reliable tools social programs are essential tools for governments that aim to mitigate the effects of socioeconomic disadvantage vulnerability morbidity and mortality researching and evaluating these programs enhances their effectiveness further benefiting public management vulnerability is often characterized by limited economic income unstable employment lower education levels challenges in accessing basic services inadequate housing and difficulty in navigating adverse situations these conditions frequently result in environments marked by violence and family conflict that often have the greatest impact on women and children this is a pervasive issue in latin america in ecuador for instance there are alarming statistics regarding child violence for instance 47 of afrodescendant parents use physical discipline on their children although this trend appears to be declining among the mestizowhite and indigenous populations it remains a concern to promote childrens wellbeing and prevent abuse early intervention and support for vulnerable families that emphasize positive parenting are crucial such programs must be evidencebased and their designs and evaluations must be firmly grounded in previous research a significant challenge in nonenglishspeaking countries arises when psychological tools developed in different cultural contexts are employed without proper adaptation or without understanding of their psychometric properties this situation complicates the assessment of programs that target childhood and family functioning several instruments assess family functioning some instruments primarily highlight problems or dysfunctional family attributes while others focus on family strengths balancing the consideration of challenges with resources and resilience johnson et al conducted an exhaustive review of 85 family assessment instruments related to childrens wellbeing they identified seven scales that were particularly promising the north carolina family assessment scale the north carolina family assessment scale for reunification strengths and stressors tracking device family assessment form family assessment checklist ackermanschoendorf scales for parent evaluation of custody and darlington family assessment system among these the ncfas emerged as the most validated scale for assessing childrens wellbeing and demonstrated excellent suitability for evaluations in such contexts the ncfas emerges as a pivotal scale for assessing family functioning that emphasizes the identification of family strengths and extensive utilization within vulnerable populations it facilitates indepth analyses of improvements in family intervention processes sustained monitoring of user progress and comprehensive assessment of program efficacy in 1991 following the approval of the intensive family preservation services program by north carolina legislation the ncfas was developed as part of a state contract the original authors were assigned to develop an evaluative tool aimed at identifying alterations in family functioning induced by the program the scale was intended to be ecologically oriented and to align with the primary objective of the ifps program of preventing unnecessary removal of children from their homes and inducing transformation while maintaining family unity over the years several versions of the ncfas have been introduced the ncfasr for reunification the ncfasg for general services and the ncfas g r which blends elements from the ncfasg and the ncfasr each version of the scale is distinctly formulated with respect to its intended objective these versions of the ncfas serve as potent tools for a holistic assessment of family wellbeing initially conceived with child welfare issues in mind the applicability of these scales have been broadened to families that do not necessarily interface with child protection agencies several studies including those by reed reedashcraft et al kirk et al kirk and martens kirk et al valencia and gómez and kirk and martens have affirmed the psychometric integrity of the ncfas across its various iterations supported by evidence of its internal consistency and validity the original ncfas and its subsequent versions have been a staple in myriad studies as delineated in table 1 examples of these studies include works by fernandez farrell et al gómez et al hurley et al conner andfraser andolsen et al lee and lindsey investigated the measurement properties of the ncfas within the realm of youth mental health services they found that the ncfas did not operate identically between child mental health contexts and child welfare frameworks this pivotal revelation underscores the necessity of tailoring the ncfas when deploying it for specific cohorts such as vulnerable preschoolaged children to ensure its potency and pertinence an agreement between the national family preservation network and the child protector of chile facilitated the translation of the ncfas into spanish the spanish rendition was developed using expert evaluations from both the nfpn and the faculty of education and family sciences of the finis terrae university of chile the translated version encompasses five components scale and definitions frequently asked questions goal establishment case studies and a powerpoint presentation for training purposes the spanish iteration of the ncfas exhibited sound psychometric properties when applied to the chilean populace the chilean exploration centered on children and adolescents who averaged 94 years of age and were enrolled in programs that catered to families with highrisk indicators for child maltreatment the ncfas has been extensively used in contexts characterized by elevated risks with the aim of preventing family disintegration in ecuador the most culturally proximate environment where the scale received validation was chile researchers investigated the psychometric properties of the scale congruent with the original objectives of its creation with a focus on highrisk children we propose that in ecuador the ncfas might be suitable for preschoolers who are vulnerable due to their social circumstances even if they are not explicitly recognized as highrisk or incorporated into the protection system the ecuadorian cohort differs from the chilean cohort both demographically and in its unique characteristics hence we address two pivotal questions what is the factorial structure of the ncfas for ecuadorian families with vulnerable preschoolers and how internally consistent is the ncfas for this sample methods recruitment and eligibility we recruited participants for this study through 14 child development center coordinators who held degrees in various fields of psychology including clinical educational and child psychology at the onset of the study these professionals were already acquainted with the children and had been familiar with their family environments for a minimum of seven months the inclusion criteria required the children to belong to vulnerable populations with families that were unable to provide adequate care due to circumstances such as poverty extreme poverty unemployment suboptimal income levels insufficient parental capabilities reduced cultural acuity andor a lack of educational attainment we determined eligibility by analyzing the vulnerability forms completed by each family sample characteristics a total of 470 children met the inclusion criteria table 2 presents the descriptive characteristics of the participants due to the constraints of the covid19 pandemic we were able to obtain socioeconomic information for only 413 of the 470 children from the collected data 29 of the children reported experiencing insufficient food availability in recent weeks and 82 of the parents were employed although 50 were employed in temporary capacities of the childrens mothers 62 were employed with only 22 studies using the ncfas in permanent positions a substantial 99 of children resided with their biological mothers however 33 did not live with both biological parents it was reported that 15 resided in households where domestic violence was prevalent procedure we obtained authorization to use the scale by contacting the nfpn which supplied us with the original spanishtranslated scale package subsequently the ministry of economic and social inclusion granted approval for the implementation of the ncfas at the 14 cdcs in machala ecuador to ensure adherence to the ncfas we conducted training using the package supplied by the nfpn involving professionals across all 14 cdcs although these professionals developed their assessment skills independently our team collaborated on completing each ncfas form to enhance the rigor of the process we recruited an external evaluator skilled in conducting psychological interviews to enable collaboration with the principal researcher in overseeing monitoring and controlling the completion of the ncfas forms we created a google forms document to optimize data collection by facilitating online registration and transitioning from paper and pencil to a digital instrument after obtaining informed consent from the childrens representative and the coordinator we began the information collection process with scheduled visits to each cdc each analysis took approximately 30 min per child during this time professionals answered the questions of the scale relying on their knowledge acquired through daily interactions and care processes and referring to individual file information this file contained a record of individuals receiving care at the center a vulnerability sheet a general data sheet a child care sheet a child nutritional status monitoring sheet and a comprehensive child development indicators sheet from july 2019 to february 2020 we meticulously executed data collection the data were coded to maintain confidentiality and preserve the anonymity of the digital records of cases measurement we used the original version of the ncfas which was translated into spanish by the nfpn it features 5 global and 31 specific items as presented in table 3 this scale is designed to assess difficulties and strengths with scoring occurring at the commencement and conclusion of the program initial ratings assist in developing intervention plans and setting objectives while final ratings assess changes after program application the evaluation employs a scaling system ranging from 3 to 2 with each value corresponding to a distinct level of family functioning a score of 3 indicates a severe problem showing deteriorating family dynamics a score of 2 represents a clear strength or an optimum level of familial functioning a score of 0 serves as the baseline representing an adequate level of functioning and suggesting no immediate need for intervention from protective services although it does not signify the absence of familial challenges a guideline is provided to aid professionals in the scoring process for intermediate values such as 1 minor strength and 1 and 2 representing minor problem and moderate problem there are no fixed criteria therefore professionals use their judgment and expertize to assign these scores kirk and reedashcraft found that certain items are not applicable in specific family structures for instance when children are not of school age or lack siblings evaluation is not feasible and the item is marked na data analysis we analyzed descriptive statistics and internal consistency using the python program we ascertained validity through data processing with jamovi version 22 computer software the data management necessitated the conversion of rating values from 2 to 3 into positive values ranging from 1 to 6 we conducted an initial descriptive analysis to ascertain the distribution of the items in this analysis we focused on global items which are equivalent to specific items and used methodologies similar to those in preceding studies of the same scale the principal descriptive statistics encompassed the mean mode standard deviation skewness and kurtosis we processed the data associated with the child wellbeing factor using a method that handles listwise deletion incorporating the items school performance and relationship with sibling this approach was essential because 233 out of the 470 children were only children and some were not of age for academic performance measurement to validate the ecuadorian iteration of the ncfas we employed both confirmatory factor analysis and exploratory factor analysis for these analyses global weighting items were omitted because their outcomes are contingent on the ratings of other items we first executed cfa on the complete sample to confirm the coherence in the item distribution based on the original ncfas following this crossvalidation was instituted by partitioning the study group into two distinct nonoverlapping subsamples the first subsample underwent a sequence of efas with oblique rotation a method that is suitable for correlated and uncorrelated factors and yields accessible interpretation finally we applied cfa on the alternate subsample to confirm coherence in item distribution in alignment with the efa outcomes and compared it with the reference values of the efa adjustment indices comparative fit index tuckerlewis index standardized root mean square residual and root mean square error of approximation indices indicative of optimal fit included cfi values of 095 or higher rmsea values of 005 or lower tli values greater than 090 and srmr values below 008 we measured the internal consistency of the ncfas indicators across all factors using cronbachs alpha with the analysis focusing solely on the specific items of each factor alpha values between 070 and 090 are reflective of satisfactory internal consistency results descriptive analysis table 4 presents the results obtained from applying the original ncfas to the ecuadorian population the mean scores ranging from 303 to 341 indicate that on average the responses aligned within the baseline or appropriate parameter the standard deviation ranging between 078 and 112 suggests the presence of family functioning problems however on average it is not a highrisk population that necessitates inclusion in the protection system factor analysis we assessed the suitability of the original ncfas structure for the ecuadorian sample by conducting cfa using the entire sample the results indicated that the original ncfas structure did not provide a good fit to the data given the inadequate fit the ecuadorian sample might have a distinct factorial structure as a result we proceeded with efas followed by a subsequent cfa we conducted a series of efas on the initial subsample to understand the internal structure of the ncfas among ecuadorian participants the primary analysis was undertaken explicitly to determine the number of factors initially a fivefactor solution was explored adhering to the structural foundation of the original scale based on the results items with insufficient loadings were excluded from the subsequent analysis similarly given that factor 5 consisted only of a single item an exploration with four factors was subsequently conducted in this refined analysis we discerned that the fourth factor comprised two items mavrou suggests that for stable and replicable solutions a factor should encompass a minimum of three items with loadings therefore an analysis focusing on three factors was subsequently performed based on the findings of the third analysis and in alignment with mavrous guidelines items with loadings 065 were retained with the exception of the item labeled child mental health which had a loading 065 in factor 3 this decision was made to maintain a threefactor structure and uphold theoretical consistency after conducting the fourth efa and applying the same analytical criteria the item transportation was excluded due to a loading 060 the final efa established a definitive model consisting of 16 items segmented across three factors factor 1 incorporated eight items factor 2 integrated five items and factor 3 was composed of three items this conclusive model is delineated in table 5 cfa analyses were conducted utilizing the second subsample initially the 16item solution produced by the efa was validated through cfa resulting in the subsequent model fit χ2 245 df 101 p 0001 rmsea 007 srmr 0052 cfi 092 tli 091 there was substantial evidence of correlated residuals among items financial management and income employment habitability of housing and housing stability financial management and housing stability and absencepresence of neglect of children and personal hygiene this refined specification culminated in a noteworthy enhancement in model fit χ2 146 df 97 p 0001 rmsea 00463 srmr 0046 cfi 0974 tli 0968 the findings were deemed satisfactory hence the ecuadorian adaptation for preschoolers conformed to a 16item model factor 1 termed parental capabilities comprised eight items factor 2 termed environment consisted of five items and factor 3 labeled child wellbeing encompassed three items we maintained three designations out of the five original factors from the ncfas the final path diagram is illustrated in fig 1 cfa was conducted utilizing the comprehensive sample to compare the outcomes the data fit was notably analogous as evidenced by χ2 228 df 97 p 0001 rmsea 0053 srmr 0043 cfi 0968 tli 0960 the quality of the finalized model was analyzed by inspecting the factor loading values as shown in table 6 in 14 out of the 16 items the factor loading values were higher than 06 and met an acceptable criterion in several instances the factor loadings were above 07 and 08 indicating exemplary outcomes in conclusion the 16item threefactor model demonstrated reasonable precision substantiated by its model fit parameters and factor loading values cronbachs alpha to evaluate the reliability and internal consistency of the ncfas scores we used the full sample we found the values for cronbachs α coefficient across all items to exceed the recommended minimum threshold of 08 indicating acceptable reliability the overall cronbachs alpha coefficient for the scale was a substantial 0926 reflecting high internal consistency similarly the separate dimensions of parental capabilities and environment showed high reliability with values of 0918 and 0919 respectively additionally the child wellbeing dimension demonstrated notable internal consistency with a coefficient of 0923 underscoring its valuable utility in assessing childrens health and wellbeing discussion our research confirms the validity of the ncfas among a subset of vulnerable preschool children in ecuador while sufficient evidence exists regarding the internal consistency and validity of the ncfas in united states populations and reliability studies are available for the versions translated into spanish for chilean populations this represents the first study to examine the psychometric properties of the instrument with vulnerable ecuadorian preschoolers the results of the exploratory and confirmatory analyses indicate that the version of the ncfas adapted for ecuador yields reliable and valid scores albeit with a condensed item set for instance the component relationship with sibling within factor e titled child wellbeing did not load any factor from the initial exploratory analysis this was primarily due to the majority of preschoolers being the only child of younger parents and consequently lacking siblings likewise school performance is not a pertinent item for preschoolers and therefore does not load in the analysis within factor d family safety five out of its six elements were excluded a phenomenon that can be attributed to the fact that the surveyed population predominantly consisted of vulnerable preschoolers and not children who were part of the family protection system as a result responses to these elements were challenging to discern by professionals operating outside of the protection system domain however the element absencepresence of neglect of children was retained for this demographic because it was more readily identifiable by professionals who observed the care behaviors of families who enrolled their children in these programs for the ecuadorian population the item absencepresence of neglect of children properly loaded and was retained in the first factor in the adapted ecuadorian version of the scale the principal factor consolidated items with substantial factor loadings originating from the four domains of the original instrument including two items from the environment three from parental capabilities two from family interactions and one from family safety for theoretical congruence this principal factor is called as parental capabilities the secondary factor termed environment integrates five out of the nine items from the original environment domain the significant scores of this factor validate its relevance and stability for the ecuadorian preschool demographic this component succinctly represents three pivotal facets for the studied population economic conditions housing quality and safety the items labeled learning environment and personal hygiene are highlighted as integral elements of parenting skills and are therefore included in the parental capabilities factor in the context of the ecuadorian demographic the item transportation is excluded due to its divergent implication in ecuador where community services are readily accessible and the population density is comparatively lower the majority of the population commutes conveniently within their communities due to the compactness of distances the third factor termed child wellbeing in the adapted version for ecuador prominently retained three integral items child mental health child behavior and relationship with peers these align with the child wellbeing factor from the original scale specifically in the concluding efa the item child mental health had a loading of 065 nevertheless the decision to retain it was made due to its theoretical significance and to maintain a composition of three items within this factor the items school performance and cooperationmotivation to stay in the family which originated from the original ncfas did not exhibit substantial loadings in the adapted version for ecuador this may be attributed to the distinct characteristics of the studied population given the age of the children they are not currently integrated into the academic system moreover the nature of the programs in which the children are enrolled is caregiving rather than protective rendering the measurement of motivation to remain within the family incongruent in preschools this is especially applicable to those who have not experienced familial separation are not classified as highrisk and are not part of the protection system we derived results from implementing the originally translated version of the ncfas when applied to the chilean population it exhibited a distinct integration of specific items despite possessing the same fivefactor structure as the original version in both the original version developed by kirk and kirk and reedashcraft and the chilean spanish adaptation by valencia and gómez and gómez the scale encompasses five factors however in the adapted version for ecuador the model comprises three factors environment parental capabilities and child wellbeing the factors related to family interactions and family safety were not substantiated in this study several of the elements were omitted due to low factor loadings with the remaining elements distributed between parental capabilities the ecuadorian adaptation of the parental capabilities factor retains five of the six items found in the chilean version notably the ecuadorian version preserves the item parentcaregiver mental health from the original version which was omitted in the chilean adaptation and integrates two additional items related to parental capabilities personal hygiene and learning environment regarding the environment factor eight of the nine items were incorporated in the chilean version in contrast with five in the ecuadorian adaptation in terms of the child wellbeing factor the items child mental health and cooperation motivation to stay in the family were excluded in the chilean version due to factor loadings less than 02 across all factors however in the ecuadorian adaptation child mental health was retained despite possessing the lowest factorial load within the final structure of the ecuadorian model while the item cooperationmotivation to stay in the family was omitted the family interactions factor which was absent in the chilean study was referred to as caregiver wellbeing in factor 5 and included items about parental capabilities and the environment this factor was also omitted in the ecuadorian version with the items bonding with the child and expectations of child reallocated according to their factor loads and theoretical congruence to the parental capabilities factor rendering the scale threefactored for the ecuadorian population the present study seeks to assess the psychometric properties of the ncfas scale within a sample of preschoolers experiencing vulnerability in ecuador our collected data reveal strong internal consistency throughout the scale as evidenced by a cronbachs alpha of 0926 for the overall instrument additionally certain subscales such as parental capabilities and child wellbeing exhibit remarkable internal consistency within the ecuadorian sample these results serve as a foundation for future research endeavors that aim to replicate these initial findings and to assess their broader applicability we believe this study serves as a stepping stone to gain insight into the reliability and validity of the ncfas in the unique context of ecuador the findings illuminate the need for further nuanced explorations and validations in varied settings to truly grasp the multifaceted implications and applications of the ncfas practical implications the proven psychometric reliability and validity of the ncfas make it an integral part of various research and intervention programs by evaluating its psychometric properties and outlining a factorial structure suitable for preschoolers within vulnerable families in ecuador we enable the use of the ncfas in childcentered programs in ecuador this allows for the quantification of the outcomes and transformations that families experience during interventions likewise we can use the scale as a pivotal tool in creating innovative programs aimed at preempting child maltreatment within familial contexts historically there has been a lack of measures dedicated to exploring family dynamics among ecuadorian preschoolers and evaluating the effectiveness of intervention schemes the ncfas fills this gap as a validated reliable concise and userfriendly tool that is essential for both researchers and practitioners in evaluating familial functions limitations we recognize the limitations of the current study our ability to generalize the findings is potentially constrained by the specific sample especially in the context of the extensive research on ncfas additionally the unique characteristics of our sample which was derived from the cdc of a single city in ecuador indicate that our results may not apply to vulnerable preschoolers in other cities or reflect the broader ecuadorian populace despite these limitations our study provides evidence of internal consistency and reliability within a threefactor model and offers empirical support for the use of the ncfas in evaluating vulnerable preschoolers this aids in identifying immediate family functioning issues that require intervention and promotes improvements in family functionality seeing this scale as the first instrument to assess family functioning with validated psychometric properties in ecuador accelerates the evaluation of programmatic outcomes in terms of economic efficacy and societal benefit furthermore it can form a basis for future studies exploring the psychometric properties of the ncfas in other representative samples covering various areas and demographic sectors in ecuador and including highrisk or nonvulnerable populations data availability all data generated or analyzed during this study are included in this manuscript the data have been deposited in bd integrada database dsheetsd1dcrj4u75yuvotscqjwqcrykhrttwqxzn2xdg2pbeqedituspsharing requests for material should be made to the corresponding authors the data held by the ministry of economic and social inclusion supports our claims for data access provide rationale at lyncfasec2023 code availability stored on google docs access requires ministry authorization and privacy adherence author contributions krm collected information and articulated the research narrative ms cowrote revised and refined content irm managed statistics ensuring accurate analysis all authors endorsed the manuscript and vouch for its accuracy funding open access funding provided thanks to the cruecsic agreement with springer nature compliance with ethical standards conflict of interest the authors declare no competing interests ethics approval all protocols with human participants were executed in compliance with the ethics and biosafety committee of the university of girona this committee endorsed the project development of positive parenting via a virtual reality and video intervention programproject code cebru003321 which includes research on psychometric properties of ncfas in vulnerable ecuadorian populations informed consent we uphold ethical standards ensuring rights protection for all participants each provided informed consent with any identifiable information either anonymized or included for academic purposes with clear consent we have permissions to publish anonymized data and adhere to the guidelines of the university of girona and the journal of child and family studies publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations 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 license and indicate if changes were made the images or other third party material in this article are included in the articles creative commons license unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons license 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 license visit orglicensesby40

positive parenting and appropriate interaction with children are globally recognized as pivotal in enhancing childrens quality of life evaluating family intervention programs is therefore vital particularly in regions that lack reliable tools for assessment this manuscript details a study conducted in ecuador a country noted for its scarcity of validated instruments to assess the impact of such interventions especially for vulnerable preschool children we focused on the application of the north carolina family assessment scale ncfas a wellestablished measure to evaluate family functioning internationally to ecuadorian families with preschool children who are deemed vulnerable the spanish translation of the original scale was administered by trained evaluators to 470 preschool children in machala ecuador our examination of the psychometric properties of the ncfas in this context demonstrated high internal consistency additionally factor analysis corroborated the reliability and validity of this adapted version of the ncfas albeit with a reduced item count this research supports the effectiveness of the ncfas in the ecuadorian setting and underscores its potential utility in further studies involving varied demographic groups within the country the results of this study have substantial implications for the enhancement of childrens quality of life in ecuador through family intervention programs

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introduction both the healthcare delivery system and public health are struggling to address the enormous impacts of chronic conditions while prevention strategies continue to evolve and have impact the fact remains that many people are still developing longterm illnesses that have significant costs for individuals families healthcare systems and society patients taking an active role in managing their healthor patient selfmanagement is increasingly recognized as a crucial strategy for addressing the challenge of chronic disease that may improve selfefficacy sm behaviors and health status as well as potentially reduce healthcare costs building effective policies programs and structures to support sm is recognized as critical to chronic disease management a number of different selfmanagement support approaches are evolving in governments health regions professional organizations and nonprofit associations the identification of sms as a key component in models for chronic disease care has undoubtedly played an important role in increasing awareness of sms in many countries for example there has been major interest in sm education programs such as the chronic disease selfmanagement program in 2005 the uk established the expert patients programme to nationally implement layled chronic condition sms and in 2007 the expert patients programme community interest company was established to increase the number of sm programs offered throughout the uk in canada sm programs such as the cdsmp are being offered in almost every province and other sm programs such as bounce back reclaim your life are becoming common the us administration on aging in collaboration with the centers for disease control and prevention and the centers for medicare and medicaid service has provided 324 million to support the broad dissemination of the cdsmp program across the usa through the aging services network other approaches to sms have also gained considerable support such as the flinders program developed in australia and cocreating health program that aims to embed sms within mainstream health services in the uk in canada there are an increasing number of sms training programs being developed for healthcare providers such as the health coaching for sm program and the practice support program learning modules some provinces have made sms a strategic focus and are starting to consider a coordinated approach to sms initiatives across multiple levels including primary community and home care and social services in 2007 the australian government announced 515 million over 5 years for sm initiatives and training in the usa the department of health and human services developed a strategic framework for multiple chronic conditions that promote sm as one of four overarching goals and the national council on aging spearheaded the sm alliance a partnership among government corporate and nonprofit sector organizations to achieve the smrelated goals of the multiple chronic conditions framework in this context of flourishing activity researchers are investigating a wide range of sms initiatives authors of cochrane systematic and rapid reviews have concluded that cdsmps and other sm interventions have small effects on some health outcomes outside of reviews on individuallevel interventions the evidence base is in its infancy for other forms of sms however a recent review has summarized the growing evidence base for sms in primary healthcare and studies have begun to evaluate implementation of sms in systems with few exceptions most sms work has focused on a single dimension of sms such as selfmanagement education or provider training but does not encompass sms broadly or address the multiple levels of the socioecological model while wagners chronic care model has increased attention to sms that model focuses primarily on sms provided in healthcare settings and does not provide specification for the development of appropriate sms sms initiatives are often centered in the healthcare domains without sufficient consideration of social environments and communities further sms developments in healthcare settings are often framed as a strategy to reduce healthcare costs by emphasizing individual responsibility for health which has been problematized by kendall and rogers among others an additional challenge of many sms approaches to date is that they do not fully address the diverse needs of the chronic condition population particularly more disadvantaged groups lowuptake lowattendance and highattrition rates are commonly identified challenges and health literacy is increasingly recognized as hugely problematic for implementing ccsm interventions in disadvantaged populations also most sm initiatives and the broader sm movement have failed to consider important ethical dimensions inherent in the promotion and development of these strategies for chronic care management the purpose of this paper is to describe a strategic framework for chronic condition sms that emerged from an international consensus process strategic frameworks are considered tools to guide future development and provide a structure within which more detailed activities on planning and implementation can occur they outline highlevel principles and priorities rather than being prescriptive about which activities to implement as any initiatives need to be developed in relation to the environment within which they will be implemented the specific aim of our strategic framework is to provide direction for policymakers planners and practitioners in developing and implementing comprehensive and coordinated approaches to sms at national regional or local levels it sets out definitions of sm and sms a collective vision eight guiding principles and seven strategic directions sample actions to enact strategic directions are also provided for illustrative purposes the ccsms framework has value for any policymaker healthcare professional local decision maker service provider chronic conditionrelated organization consumer advocate researcher andor any organization that pays for healthcare who wants to advance sms using a comprehensive strategic structure framework development and validation process the framework development process began with an intensive 3day roundtable discussion among 23 subjectmatter experts from 5 englishspeaking countries to share knowledge discuss gaps in sms and propose future directions participants were selected by an international steering committee to provide sm expertise from a diverse range of disciplines and sectors a thematic analysis of meeting transcripts was used to create an initial draft framework it was then reviewed and refined through a twostaged modified delphi esurvey process with roundtable participants to build consensus on the frameworks definitions guiding principles vision and strategic directions to validate the roundtable participant framework we engaged in a broader international stakeholder consultation via an esurvey process that resulted in feedback on the framework from 203 individuals in 16 countries reviewers were initially obtained using a purposive sampling approach whereby we solicited names from roundtable participants targeted email list serves conferences and online searches we extended email invitations to these people to review the framework and encouraged them to forward the survey to organizations andor individuals that should be involved in the review process the respondents largely worked in universities or colleges healthcare organizations notfor profit community organizations andor government organizations they included researchers educators healthcare providers policymakers program managers consultants patient group representatives program planners and consumers results from the international stakeholder econsultation demonstrated very high levels of agreement for all content of the sms framework the framework development and validation process as well as details on participant characteristics are described in more detail elsewhere ethics approval was obtained from the university of british columbia behavioural research ethics board we recognize that the general applicability of our framework may be limited by the nature of the participants who engaged in the process this initiative was based on the understanding that expert opinion and experience across sectors and countries is a valuable source of knowledge to support an evolving evidencebase for a field of policy and practice our consensusbuilding process harnessed knowledge of subject matter experts to create a roadmap for future sms initiatives the framework was originally developed by englishspeaking participants from developed countries for implementation in countries with similar characteristics however the validation process found strong agreement with the content from a much larger range of developed countries that were not all primarily english speaking these findings suggest that the framework may have relevance in developed nonenglishspeaking countries beyond the original five countries represented at the roundtableeven though it is reasonable to assume that understandings of sms may be different in other countries and cultures although we only had one participant from a developing country there is no reason to believe that this framework might not be useful in lowincome countries but it may be more difficult to operationalize with more resource limitations or where other social and environmental barriers may exist the international chronic condition selfmanagement support framework the purpose of the international framework for chronic condition selfmanagement support is to help stakeholders in a variety of sectors influence policy practice and research developments related to sms for chronic conditions it aims to promote the development and evaluation of effective interventions and support mechanisms that consider and value the diverse ways people adapt to and live with chronic conditions and encourage integration of these sms initiatives into health social and community settings we hope the framework will ultimately help to strengthen our capacity for supporting people with chronic conditions reduce health inequities and improve health in chroniccondition populations collective vision this framework reflects a commitment to fostering a culture that creates structures enacts policies and offers services to reduce the impact of chronic conditions and support peoples sm behaviors sms services should provide individuals and their families with a menu of effective options and opportunities to engage in sm that appropriately fit their needs and optimizes their health and wellbeing such services should also enhance health and reduce health inequities in chroniccondition populations conceptualizations of sm and sms sm incorporates all of the tasks that individuals engage in to manage their symptoms treatments and the physical emotional and social impacts of living with chronic conditions in daily life health social and physical environments influence individuals and their families capacities to selfmanage many aspects of life such as income education ethnicity and genderas well as related constraints of services structures and environmentsplay an important role in sm attitudes and behaviors these factors are sometimes referred to as social determinants of health individuals and their families selfmanage chronic conditions in the context of their daily lives which often include interactions with a wide range of support services sms is a grouping of structures systems policies services and programs that extend across healthcare social sectors and communities to support and improve the way people manage their own chronic conditions and optimize their health and live well sms can increase peoples capacity to live well with chronic conditions by addressing some of the broad social and individual factors that influence their behavior and is a shared responsibility between individuals and society sms adapts and responds to the social contexts of individuals and their families and local and community needs and builds on and integrates peoples experiences of living with and managing chronic conditions sms includes infrastructures and policies that minimize conditions and barriers that limit peoples capacity to selfmanage chronic conditions services and programs that support individuals and their families to engage in sm and feel happy and fulfilled to make the most of their lives despite the condition and skills resources and social networks people have in their daily lives sms resources provide people living with chronic conditions with access to timely information informed guidance supportive interventions and confidencebuilding tools that can facilitate participation and partnership in health and social care decisionmaking and social engagement in order to achieve the best possible medical social and psychological results sms programs can involve individuals families and social networks take place in a wide range of environments such as homes workplaces hospitals and community settings be delivered by a wide range of services and organizations including primary care home care and social services and disability and nongovernment agencies and be provided through oneonone or group interactions or via electronic means guiding principles eight guiding principles reflect shared values and priorities for advancing the field of sms they are overarching statements that can help to guide decisionmaking processes and promote a valuebased approach to policy and program development strategic directions seven key strategies have been identified to promote sms in research policy and practice stakeholders can use these strategic directions to move sms forward at local community regional provincialstate andor national levels sample actions provide ideas on how to address strategic directions but specific initiatives must be developed in response to the needs resources and systems in specific contexts it is recognized that some strategic directions maybe more relevant to particular organization or groups either based on their area of focus or where an organization is at with sms developments as with all strategic frameworks users prioritize what is most relevant to their purposes and this will likely shift over time a schematic representation of the key elements of the framework is found in figure 1 the principles are foundational values though which we should view all sms efforts the strategic directions are where movement and development need to occur in sms field the local context specific actions are where operationalization of initiatives needs to happen specific actions and activities should be developed by people with knowledge of local needs and context and be relevant to an organizations mission and goals discussion the framework combines important and relevant sm issues into a comprehensive strategic document that provides value to the sms field to two important ways at a practical level it provides principles and strategies that can help decisionmakers plan sms initiatives the operationalization of the framework will be facilitated by organizations and people with a strong commitment to sms principles prior experience with sms initiatives a system of care that integrates health and social services a patientoriented system with welldeveloped mechanisms of engagement strong quality improvement culture and available resources for innovation and development to name a few barriers can potentially include fragmented systems lack of integration of primary and community services weak leadership and commitment as well as insufficient resources for program development and evaluation a more detailed understanding of how to operationalize the framework will evolve as we collect information from policy and practice environments using it these data will enable researchers to identify important contextual factors that influence the uptake of the principles and strategies and shape the nature of the local actions on sms it also provides value by catalyzing and expanding our thinking about the sms field in four key directions system thinking shared responsibility health equity and ethical dimensions these four themes emerged in our roundtable discussions in response to identified gaps and were solidified through delphi and the evalidation process collectively they create a broad conceptualization that underpins the framework content and represent a simple yet important paradigm shift from historical approaches and thinking on sms the framework emphasizes the importance of situating sm within a broader systems perspective where the focus is on supports for chronic condition sm across the continuum of services that people use in daily life when living with longterm illness system thinking helps to illuminate the bigger picture of care but also the wider context and interactions among different services and activities in many places sms is being driven within the healthcare sector as an essential piece of chronic disease management as outlined in the chronic care model and the expanded care model but it is increasingly recognized that personal communities voluntary and community groups and social services play an equally important role in sms developments the framework definition of sms includes social sectors communities and families in supporting and improving the way people manage their chronic conditions which differs from other healthcare centric definitions that dominant the sms field the framework also emphasizes that sm of chronic conditions is a shared responsibility between individuals and society sm behaviors are influenced guiding principles 1 informed by evidence and evolve in response to the needs of the chronic condition population 2 centred on the person or family and reflect the differing goals needs and preferences of individuals and their differing social contexts 3 focused on improving an individuals capacity to be healthy and live well according to their values 4 created to be equally available appropriate and accessible to all persons with chronic conditions 5 developed to promote benefits and minimize potential harms 6 implemented in ways that respect an individuals choice autonomy and rights to determine their own goals and participation in sms 7 embedded in the management and treatment of chronic conditions 8 integrated across the continuum of health and community services from prevention to palliative care table 2 seven strategic directions and sample actions strategy 1 support people with chronic conditions and their families to be meaningfully engaged in decisionmaking planning and evaluation of sms initiatives sample actions provide information on available sms supports and resources to people with chronic conditions and work collaboratively with them to determine the services that best meet their needs access individuals capacities to become engaged in sms activities and find ways to support those who struggle to benefit from sms create ways to motivate and support people with chronic conditions to use the services and stay engaged in sms initiatives use available technology to support peoples ability to selfmanage and engage with sms services strategy 2 expand reach and range of and access to sms interventions programs and services in healthcare systems and communities sample actions create sms programs and services that can meet a wide range of differing goals needs and preferences of individuals and their families given their differing social contexts and illness trajectories develop specific programs to target vulnerable and disadvantaged populations and engage hardtoreach individuals living with chronic conditions identify and reduce barriers to effective sm when developing interventions and programs promote system reform and service redesign that supports a range of sms programs educate and sensitize healthcare providers program leaders and others in the sms field to the needs of those who are in situations much different from their own strategy 4 improve quality of sms services programs and interventions sample actions address barriers that prevent access to evaluation and monitoring data for quality improvement in sms monitor and evaluate sms programs and interventions to better understand the effects of sms for various groups and communities develop systems for continuous quality improvement in all sms initiatives that incorporate evaluation results and new evidence into practice and programs integrate evidenceinformed practitioner tools that can support sms across the continuum of care support consumers and providers to use information technology for sms activities include sms in health information systems strategy 5 forge and strengthen linkages within and between sectors policies programs and service providers sample actions develop policies and programs in partnership with a range of stakeholders including ngos consumers and their families local regional and national governments healthcare practitioners and consumer advocates continued by broader social determinants of health as well as individual level factors the framework acknowledges that many factors including income education ethnicity and gender in addition to related constraints of services structures and environment play an important role in sm attitudes and behaviors further the framework brings issues of health equity to the forefront of sms considerations it states the importance of ensuring that sms interventions programs and services are accessible to all who can benefit but also acknowledges that specific programs should be developed to target more vulnerable disadvantaged and hard to reach populations perhaps most importantly the framework also draws attention to important ethical dimensions of sms most notably the need for decision makers to consider that sms approaches might not work for everyone or be desirable to all people living with chronic conditions and that they could potentially cause harm for certain individuals or groups who may not have the capacity or resources to selfmanage reviewers of the framework have demonstrated high interest in using the framework to direct work in many areas including sms practice and patient care and policy development and implementation and future research the framework is designed to guide the sms development process so regardless of whether it is a small town hospital in the usa a provincial government in canada or the national health service in the uk the framework identifies facets to be considered in developing sms for particular groups and a structure for developing a comprehensive approach the national centre for chronic disease prevention and health promotion has used the ccsms frameworks sms definition to ground its public health approach to sms and its seven strategic directions as a structure for organizing their activities the framework has also been used as a lens to organize evidence on chronic disease approaches within older ethnic minority populations in canada although the framework has not been formally released we have anecdotal reports that suggest its potential value at educational policy and practice levels a number of international reviewers suggested that the reduce the health and social inequities for individuals with chronic conditions build links to communitybased sms resources into clinical information systems explore webinars or other online meeting venues to foster collaboration among stakeholders in sms include sms in undergraduate education with opportunities for interprofessional learning and collaboration on sms initiatives strategy 6 foster leadership commitment and accountability for sms at all levels of healthcare and social and community services sample actions create a business case for policymakers at all levels to invest in sms initiatives supporting structures and information develop sms as a strategic priority within all levels of policy and planning for chronic disease management educate leaders in government communities ngos workplaces public health and healthcare settings about their role in sms create sms champions across sectors and in diverse stakeholder groups engage in activities to increase public awareness of the importance and benefits of sm and sms initiatives strategy 7 build infrastructure to support sms initiatives and provide resources and funding to support these initiatives sample actions provide training and education to staff to foster appropriate sms in all settings allocate or reallocate resources to adequately develop and implement sms initiatives and sustain research innovation redesign funding models to provide incentives for and reduce barriers to sms and support the integration of sms into healthcare systems and social and communitybased services create systems that support reinforce and sustain provision of highquality sms services and programs including organizational policies job descriptions and training opportunities create a business case on how sms initiatives can assist in creating sustainable health and socialcare systems and quality of chronic care framework could be used for training purposesboth in formal education curricula but also in building knowledge and capacity of healthcare professionals decision makers have described how the framework is providing a vehicle for sharing and disseminating emerging understandings to policymakers practitioners consumers and organizations to help clarify the boundaries of the sms field and integrate sms into healthcare social and community services we have also been told that the framework has been used as a guiding document for the development of provincial and international sms initiatives looking ahead the framework promotes the development and evaluation of effective interventions and supports mechanisms across multiple levels of the healthsocial system that value the diverse ways people adapt to and live with chronic conditions it encourages the integration of sms initiatives into health social and community settings feedback collected on the framework during the consensus building process suggest that future iterations of the framework could offer a more indepth consideration of patient centeredness mental health social justice culture and ethnicity and gender and diversity there is a need for structures and resources to support the implementation of the frameworks strategic directions as well as for research to evaluate the utility of this type of framework in advancing a developing field of knowledge and practice building an extensive reference list of research evidence that supports the strategic directions creating a list of potential implementation approaches and disseminating case studies of effective sms approaches may be helpful identifying mechanisms for collaborative research could also be beneficial for the sms community to further knowledge development given the disproportionate burden of chronic diseases in lowincome countries it is imperative that we consider how the framework might be used in regions beyond our consultative scope one possible process would be to convene stakeholders in the country of interest and ask them to assess how relevant the guiding principles and strategic directions are in their cultural political and economic context and healthcare system and to make recommendations on how to adapt the framework to best suit their needs in summary the ccsms framework reflects an urgent need to build consensus on how to best move forward in sms given the increasing activity at policy and practice levels and absence of solid evidence in all developing areas it provides guidance for how we approach sms nationally and internationally and should continually evolve as more evidence is available and approaches and understandings in sms develop it is our sincere hope that the framework will stimulate essential discussions and debates that can advance sms research policy and practice in the years to come

selfmanagement support sms initiatives have been hampered by insufficient attention to underserved and disadvantaged populations a lack of integration between health personal and social domains over emphasis on individual responsibility and insufficient attention to ethical issues this paper describes a sms framework that provides guidance in developing comprehensive and coordinated approaches to sms that may address these gaps and provides direction for decision makers in developing and implementing sms initiatives in key areas at local levels the framework was developed by researchers policymakers practitioners and consumers from 5 englishspeaking countries and reviewed by 203 individuals in 16 countries using an esurvey process while developments in sms will inevitably reflect local and regional contexts and needs the strategic framework provides an emerging consensus on how we need to move sms conceptualization planning and development forward the framework provides definitions of selfmanagement sm and sms a collective vision eight guiding principles and seven strategic directions the framework combines important and relevant sm issues into a strategic document that provides potential value to the sms field by helping decisionmakers plan sms initiatives that reflect local and regional needs and by catalyzing and expanding our thinking about the sms field in relation to system thinking shared responsibility health equity and ethical issues the framework was developed with the understanding that our knowledge and experience of sms is continually evolving and that it should be modified and adapted as more evidence is available and approaches in sms advance

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introduction the virtual learning network began in the mid1990s in several geographic regions as a way to provide a wider curriculum choice for students in primarily rural jurisdictions the first of these geographic networks or elearning clusters was casatecha regional network in rural canterbury this was followed by the introduction of the otagonet elearning cluster in 2002 and the farnet elearning cluster around the same time these early networks all of which were funded under different types of regional and national schemes and programmes formed the basis of what would eventually become the vlna loose network of cooperating clusters throughout new zealand the online courses are offered in a reciprocal model in which the 12 current clusters work together to share their human resourcesnamely teachers who deliver online who are known as eteachers each cluster contributes to the vln a programme of learning delivered by an eteacher this sharing allows the member schools to participate in courses that they are unable to deliver there is no formal training in the developing pedagogy for the eteachers nationally although individual clusters offer a range of training opportunities the formal training received by most eteachers has been on using videoconferencing technology as a result there is now a wide range of models of delivery of online classes this case study examined the preparation and practice of eteachers as well as effective strategies for engaging students particularly māori students this general purpose led to three research questions 1 what delivery models are being used to provide classes on the vln 2 what are the perceptions of eteachers about the professional development they have received 3 what web 20 tools are eteachers using in their online classes to engage student learning given the focus of the study upon the farnet elearning cluster a casestudy methodology was deemed appropriate to address these research questions in this article we describe the background of virtual teaching in new zealand followed by a discussion of our casestudy methodology next we discuss the four main themes from the findings of our study finally we discuss two implications for practitioners and make two suggestions for future research literature review the current generation of students is often referred to as the net generation and digital natives and there is an assumption that they are technologically savvy however online learning is still relatively new and most students regardless of age do not possess the cultural norms for engaging in online learning online or virtual teaching requires even the most experienced classroom teacher to make a thoughtful transition to the new environment learners must be well prepared for entering this environment and the teacher may have to provide serious support for students as they learn how to learn online hobgood identified successful virtual learners as those students who have been fully prepared and this requires more planning on the part of the teacher than is normally seen in the traditional classroom jeffares traced the development of virtual learning in the schools sector in new zealand as growing from a long history of more traditional forms of distance learning further she indicated that virtual learning as it has been operationalised in new zealand for much of the recent decades has focused on the medium of video conferencing jeffares also believed that video conferencing and virtual learning in new zealand schools had the potential to offer more than simply widening students curriculum choices as was often the rationale or logic behind distance education finally she stressed the importance of schools transforming to assimilate or reconcile the traditional teaching model with a teaching model that was more aligned with 21st century learning skills to better meet the changing needs of students at present a range of teaching models including a blend of virtual teaching and opportunities for facetoface interactions is being used through the vln as part of the students programme the facetoface opportunities often occur on an initial eday and in further site visits to their schools during the year several vln elearning clusters have organised one or more edays each term at which all of the students from an individual cluster come to a single school to meet their eteacher these edays also provide students with an opportunity to meet and get to know their fellow studentsthese meetings can help to build relationships and a sense of community in their virtual classes research has demonstrated that distance and virtual learning puts more responsibility on students to direct their own learning in general and video conferencing was found to be no exception students have to be motivated and comfortable with learning independently if they are to be successful in the virtual learning environment because students need more independent learning skills the onus is also on the virtual teacher to ensure that they take advantage of all of the tools and pedagogical strategies provided in the virtual setting to create a welcoming environment that encourages students to take that responsibility however recent research into the effectiveness of engaging students through the vln found that many virtual teachers using video conferencing employed more traditional teaching techniques in their virtual classes the authors suggested that perhaps these virtual teachers were not fully exploiting all the opportunities and potential new learning methods that the virtual medium had to offer this suggestion was consistent with other research that has found that considerable time and money needs to be invested in providing quality professional development and ongoing support networks for teachers and students who are working in these virtual environments while todays students may use technology extensively few students know how to use that technology to learn in distance or virtual settings yet for many students using technology is the only way to access certain curricular opportunities unfortunately many of the teachers engaged in delivering these virtual learning opportunities have similar deficits when it comes to using technology as a teaching tool clearly there is a need for additional research to better understand the perceptions and needs of virtual teachers in this emerging learning environment methodology the case study was conducted with the farnet vln elearning cluster during the 2009 school year when more than 80 of the enrolled students identified as māori at the time of the study farnet had nine schools but they did not all have students enrolled in online classes via video conferencing through the vln a total of 63 students were enrolled in online classes via video conferencing through the vln and the majority of those were from northland college these students were enrolled in 12 different programmes of learning taught by 12 different teachers these teachers were referred to as eteachers all of the schools agreed to participate in the study and so 12 eteachers were asked to complete an online survey participate in a semistructured interview and provide access to their online classroom of the 12 eteachers only six completed the online survey four were selected to be interviewed and seven provided access to their online classes the online survey elicited eteachers opinions on effective professional development online class size building relationships in the online environment communication methods web 20 tools student collaboration eteacher support and reflective practice the semistructured interviews involved four eteachers the purpose of the interview as a secondary data collection method was to gather a more indepth understanding of how the virtual classes were run and how web 20 tools were used to engage estudents especially those estudents who identified as being of māori descent the interview protocol also included questions that asked the eteachers to provide greater detail about some of the findings from the online survey and some of the findings from a similar study conducted with other estudents reflective questioning was used to promote collaborative dialogue from the eteachers the first level of questioning was to clarify the details about the interviewees online experience the second level of questioning was used to clarify the purposes or reasons and the intended consequences of a certain action which the interviewee had referred to and the third level of questioning was used to encourage the interviewee to reflect on the consequences of the action that they had taken the interviews were conducted in person via skype and using the videoconferencing system each interview was recorded with audio or video and then transcribed participants were given copies of the transcriptions so they had an opportunity to member check the documents before the data was analysed finally the online course content was analysed with an observation tool that was developed from the doityourself course design evaluation sheet this evaluation form was used to measure the effectiveness of an online course multiple methods of collecting data were used to address each of the research questions according to lawrencelightfoot and davis methodological triangulation assists in the analysis phase particularly by making it easier to discover and verify themes from the different sources of data the data was analysed using the method outlined by miles and huberman results and discussion the six eteachers who completed the online survey represented five schools and one tertiary organisation one eteacher identified themselves as being of māori descent three eteachers recognised themselves as new zealand european and two eteachers indicated other four of the participants were male and two were female three of the eteachers had taught for 2 to 3 years one eteacher had taught for 4 to 5 years and two eteachers had taught for more than 5 years most of the eteachers taught classes that had 10 to 12 students and they all indicated that they were aware of the nationalities of their estudents five of the six eteachers had a learning management system to support their teaching and visited it at least once a day the general trends from the data which included the online surveys interviews and the review of the asynchronous course content was organised into four areas overall perceptions communications relationships and professional development overall perceptions eteachers identified a range of features they liked about teaching in a virtual classroom table 1 sample of eteacher responses interaction with students and giving them responsibility meeting other students and working with them to reach their potential focus is on learning and not classroom management the use of technology the enthusiastic nature of the students making learning activities up as we go the unpredictability the freedom to design new curricula playing with the toys moodle rocks the flexibility of only being in front of a class one hour out of my week but the flexibility of working online at times that suit me the same eteachers also identified a range of features they did not like about teaching in a virtual environment table 2 sample of eteacher responses sometimes communication is a bit weak especially between the home school and not being there to help the students in person when they struggle extra workload students not keeping up with work and not attending classes negative influence of other teachers lack of support for the estudents at their own schools the expectation that video conferencing replaces facetoface when it is in fact a completely different mode of delivery when technology fails going back to chalk and talk although the eteachers both in the online survey and in the interviews provided a list of things that they did not like about being a virtual teacher they all acknowledged that the learning experience was new to them and that as it became more embedded in their schools the pressure from their colleagues about the job of an virtual teacher being seen as an easy ride would disappear they also felt that many of the other negative sentiments would also decline over time as virtual learning became more common and their own experience with the virtual environment increased communications the most common way to communicate with estudents was by email which all of the eteachers reported using regularly four of the six eteachers also indicated that they regularly used video conferencing to communicate with students while three indicated that they also communicated with their estudents by fax text message and phone additionally one eteacher successfully experimented with skype through which he provided a very personalised learning programme for his estudent most of these skype sessions occurred outside normal school hours at a time agreed by both parties this method of communication relied upon the estudent having adequate internet access which was not always the case in the geographic areas represented by the farnet elearning cluster the lms was also used extensively for example three of the eteachers reported that they used the discussion forums as a means of communicating regularly with their estudents five of the six eteachers indicated that they regularly posted work in the lms and that this was how teachers preferred their estudents to submit their work it is interesting that almost all of the eteachers reported using the lms in some fashion but only half of them indicated that they used the discussion forum feature as jusri described in their own study of virtual learning teachers identified discussion forums as being effective for developing online community and collaboration as well as for selfand peerappraisal even more interesting was the fact that half of the eteachers encouraged their students to collaborate and communicate with each other as the internet have evolved web 20 tools have become a common medium for collaboration by both students and teachers the web 20 tools identified by eteachers in this study as being used in their classes are identified in table 3 one of the challenges acknowledged by all of the eteachers was that they were on a steep learning curve and that they often used tools based on suggestions by their estudents interestingly google docs was not used at the time by any of the eteachers in this study although four of the eteachers noted during the interviews that they had recently identified google docs as having the potential to collaborate with their virtual classes finally there was a great deal of variation in the amount of formal reporting by the eteachers only three of the six eteachers indicated that they sent out reports at the end of the first term four prepared reports during the second term and five did so during the third term it is worth noting that all four eteachers who were interviewed indicated that they believed that reports for the estudents should be prepared each term including term four the metasynthesis work conducted by hattie supports the notion of increasing communication to students in a variety of formats for example three of the top ten effect sizes found by hattie focused on communication between student and teacher on the other hand only three of the six eteachers used some form of course evaluation with their estudents at the end of each course to gain their opinions on the design and delivery of their virtual course however all of the eteachers believed that using this form of course evaluation would be a good way to gain valuable feedback on the estudent experience and to assist in their own reflective practice relationships developing relationships in the virtual class was seen as being important to the estudents overall learning experience these relationships were broken down into two types studentstudent relationships and teacherstudent relationships five of the eteachers judged relationships amongst estudents as being important but all six eteachers judged the relationship between estudents and the eteacher as being important the work of bishop berryman tiakiwai and richardson argued the importance of developing strong relationships with students to engage them in learning these authors were especially aware of the considerations needed for some māori students when their absence from their weekly videoconferencing classes was due to a cultural activity the interviews pointed to eteachers understanding of the importance of knowing which of their estudents were māori and who could therefore have cultural activities to attend however the interview data also suggested that the initial data provided to the eteacher by the participating school at the beginning of the year often did not provide this valuable information one eteacher suggested that there was a danger in having this information because it might lead them to make assumptions about the estudenta phenomenon bishop et al described as deficit theorizing while the data indicated the importance some eteachers placed on developing opportunities for estudents to develop relationships with each other most of them had not provided systematic opportunities for this activity during the previous school year in addition to relationships between the eteacher and estudents and amongst estudents four of the eteachers believed that the relationships between eteachers and their local school coordinators were important further three eteachers reported that they felt the relationship between eteacher and eprincipal was also important eteachers expressed a desire to be more aware of who held the position of the local school coordinator so they could ensure that the estudent was well supported in most situations the eteacher indicated they had either visited the estudents in person in their own school or met them at an eday at the beginning of the year interestingly the eteacher based with the tertiary provider felt it was very important that he visited estudents regularly during the year to reinforce their learning and he also regarded the visits as opportunities to further develop the relationship with his estudents finally he noted that based on his own anecdotal evidence these relationships resulted in many of those estudents who took a virtual course at their local school through video conferencing going on to study full time at his tertiary institution professional development all six of the eteachers reported that they had been involved in a wide range of professional learning and development opportunities to support their role both in the surveys and during the interviews eteachers indicated that they had attended conferences participated in training organised by their elearning clusters or by asnet been involved in research and peer support as an efellow or involved in the ministry of education eleadership clustership project and finally received regular training via video conferencing overall the eteachers felt that the professional learning and development identified was effective and they especially mentioned training that focused on the pedagogy the eteachers also indicated that they believe that receiving their training through video conferencing was very effective as it reduced the time involved in travel to the training the data also suggested that eteachers felt it was of paramount importance for all eteachers to start the year with a 2day ehui which many clusters ran either at the end of the previous year or at the beginning of the year the ehui was viewed as the most effective professional development at least in terms of networking with other practitioners and community building eteachers had a sense of coming to share their experiencesboth good and badand they could also challenge those teachers who had been doing the same thing year after year without embracing the teaching opportunities provided by web 20 and other online tools finally the data indicated the need for further professional learning and development opportunities but that all of the eteachers felt they were well past the stage of simply learning how to use the equipment and technology all eteachers reported that they had received a range of opportunities for this kind of professional learning and developmentsome paid for by the cluster or individual school and some paid through information communication technology professional development funding all of the eteachers had also experienced some form of online professional development and they each felt this was often the most effective form of professional development because it was specific to their needs required no travel and saved on human resource time overall the data suggested that eteachers believed they required ongoing professional development opportunities both in facetoface and online formats to develop their pedagogy of virtual teaching observing good practice amongst practitioners and being part of online communities of practice have been identified as effective ways to develop a virtual teachers understanding and to support their own practice rodriguez ooms and montanez found that teachers needed support to promote improved learning experiences and to develop relationships time was identified as the greatest barrier to achieving these goals it should also be noted that there is a growing literature base arguing that professional development for teachers in the virtual learning environment is more important than for those in the facetoface environment roblyer and mckenzie who were among the first of these scholars argued that while many of the factors that make a successful virtual teacher were similar for any successful teacher teaching in a virtual environment requires several skills that are unique to that environmentand in many instances these unique skills are tied to the everchanging nature of the tools used by virtual teachers for example easton indicated that virtual teachers needed more advanced skills in managing instructional activities and assessments and stronger engagement skills because interactions with students are separated by both time and space recognising that virtual teaching requires additional professional development the government of nova scotia and the nova scotia teachers union even included a requirement for higher levels of professional development for virtual teachers than facetoface teachers as a part of their collective agreement in that canadian province the data in this study underscores many of these themes found in north america conclusions and implications the eteachers enjoyed their virtual teaching experiences although they also indicated that they still faced challenges teaching in this new and innovative mode as a part of their virtual teaching eteachers used a variety of methods to communicate with their estudents the primary method that was used was email and almost all of the eteachers indicated they felt they still underused many methods of communication communication was regarded as being particularly important to the eteachers because they felt it was critical for them to establish strong relationships with their estudents further eteachers believed relationships with their māori students were especially important because many of the tools available were underused eteachers were quite interested in professional development opportunities to these eteachers effective professional development began with initial facetoface sessions at the beginning of the school year followed by distance opportunities finally eteachers found professional development that focused on pedagogy rather than the tools to be most effective there are two main implications for practice first it would benefit any elearning clusters to ensure that a range of professional development opportunities are available to their eteachers this professional development should be provided not just at the beginning or end of the school year but consistently throughout the school year further elearning clusters and individual schools participating in the vln should seek funding to provide the opportunity for eteachers to attend conferences such as ulearn and to further their professional training this funding should be provided on condition that those eteachers provide a workshop and support for other eteachers and schoolbased teachers when they return teachers also identified the need to share their experiences with others which could be provided by developing and joining online communities of practice finally there are also two main suggestions for future research first due to one of the researchers knowledge of the models available selection of the eteachers for the interviews and the online courses observed was based on knowledge that they were offering an effective virtual classroom researchers conducting future studies would need to include both those eteachers and courses that were perceived to be effective and those that are perceived as not being as enjoyable or effective to provide a balance and more accurate picture of existing virtual teaching models second although one of the researchers was the eprincipal for this particular cluster a great deal of information was learned from this study it is recommended that the administration of any of the elearning clusters should undertake systematic examination of the perceptions of the estudents eteachers and edeans to gain their opinions on what is working and where there are still challenges within the system each of these groups provides different and varying perspectives that could provide valuable guidance for the future development of the elearning cluster

the virtual learning network vln provides schools particularly those in rural and remote areas with the opportunity to cooperate to expand curricular offerings for their students each school that participates in a vln cluster contributes at least one course delivered by an eteacher allowing member schools access to any course offered through the vln that they cannot offer locally at present there is no formal national training for the eteachers although individual clusters offer a range of training opportunities this case study focused on the eteachers perceptions of the learning curve required for them to be adequately and effectively prepared to teach in the virtual environment results indicated that the experiences of eteachers in this new learning environment were positive but still embedded in the norm of a school further eteachers desired professional development beyond learning how to use the technology but wanted more assistance in developing their pedagogy to work in the online environment it is recommended that vln cluster administration and the ministry of education provide a range of professional development opportunities in a variety of formats the focus of this professional development should move beyond the technological tools and focus on how to use those tools in a virtual learning environment

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introduction cardiovascular diseases which include coronary heart disease and cerebrovascular disease are the leading cause of mortality worldwide 12 cvds are responsible for an estimated 179 million deaths each year an estimated 31 of all deaths worldwide 3 four out of five cvd deaths are attributed to heart attacks and strokes 3 premature death in people under 70 years of age also makes up one third of these deaths 3 in addition to being the leading cause of death ischemic heart disease and stroke are the top three global causes of disabilityadjusted life years in 2019 1 in singapore cvds are the second highest cause of mortality accounting for 246 of deaths in 2019 4 hyperlipidemia is one of the important modifiable risk factors for cvds lowering lipid levels with hmgcoa reductase inhibitors or statins is a proven effective therapy to reduce mortality multiple randomized controlled trials have unequivocally proven that statin therapy reduces the risk of major vascular events by about onequarter for 1 mmoll reduction in ldl cholesterol each year after the first year 5 effective statin dose can reduce ldl by 2 mmoll and could reduce close to half the patients risk of heart attacks and strokes 5 despite the many benefits adherence to statin therapy for primary and secondary prevention is low 67 furthermore it is of concern that exaggerated claims about sideeffects of statin may be responsible for its low adherence among individuals at increased risk of cardiovascular events educating the general public with adequate knowledge and awareness of cvd risk factors is an important step in reducing cvd burdens although knowledge does not always result in the adoption of preventive behaviour 8 9 10 knowledge is crucial to building necessary skills to apply what is learned and making an informed decision studies have shown that there are gaps in the level of understanding of cholesterol and its treatment 1112 however much of the existing literature on cholesterol knowledge has focused on patients with hyperlipidemia 13 14 15 populationbased research on the general publics knowledge and misconception of cholesterol is scarce particularly in asian population 1112 in this nationwide multiethnic population survey we aimed to assess public awareness and knowledge of cholesterol and its management and identify factors associated with the level of knowledge methods sample and setting we engaged a professional market survey company to conduct a nationwide populationbased survey the residential areas in singapore were divided into 26 subzones the participants sample selection was stratified first by subzone then by housing type random sampling of households to approach was carried out our study included singapore citizens and permanent residents between the ages of 21 and75 we sampled an equal number of individuals from the three major racial groups in singapore a total of 1000 members were recruited for the survey door to door survey was conducted from april 2018 to may 2018 the survey was administered in one of the four national languages english mandarin malay or tamil only one respondent was interviewed per household this study was approved by national university of singapores institutional review board verbal consent was obtained before proceeding with the survey instrument a structured questionnaire pilottested with ten respondents was used to collect demographic data including age gender race cardiovascular risk factor education employment status pilot participants were selected based on age gender and language used for daily communication facetoface cognitive interviews were carried out in the patient waiting areas of the public hospitals feedback was collected to assess content validity of the questionnaire items modifications were subsequently made cardiovascular risk factors were categorized into yes if any of the following was present and no if none was present education was classified into low intermediate or high employment status was classified into working retiredhomemakers others participants were asked questions on possible symptoms of high cholesterol safety of cholesterollowering herbal remedies versus western medications effectiveness of diet and lifestyle in cholesterollowering versus medication and their knowledge of cholesterollowering medications responses were recorded as true false or dont know a score was generated for the knowledge of cholesterol and its management with one point given for each correct answer subjects were classified into a good knowledge group and a poor knowledge group statistical analysis data was summarized and presented using descriptive statistics counts and percentages for categorical variables means and standard deviations for continuous variables results weighted by race on knowledge scores of cholesterol and their associations with sociodemographic variables were reported logistic regressions were performed based on weighted results on race the multivariate analysis included variables that were significant in the univariate analysis statistical analysis was performed using stata version 15 with statistical significance set at p 005 results sociodemographic characteristics of the 1000 participants who were interviewed 479 were male and 521 were female three hundred and fiftyseven 321 and 322 were chinese malay and indian respectively mean age was 45 years more than two thirds of participants had an intermediate level of educational attainment two thirds of respondents were in the workforce there was no missing data the majority of participants did not have a cardiovascular risk factor with 96 having one cardiovascular risk factor and 42 having two or more risk factors seventy had hyperlipidemia sociodemographic characteristics of the sample are summarized in table 1 public perception and knowledge of cholesterol and its management table 2 shows the statements from the questionnaire and participants responses all the statements were false statements nearly two thirds of respondents thought that people with high cholesterol usually have symptoms such as breathlessness or chest pain sixty eight percent of respondents believed that long term statin therapy could lead to kidney or liver damage and more than half of the respondents had the misconception that statin was associated with higher risk of cancer the majority of respondents thought that lifestyle modification such as diet and exercise would be as effective as medication at lowering cholesterol in terms of the safety of alternative medicine one third of respondents thought that herbal medicine or supplements are healthier and safer as compared to western prescribed medication a substantial proportion of respondents believed that statin therapy should not be taken long term a considerable percentage of respondents felt that one could stop taking cholesterol medication when cholesterol is under control factors associated with public knowledge of cholesterol and its management twentysix participants who answered dont knowunsure to all 8 statements were excluded from logistic regression analysis in the multivariable logistic regression model malays were more likely to have poor knowledge as compared to chinese participants with intermediate education were more likely to have good knowledge as compared to those with primary education the logistic regression model is shown in table 3 three factors were statistically significant in univariate analysis but were not statistically significant after multivariate analysis these were age group between 6075 retiredhomemakers and university or above education p 0004 adjusted or 163 95 ci 094283 p 0085 discussion this study examined the knowledge of the general public on cholesterol and its management our findings suggested that overall public knowledge on cholesterol remains very low in our study 85 did not know that cholesterol medication should be taken long term and 81 did not know that high cholesterol per se does not produce any symptom this finding echoes prior literature for example a study by nash et al 11 in united states reported that 51 of healthy adults aged 40 years and above did not know their own cholesterol level while 531 overestimated the cholesterol goal for a healthy adult similar findings were observed in patients with high cholesterol where better knowledge could have been anticipated consoli et al 13 found that one in four hypercholesterolemic patients in france thought that they could sense an increase in their blood cholesterol level without needing to see the blood test results and only half of patients knew the acceptable upper limit for blood cholesterol in a global survey of 1547 patients with high cholesterol in ten countries 14 around 60 heard of bad or good cholesterol but 19 of patients were unable to specify any consequences of high cholesterol a similar lack of understanding of cholesterol was also observed in asian patients a survey of 853 patients with high cholesterol in india found that 57 did not know that they had high cholesterol while 224 did not understand the reason for taking cholesterol lowering medication 15 lack of knowledge of ones cholesterol level can cause undiagnosed hypercholesterolemia in our study the selfreported rate of hyperlipidemia is 7 data derived from a national sample of 19489 adults in korea found that in younger adults who had high cholesterol only 8 were aware of the condition 16 in our study a large proportion of respondents thought that diet and exercise alone were as effective as medication at lowering cholesterol in addition the vast majority had misconceptions about the association of statin therapy with liver and kidney failure and higher risk of cancer this finding is consistent with previous literature 13 that lipid lowering drugs were commonly believed to have drawbacks and that only 45 of hypercholesterolemic patients believed that drug therapy was the most effective way of lowering blood cholesterol a qualitative analysis 17 of social media posts about statin identified that beneficial effects of statins accounted for 46 of the total posts while beliefs about harms or medical mistrust accounted for 20 of the posts posts on harm were either general reference to statin as dangerous or poisonous or adverse events such as dementia liver failure and mortality our finding together with previous literature suggests that there is a need to improve the knowledge of cholesterol in the general public and patients with high cholesterol our study identified race as a factor that influences knowledge on cholesterol and belief on statin malays were more likely to have less knowledge of cholesterol and more misconceptions about cholesterol management compared to chinese the difference in patient perceptions of statin efficacy and safety by race was demonstrated in a previous study 18 nanna et al 18 found that african americans were less likely than whites to believe that statins are safe and effective african americans also had lower knowledge of personal and target cholesterol compared to whites 19 our findings also suggested that education level was associated with knowledge on cholesterol people of primary education level were more likely to have poor knowledge compared with those of intermediate education level this association was not evident in the group with high education level which could be due to much smaller numbers in the high education group leading to the result being insignificant our finding is in line with a previous study in france 13 that knowledge of cholesterol differed markedly according to the patients educational level with hypercholesterolemic patients with lower education having poorer knowledge our findings demonstrate that health promotion efforts to increase personal awareness of cholesterol and its management should target subgroups of population such as the malay and people of lower education in addition to guidelines for clinical management of hyperlipidemia 20 21 22 23 more efforts should equally focus towards prevention the world health organization noncommunicable disease global action plan 20132020 emphasizes the role of cholesterol management to prevent cvd event 24 the global action plan aims to lower the mortality of four major diseases by 25 and provide appropriate medications in �50 of patients to prevent heart attack and stroke 24 the who recommends prescription of statins along with antiplatelet antihypertensive medications highlighting the importance of lipid management in the prevention of first heart attack or stroke in adults aged 4079 years 24 in us healthy people initiated by the us department of health and human services since 1980 sets measureable objectives for improving health and wellbeing nationwide objectives of the healthy people include increase in the proportion of patients going for blood cholesterol evaluation reduction in the proportion of patients with high cholesterol and reduction in mean total cholesterol levels by 2020 25 in 2017 88 of adult population had their blood cholesterol screening compared to 746 in 2008 25 million hearts1 initiative which began in 2012 aims to prevent 1 million heart attacks and strokes within 5 years it focuses on implementing evidencebased priorities and targets to keep people healthy to optimize cardiovascular care the program aims to increase aspirin use blood pressure and cholesterol control and smoking cessation to 80 in its first 5year cycle million hearts1 had prevented an estimated 135000 heart attacks strokes and related acute cardiovascular events 26 similarly in the uk the english national health service health checks program started in 2009 aiming to reduce cvd mortality the program aims to provide a routine structured clinical assessment and management for adults aged 4074 years without preexisting diabetes or cvd four years after its implementation an analysis showed a high rate of newly identified comorbidities 27 of the high cvd risk attendees 193 were newly prescribed statins therapy 27 a similar approach could be considered to improve public knowledge of cholesterol and reduce the risk of developing cvd and its complications in asian populations including singapore this study has several limitations this is a public survey and only a small proportion of participants had cvd risk factors therefore we were unable to determine whether having cvd was associated with the level of cholesterol knowledge future research can aim at investigating the knowledge of cholesterol and management in asian patients with hyperlipidemia those who participated in this survey may have been more health conscious or aware of hyperlipidemia than the general population in addition compared to the general singapore population our study population had a greater proportion of participants with intermediate educational attainment and a lower proportion of participants with university and above educational attainment 28 which might have affected our findings the selfreport nature of the risk factors such as hyperlipidemia and hypertension might have introduced a social desirability bias a notable limitation to the study was that all eight statements assessing the cholesterol knowledge were false participants who were unsure of the answer might have chosen some statements to be true to give a balanced answer this may have influenced the results of the study 2930 conclusion public knowledge and awareness of high cholesterol and its management remains poor in asian multiethnic populations understanding gaps in public knowledge can inform the implementation of health promotion programs to effectively raise awareness of cholesterol and its management future interventions should focus on developing culturally tailored public health messages to close some of the racial disparity in cholesterol knowledge greater emphasis could also be placed on targeted educational efforts among lower education groups all relevant data are within the manuscript and its supporting information files

cardiovascular diseases cvds are the leading cause of mortality worldwide hyperlipidemia is one of the important modifiable risk factors for cvds raising public awareness of cvd risks is an important step in reducing cvd burdens in this study we aimed to assess public awareness and knowledge of cholesterol and its management in a multiethnic asian populationwe recruited 1000 participants from three major ethnic groups for this nationwide populationbased survey a structured questionnaire was used to collect sociodemographics knowledge of cholesterol and cholesterollowering medications univariate and multivariate analyses were conducted to identify factors associated with good knowledge on cholesterol and its managementof the participants 65 thought that high cholesterol produces symptoms and that lifestyle modification would be as effective as medication at lowering cholesterol nearly 70 believed that long term statin could lead to kidney or liver damage and 56 thought that statin was associated with higher risk of cancer a third saw herbal medicine or supplements as healthier and safer about 45 believed that statin therapy should not be taken long term and that one could stop taking cholesterol medication when cholesterol is under control malays were more likely to have poor knowledge adjusted or 068 95 ci 047098 p 0039 compared to chinese participants with intermediate education were more likely to

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background research shows that the prevalence of depressive symptoms is significantly higher among adult ethnic minorities than among native populations in europe 1 in the netherlands it was found that turkish migrants one of the largest ethnic minorities in the netherlands have a significantly higher 1month prevalence of depressive andor anxiety disorders in comparison with dutch as well as other ethnic minorities such as moroccans 2 moreover turkish women especially have a higher risk of prevalence of these affective disorders however in an international comparison study it was shown that the 1month prevalence of depressive and anxiety disorders for turkish nationals living in turkey was 31 3 it seems thus that the higher prevalence of depression among turkish migrants may be related to migration while the turkish population is at an increased higher risk for developing depression in comparison to other ethnic groups this is comparable with research concerning ethnic minorities in general for example in a european study in 23 countries it was found that depressive symptoms were more prevalent among immigrants and ethnic minorities than among native populations 1 a possible explanation for this higher risk may be lower socioeconomic status and discrimination perceived by ethnic minorities in their host countries 1 this increased risk for developing depression therefore is probably generalizable to many ethnic minority groups including turkish migrants in the netherlands one of the first definitions of acculturation was given by redfield and colleagues 4 in 1936 as the changes that occur in the ethnic cultural patterns when groups or individuals with different cultures come into continuous contact with each other later in 1980 berry 5 applied this definition as a basis for his bidimensional model in which he defines acculturation as a the degree of participation in the host culture by migrants and b the degree of maintenance of their own ethnic culture these two dimensions can vary independently of each other and can lead to four acculturation strategies according to berry 6 the first strategy can be described as integration the combination of maintenance of the ethnic culture and participation in the host culture assimilation is the second strategy which consists of participation in the host culture but rejection of the original ethnic culture third separation implies maintenance of the ethnic culture but no participation in the host culture and finally marginalization when both the host and ethnic cultures are rejected in the past decades alternative definitions have been given to acculturation such as a secondculture acquisition 7 or enculturation 8 both of these conceptualizations are viewing acculturation unidimensional as one particular culture 9 when viewing acculturation in a onedimensional manner the migrant chooses either to adapt the host culture or to maintain the ethnic culture however this onedimensional approach neglects the dynamic of acculturation according to the very first definitions of acculturation by redfield acculturation includes the interplay or transmission of one or more cultures which is a criterion for acculturation nowadays 9 the bidimensional model posits the independency of the two cultural orientations which is shown to be a more valid approach of acculturation 10 therefore its assessment by defining it in acculturation strategies has become an essential feautre of acculturation the integration strategy has often been associated with better psychological outcomes in comparison with the other three acculturation strategies for example migrants who are better integrated in the host culture show higher selfesteem more prosocial behaviours and less depressive symptoms in a recent metaanalysis by gupta and colleagues 15 based on 38 studies on asian americans it was found that participation in the american culture was related to lower depression scores among asian americans furthermore they found that maintenance of the asian culture had a negative but nonsignificant relationship with depression scores although acculturation was measured according to a bidimensional model the combination of both strategies was not analysed by gupta and colleagues 15 most research on ethnic minorities and mental health shows a negative association between acculturation and mental health for example in a study among korean immigrants in the usa selfreported language profiency of english was shown to be related with depression 16 furthermore integration has been shown to be associated with lower mental health problems in black male adolescents in the uk 17 in chinese american students it was found that maintenance of the ethnic culture was related to fewer depressive symptoms 18 however there are also examples of studies in which this association hasnt been found for example beirens and fontaine 19 evaluated differences in wellbeing in turkish immigrants in belgium turkish majority members and belgian majority members results showed no relationships were found between adaptation and maintenance and sadness anxiety nor with anger in the netherlands it was found that having fewer skills to enable participation in the host culture is generally related to more psychological distress 20 21 22 this association was also confirmed for turkish migrants for example by fassaert and colleagues 23 however previous dutch studies have not analysed acculturation according to the aforementioned four acculturation strategies it is not yet clear whether the acculturation strategies are associated with affective disorders in turkish migrants in the netherlands since the literature shows that an integration strategy is related to lower levels of psychological distress in migrants it is important to evaluate this explicitly in order to improve our understanding of the relationship between acculturation strategies and the prevalence of affective disorders among migrants in addition ethnic minorities seem generally to receive less help from mental health care services than native citizens of western countries eg 26 27 28 29 one of the reasons for this lower uptake is that ethnic minorities seek mental health care often at a later and at a more advanced stages of their mental health problems 1617 moreover ethnic minorities have a higher chance of dropping out from psychological treatment prematurely 18 although dutch national data is lacking there are signals that the dropout rate is twice as high in ethnic minorities in mental health care compared to native dutch people in the netherlands 30 research also shows that the perceived need for mental health care is higher for turkish migrants than in moroccan and dutch people 24 this may be related to their higher levels of mental distress and their less often met need perceived by turkish migrants 24 several studies suggest that greater participation in the host culture is associated with higher general health service use earlier dutch research found a significantly positive association between communication in dutch and the use of care from general practitioners among turkish men in the netherlands 25 however an association between the four acculturation strategies and gpcare uptake by migrants was also not studied in the study of fassaert and colleagues 25 we therefore decided to examine the relationship between the four acculturation strategies and mental health in terms of prevalence of depression and anxiety disorders in turkish migrants living in amsterdam as well as the association between these strategies and gpcare uptake for this purpose we reexamined existing data from the general health monitor of amsterdam of 2005 using the bidimensional framework of acculturation we hypothesized that 1 higher integration is associated with lower prevalences of depression and anxiety disorders and 2 higher integration is associated with higher gpcare uptake methods the amsterdam health monitor the amsterdam health monitor consists of crosssectional health surveys conducted by the public health service of amsterdam these surveys are performed periodically in order to monitor the general health of the population living in amsterdam and are representative for the population data for the current study were derived from the survey conducted in 2005 which was a study of the ahm of 2004 stratified by age and ethnicity and specifically aimed at studying mental health the followup consisted of structured interviews conducted by trained bilingual lay interviewers the first phase of the survey included 1449 respondents from the four largest ethnic minority groups all of these respondents were asked for a second approach without mentioning the topic of the study one year after the first phase this second phase consisted of a structured interview conducted by bilingual interviewers a total of 1210 respondents gave permission to be approached for the followup study by invitation letter for a home visit by the interviewer appointments for a home visit could be changed by telephone up to 8 attempts the interviews took place between february and june 2005 while summer vacation christmas and ramadan were avoided the interviews could be held in dutch turkish moroccan or berber depending on the preference of the respondent the interviewers were intensively trained and coached before and during datacollection the interviews were also recorded in order to check and coach the researchers after completing the interviews these were checked for consistency and completeness the second phase resulted in 812 respondents of whom 321 were dutch 191 moroccan 213 turkish and 87 surinamese or antillean all the study procedures were approved by the ethics commission of the amsterdam academic medical center for more detailed information about the recruitment procedures and details we refer to previous ahm publications for the current study we selected the data of the turkish group comprising 210 respondents with complete information measures the structured diagnostic interview consisted of several translated instruments of which we selected only the following sections demographic information the lowlands acculturation scale and the composite international diagnostic interview and the use of health care services the questionnaire was translated into turkish by official translators a back translation to dutch was performed by another translator and checked by the researchers any inconsistencies with the original were discussed with both translators and adjusted the interviewers also reported back when they had difficulties with the translation and then together a standard was chosen of the acculturation scale and the measurement of anxiety and depression official turkish translations were available and used in this study sociodemographic variables sociodemographic information included gender age level of education daily occupation and partnership status turkish ethnicity was defined as when the respondent or at least one of hisher parents was born in turkey first and second generation migrants were taken together as one group these items were translated from dutch to turkish and back to dutch by professional translators acculturation the level of acculturation was measured with the lowlands acculturation scale which was used in the ahm of 2005 34 the validated turkish translation was used 34 it consists of 25 items that are rated on 6point likerttype scales ranging from totally disagree to totally agree the las can be divided into 5 subscales skills traditions social integration values and norms and feelings of loss however for the purpose of the research question addressed in this paper we did not use the original scales of the las we developed four new acculturation strategy scales based on the items of the las questionnaire in two steps first following the twodimensionality theory of berry 56 two new scales were developed for the questionnaire these scales were participation and contact in the host culture and maintenance of the ethnic culture the twodimensionality of the items on the las questionnaire was created by explorative factor analysis with a twofactor solution based on the respondents of the ahm 2005 however eight items concerning emancipation were excluded from further analyses because it was not possible to determine how this scale was associated with acculturation due to the lack of information about emancipation in the ethnic dutch and turkish cultures the two factors participation and maintenance were yielded with the rotation solution as shown in table 2 the participation factor accounted for 169 of the item variance and the maintenance factor accounted for 216 of the item variance with a cutoff point of 40 for the loadings 35 only 3 items were excluded from both factors in order to fit the las items to the scales some items were recoded by adjusting the range of the response options so that higher scores indicated lower levels of maintenance or participation internal consistency for the participation and maintenance scales of the las were good with cronbachs alpha indicating strong reliability for both of the scales each 86 second in order to combine participation and maintenance to create the 4 acculturation strategies the medians of the two scales were used as the cutoff scores indicating high and low levels of participation or maintenance choosing a median split instead of a continuous measure was based on the fact that the distribution of the dimensions was not normal distributed and therefore the dimensions could not be validly included as continuous measures and were therefore dichotomized this also made it feasible to compare the four strategies instead of two separate dimensions the median for participation was 200 and for maintenance it was 500 this resulted in four scales of acculturation strategies the scale integration was composed of the combination of high participation and high maintenance the scale assimilation was composed of the combination of high participation and low maintenance the scale separation consisted of low participation and high maintenance finally the scale marginalization was the combination of lower levels of both participation and maintenance anxiety and depressive disorders the composite international diagnostic interview was used to establish the presence of depressive and anxiety disorders 36 depressive disorders included major depressive disorder and dysthymia anxiety disorders included social phobia agoraphobia panic disorders and generalised anxiety disorders all disorders were coded according to the dsmiv criteria 37 the who turkish version of the cidi was used and was conducted by trained lay interviewers use of health care services the outcome measure for health services utilisation was evaluated in terms of contacts with a general practitioner by a selfreport measure contacts were defined as consulting hours telephone contacts number of consultations with the gp for general health in the 6 months preceding the interview a distinction was made between low and high number of contacts analyses sociodemographic variables depressive disorder anxiety disorders comorbidity and the use of health care services were analysed in terms of associations with acculturation strategies to assess the significance of an association between these variables and the acculturation strategies pearsons chisquared test was used for cross tabulations with low cell frequencies the likelihood ratio test was performed acculturation was also analysed in terms of a division in two general dimension in order to explore one specific cultural attitude to control for possible confounding variables we conducted three twostep logistic regression analyses with the binary psychopathology variables as dependent variables in step 1 of the analysis we entered the five sociodemographic variables listed as an independent variable in step 2 we added the four acculturation variables next a chisquared test of the log likelihood of model 1 versus model 2 was used to test the relationship between acculturation and psychopathology taking into account the effects of sociodemographic variables associations were considered statistically significant if p 05 all analyses were conducted in spss 200 results socio demographic characteristics of participants the sample consisted of 210 turkish migrants as shown in table 1 more than half of the migrants were male and most were over 36 years of age almost half of the participants had only primary education and 80 were unemployed likewise 80 were in a longterm partnership the 1month prevalence of depression and dysthymic disorders was 171 while the 1month prevalence of anxiety disorders was 10 the prevalence of comorbidity of both disorders was high namely 67 almost half of the of the participants reported 0 to 3 contacts with their gp for their general health in the last 6 months of whom 644 had no contact at all finally 29 had contact with their gp on more than 3 occasions acculturation and demographic characteristics several associations were found between acculturation strategies and demographic characteristics as shown in table 3 results show that age education daily occupation 3222 p 001 and partnership status 912 p 03 were significantly associated with acculturation gender did not show an association with acculturation 620 p 10 table 3 also illustrates the proportions of demographic characteristics of migrants in the four acculturation strategies the acculturation scale separation had the highest percentage of migrants and marginalization had the lowest percentage of migrants the integration scale consisted mainly of migrants who were aged between 18 and 35 and 50 years or older and unemployed the assimilation scale included migrants with slightly different characteristics than for the integration scale namely those aged between 18 and 35 were employed or were students the separation scale comprised migrants with a different profile than the previous scales ie 540 were older migrants 552 were female 701 had a lower educational level and 874 were unemployed the marginalization scale had a similar profile of migrants to those in the separation scale with the exception of the relationship status in the separation scale 333 of the migrants had no relationship acculturation and depressiveanxiety disorders table 3 also presents the results of the association between acculturation and depressive and anxiety disorders acculturation was significantly associated with depressive disorders but not with anxiety disorders nor with comorbidity of these disorders migrants who had a depression diagnosis were mainly represented in the separation scale while the integration scale had the lowest number of migrants with depression acculturation and anxietydepressive disorders controlled for sociodemography tables 4 and5 present the results of the three regression analyses we conducted in order to control for possible cofounders results were similar to the results of the original analyses presented in table 6 accounting for the effects of sociodemographic variables acculturation strategies were related to depression but not to anxiety although the relationship with anxiety approached significance risk of depression was significantly lower among those adopting an integration strategy combining acculturation strategies additional analyses were performed on the basis of a division into two combined acculturation strategies participation in the host culture consisting of integration and assimilation and nonparticipation in the dutch society consisting of separation and marginalization shown in table 6 the two combined strategy categories showed no significant association with depressive disorders however there was a trend towards statistical significance 380 p 051 for anxiety disorders there was a significant association between the two acculturation categories finally comorbidity likewise showed a significant association between the two general acculturation strategies for all three measures of psychopathology results showed a higher prevalence among those with a nonparticipatory strategy next we focused on the same regression analysis method to examine the relationship between acculturation strategies and psychopathology as shown in table 5 the acculturationstrategy category of participation did relate to each of the three measures of psychopathology participation was associated with decreased risk of depression anxiety and comorbidity acculturation and the use of health care services as presented in table 3 acculturation did not show an association with the frequency of contacting the general practitioner 373 p 29 discussion in this paper the relationship between four acculturation strategies and depressiveanxiety disorders among turkish migrants living in amsterdam was examined for this purpose we used existing data from the general health monitor of amsterdam dating from 2005 eg 2 23 24 25 33 results showed that age education daily occupation and partnership status were significantly associated with acculturation we also found a significant association between the acculturation strategies and depressive disorders migrants who adopted the integration strategy had a significantly lower risk of depression compared to those with one of the other three strategies there was no association between any of the four acculturation strategies and the frequency of contacting the general practitioner when the four acculturation strategies were combined into two categories or nonparticipation in the dutch society our results suggest that participation in the host country seems to be associated with lower risk of depressive and anxiety disorders and comorbidity of both these disorders it is noteworthy to mention that the migrants included in the study have a high level of unemployment across all acculturation strategies the unemployment rate in our sample was much higher than found in the general turkish population in the netherlands which was 148 in 2005 38 this means that our results are mainly indicative for unemployed turkish migrants furthermore migrants who applied a participatory strategy were often young female and higher educated while those in the nonparticipating strategy comprised mainly migrants aged 50 or older who were lower educated several studies have shown that a low socioeconomic status is a risk factor for developing mental health disorders in general and also for developing depression comparison with prior work our results are in line with the general finding that an integration strategy among migrants is associated with better psychological outcomes as found in the studies by chen and colleagues 13 and schwartz et al 14 these authors found that migrants who hold an integration strategy experience higher selfesteem and less depressive symptoms 1314 moreover the two combined acculturation strategies seem to be independent mechanisms as participation is associated with depression while nonparticipation is not corresponding to the independent bidimensional theory of berry 56 there are number of possible explanations for the lower risk of depression among migrants with participatory acculturation strategies earlier research showed that migrants who have integrated into the host society have cultural knowledge about the host society are better able to control the degree of contact and have positive cultural group attitudes all these factors may contribute to minimising cultural distance between migrants and their host society 4243 in turn integration may enable migrants to manage their daily life in the host society better and therefore lower their risk of depression since integration involves a positive multicultural attitude 44 that enables migrants to manage daily life in a new context it is likely that these behaviours play a role in a decreased prevalence of depression in turkish migrants who adopt such a strategy finally our results showed no association with the acculturation strategies and uptake of gp care and thereby confirmed the generic analysis of acculturation and gp care uptake by fassaert and colleagues 25 however our results are not in line with earlier research which showed that participatory strategies were associated with higher use of general health care services for example having higher levels of skills to participate in dutch society was related to greater use of health care by migrants in the netherlands 32 it thus seems that turkish migrants make use of gp services to the same degree regardless of their acculturation strategy limitations this study has several limitations first the definitions of immigrantsmigrants will undoubtedly have affected the results first and second generation immigrants were taken as equal groups in the analysis because the number of second generation migrants in the study was too small to study this group separately therefore these results mainly represent first generation migrants yet it is likely that each of these groups will experience the process of acculturation through different ways which were not monitored second the crosscultural validity of the four created acculturation strategy scales was not tested although the new scales showed good reliability the small size of the groups distinguished by acculturation strategy resulted in low power to detect possible associations and differences we found several associations however not all were significant furthermore the absence of the crosscultural validity of the cidi is also an important limitation third the theoretical conceptualisation of acculturation is complex we adopted the bidimensional model of berry 56 however acculturation does not take place in a vacuum acculturation is a dynamic process that encompasses not only certain life domains but also contextual political economic and social factors that require further exploration 45 it was beyond the scope of our study to include all these factors in our analyses furthermore the response rate over the first and second phases was 26 it is not clear why the response was that low however despite efforts put into reaching and recruiting ethnic minorities it seems that this low response rate is the highest possible response to be attained in ethnic minorities 246 there may have been a selective response which is a limitation however the response rate of the turkish group was similar to the other ethnic minorities in the data suggesting that in case of selective response this was similar in all the ethnic minority groups finally the crosssectional design of the study restricts the causality of the associations implications and future research the finding that integration may play an important role in a lower risk of developing depression is also of importance for public health policy makers clinicians as well as for researchers supporting immigrants in the process of adjustment to the host society while encouraging ethnocultural maintenance at the same time is an important task for the dutch society as well as for ethnic minorities themselves this process can be aided through several pathways including educational and public health policies such as implementing acculturation in prevention programs although integration has been found to be related to a lower risk of depression its causality and implications for prevention and clinical practice should be examined in more detail for example the potentials of including it as component in screening or treatment strategies awareness by practitioners and professionals of the acculturation strategies of ethnic minorities should be promoted in order to optimize health services for mental health problems the assessment of the acculturation strategies migrants adopt may be useful in identifying high risk profiles of migrants who are at increased risk for depression from a public health perspective it may thus be advised to include types of acculturation strategies in screening procedures for depression it is also of importance to examine what factors are affecting the relationship between integration and depressive disorders and whether these also hold for the employed turkish migrant population moreover future research should also explore the influence of socioeconomic status on the relationship between acculturation and depression conclusion turkish migrants who participate in dutch society while at the same time maintaining their ethnic culture may have a lower risk of developing a depressive disorder compared to those who adopt other acculturation strategies participation in dutch culture is associated with a decreased risk of depressiondysthymia anxiety and comorbidity of both disorders no association was found between the acculturation strategies and gp care future research should focus on the assessment of acculturation in the detection of depression abbreviations gp general practitioner ahm amsterdam health monitor ggd public health service las lowlands acculturation scale cidi composite international diagnostic interview competing interests the authors declare that they have no competing interests authors contribution the ahm data was provided by the ggd amsterdam büi drafted the manuscript and all authors contributed to further writing of the manuscript all authors read and approved the final manuscript

background turkish migrants in the netherlands have a high prevalence of depressive andor anxiety disorders acculturation has been shown to be related to higher levels of psychological distress although it is not clear whether this also holds for depressive and anxiety disorders in turkish migrants this study aims to clarify the relationship between acculturation strategies integration assimilation separation and marginalization and the prevalence of depressive and anxiety disorders as well as utilisation of gp care among turkish migrants methods existing data from an epidemiological study conducted among dutch turkish and moroccan inhabitants of amsterdam were reexamined four scales of acculturation strategies were created in combination with the bidimensional approach of acculturation by factor analysis the lowlands acculturation scale and the composite international diagnostic interview were used to assess acculturation and mood and anxiety disorders sociodemographic variables depressive anxiety and comorbidity of both disorders and the use of health care services were associated with the four acculturation strategies by means of chisquared and likelihood tests three twostep logistic regression analyses were performed to control for possible confounding variablesthe sample consisted of 210 turkish migrants significant associations were found between the acculturation strategies and age p 01 education p 01 daily occupation p 01 and having a longterm relationship p 03 a significant association was found between acculturation strategies and depressive disorders p 049 integration was associated with a lower risk of depression separation with a higher risk using the axis separately participation in dutch society showed a significant relationship with a decreased risk of depressive anxiety and comorbidity of both disorders or 15 95 ci 024 98 nonparticipation showed no significant association no association was found between the acculturation strategies and uptake of gp care conclusions turkish migrants who integrate may have a lower risk of developing a depressive disorder participation in dutch culture is associated with a decreased risk of depressive anxiety and comorbidity of both disorders further research should focus on the assessment of acculturation in the detection of depression

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résumé alors que les savoirs autochtones et la biomédecine se rejoignent dans les soins de santé aujourdhui il est essentiel dintégrer cette rencontre dans la formation des médecins afin daméliorer les issues de santé et de renforcer lidentité culturelle des peuples autochtones à laide dexemples tirés de la littérature et des méthodes pédagogiques et pratiques employées à luniversité de toronto la présente revue narrative vise à offrir aux éducateurs des conseils pratiques sur lintégration de ce sujet dans leur programme la méthodologie utilisée pour la recherche de littérature scientifique comprenait une consultation de la base de données informatique medline quant aux informations sur le programme détudes de la faculté de médecine de luniversité de toronto elles ont été obtenues par le biais du schéma tutoriel officiel et du bureau de la formation médicale autochtone de luniversité nous présentons six recommandations pour un enseignement réussi du croisement des savoirs autochtones et de la biomédecine dans le cadre dun programme culturellement sécuritaire sur la santé des autochtones introduction indigenous healing practices have been an important part of indigenous knowledges and ways of knowing that have existed for thousands of years colonization forced assimilation and racism have all contributed to these practices being split off from indigenous healthcare 1 consequently this has further impacted health disparities seen among some indigenous communities today 1 an important aspect of restoring these knowledges is the promotion and reclamation of indigenous healing which includes making space for indigenous practices and knowledges alongside biomedicine 2 ways of making space take different forms in various programs from including elders in treatment care planning to taking communitybased approaches that enable communities to set and lead their own health priorities 3 ultimately these programs which integrate indigenous knowledges with biomedicine improve health outcomes and strengthen cultural identity among indigenous peoples 2 therefore instead of learning about these knowledge systems separately healthcare providers will benefit from learning about the convergence of indigenous knowledges together with biomedicine during their training 2 in fact there is a willingness and motivation to learn about indigenous healing practices among healthcare professionals 4 however there are misguided practices to navigate in order to make these teachings successful and to avoid furthering the racism or inequities that we seek to redress in addition to the knowledge we seek to disseminate we also need to consider the pedagogical approach and ensure critical reflection on the history of harmful ideas and practices that can occur in teaching about the health of indigenous populations some of these practices include presenting only health disparities and risks while omitting discussion of indigenous community knowledge and strengths creating curricula without indigenous peoples guiding leading and being educators in this process 5 or taking a one size fits all approach that fails to see the heterogeneity of indigenous peoples 6 instead of striving to teach everything there is to know about complex and often privileged knowledge systems it is far better to model cultural humility 7 moreover we and others believe both indigenous and nonindigenous knowledge systems must be equally valued for the teachings to be meaningful 8 with these considerations as a foundation here are six recommendations to help introduce medical trainees to indigenous knowledges medicine and healing practices use multiple teaching methods to introduce indigenous knowledges according to various indigenous leaders and patients a way to develop respect and equal valuing of both indigenous and nonindigenous knowledge systems is by providing education and awareness to health professionals through training 9 this education should be provided using multiple teaching methods this means not only providing lectures or modules but also using experiential methods to better understand indigenous worldviews cultural practices and traditional ways of knowing 10 in fact a māori study which looked at indigenous teachings in the medical curriculum found that students enjoyed multiple teaching methods since it helped them engage with the content more and encouraged high levels of interaction between each other 11 these multiple methods included lecture style teaching small group discussions participating in simulated patient interviews and workshops 11 furthermore an example of how to use multiple teaching methods can be seen with what is done at the university of toronto medical school while there are lectures modules and casebased learning sessions related to indigenous health every student participates in a kairos blanket exercise as a way to experientially learn about indigenous histories and explore the nationtonation relationship between indigenous and nonindigenous peoples in canada 12 encourage selfreflection and cultural humility among learners cultural humility is a process of selfreflection to understand systemic and personal conditioned biases 7 it is a way for learners to acknowledge oneself as a perpetual learner when it comes to understanding anothers experiences indigenous leaders have been encouraging the use of the concept of cultural humility instead of cultural competency because a person can never fully achieve cultural competency through training or a course 7 instead learning about another persons culture is a lifelong learning process healthcare providers should be encouraged to acknowledge the lifelong journey of learning and selfreflection while being open to listening to what better care means for indigenous peoples an example of encouraging the concept of cultural humility in a learning environment is what is done during the kairos blanket exercise this includes ensuring there is space for students to ask questions to talk about difficult topics including racism and have a moment during the teaching for selfreflection 12 ultimately cultural humility is a vital part of creating a healthcare system which is culturally safe for all 7 invite elders and other indigenous community members to guide facilitate andor teach teachings involving the convergence of indigenous knowledges and biomedicine should involve indigenous educators as they are more knowledgeable about the cultures histories and worldviews of indigenous peoples even if it is not possible to have these educators directly teach having an elder or other indigenous community member oversee how and what is being taught is important to ensure the content is presented well without any negative bias 13 in fact the office of indigenous medical education at the university of toronto created a truth and reconciliation report reading group where an elder was involved in the planning initiation and facilitation process of three small group sessions with only an idea in mind of having a trc reading group the medical student who helped organize the event met and communicated over email with the elder multiple times to aid in planning and initiating the group the elder provided guidance in what the sessions would entail including the idea that there should be smudging practices done to commence each session 14 moreover it is important when having an elder partake in teachings to ensure the honoraria provided to the elder is respectful and appropriate for their knowledges provided 14 indeed elders traditional teachers and knowledge keepers are now a vital presence at uoft and the university encourages staff students and faculty to engage and grow in connection with them 15 consider the setting and learning environment although lecture halls can be used as a teaching environment learning about indigenous histories and knowledges can be more meaningful in other environments for example if the teachings involve traditional practices like smudging it is important to find a room that supports this or maybe you want to find a room in a building which is significant for indigenous peoples like a sweat lodge or indigenous gathering place or even a university building meant to support indigenous students with consultation of indigenous educators finding a learning environment different from a lecture hall is possible and can positively impact the teachings for the students in fact the māori study looking at the indigenous health curriculum for medical students found learning at a marae motivated the students to engage with the course content more deeply 11 this learning environment also allowed students to experience specific traditional protocols making their learning more meaningful 11 likewise the trc reading group done at the university of toronto considered the learning environment when choosing where to conduct the sessions in consultation with the elder two rooms were found which would allow for a smudging practice which allowed for an enhanced learning environment 14 the two rooms used were the labyrinth room in womens college hospital which is meant as a quiet prayerreflection room and the lounge in first nations house which is a place that provides culturally supportive student services to indigenous students at the university 14 cultivate the perspective of holism and teach a relationshipbased approach to making space for indigenous knowledges and practices within biomedicine while it is vital to think about how to best teach students from a learning environment and teaching methods perspective it is also important to think about the content after reviewing the literature on programs which converge indigenous knowledges with biomedicine here is what students should know about the key factors to successfully doing so • build upon holistic models of wellness in the creation of programs that bring together indigenous knowledges with biomedicine while working with local indigenous organizations leaders and clients although there is great diversity amongst indigenous nations and cultures many share an approach to health that is wholistic this includes spiritual emotional physical and mental dimensions of life including connections to the land and other nonhuman aspects of the world 161718 • ensure that communities who are the intended recipients of health care participate in all stages of the development and implementation of integrated indigenous and biomedical programs recruit mentor and support program leaders and practitioners from within local indigenous communities 1920 • build and nurture strong partnerships between indigenous and nonindigenous peoples as the foundation for creating and maintaining integrated programs this process of twoway learning allows for sharing of knowledge while maintaining integrity and respect of individual expertise from each cultural domain 8 • build time and space when integrating indigenous knowledge with biomedicine for individuals to focus on building trusting relationships 1921 while partnerships are important the process of developing collaboration through relationshipbuilding is equally vital relationship building is an essential process to many indigenous communities and is deeply embedded in history and context 22 6 teach the concept of wise practices as a way to bring indigenous knowledges and practices alongside biomedicine in a respectful and meaningful way wise practices are locallyappropriate principles actions tools or decisions that contribute significantly to the development of equitable and sustainable social conditions 23 an approach which values wise practices is especially important in healthcare when considering indigenous knowledges and practices in the context of biomedicine 23 therefore this is an important concept for medical trainees to understand before going into practice in contrast to the best practices approach which creates a knowledge hierarchy and applies a proven method or process to many communities wise practices acknowledges the heterogeneity of indigenous peoples 23 failure to recognize this diversity and nationspecific knowledges and practices can lead to panindigenous approaches that over simplify andor overgeneralize knowledge developed in one community to apply in other communities 23 indeed each community has their own cultural background knowledges social practices and unique experiences of colonization and therefore generalizing practices into other contexts should not be the answer 24 in fact viewing indigenous culture as a monoculture can reduce the effectiveness of indigenous and mainstream health partnerships 6 ultimately healthcare professionals need to understand the core of this approach as a relational covenant of respect and honor the autonomy and sovereignty of indigenous peoples and communities conclusion since medical schools across the country and world have different curricula class sizes and resources teaching on the convergence of indigenous practices with biomedicine will vary and have its own challenges for example a school may not have the funding to support an elder to facilitate teachings or a learning environment which would make indigenous teachings meaningful however an approach based on the principles of cultural humility holism and the existence of a diversity of knowledges and practices will create a culturallysafe indigenous health curriculum in which wise practices can flourish this flourishing though cannot simply be imparted on an individual learner basis instead it will only thrive in institutional and social settings that also value indigenous knowledges and in health profession faculties that recruit and sustain students and teachers from diverse indigenous backgrounds ultimately these recommendations are based within the specific social location of uoft and future research can include ways in which different social locations successfully involve indigenous knowledges with biomedicine in their medical school curriculum note from authors as authors we recognize there are other examples of indigenous health frameworks in medical schools across canada however we have chosen to focus on the uoft framework because of our specific social location of having developed and experienced the indigenous health curriculum specifying social location is vital to the context of indigenous peoples epistemology and education therefore we would like to specify our social location as a medical student who experienced the curriculum an anishnawbe physician and a nonindigenous physician who has worked extensively in the field of indigenous health conflicts of interest none funding from the canadian federation of medical students indigenous mental wellness summer studentship these funds were used to support the medical student for their research work commitment and to aid with transport costs needed to complete the research

as indigenous knowledges and biomedicine come together in healthcare today to improve health outcomes and strengthen cultural identity among indigenous peoples it is vital for physicians to learn about this convergence during their training this narrative review article aims to provide practical advice for educators when implementing teaching regarding this topic using examples from the research literature and pedagogical and practicebased methods used at the university of toronto uoft the methodology on obtaining the research literature included a search of a computer database called medline moreover the medical school curriculum information specific to uoft was obtained through the formal curriculum map and uofts office of indigenous medical education the following six recommendations provide a way to successfully implement the teachings on indigenous knowledges and biomedicine within a culturallysafe indigenous health curriculum

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introduction childhood lead poisoning continues to be a significant public health concern throughout the united states despite federal regulations to eliminate lead from paint gasoline and other consumer products 1 lead is a persistent and pervasive contaminant that is found in paint dust soil potable water piping and air 1 while the centers for disease control and prevention classifies childhood blood lead levels at or above 5 μgdl as elevated there is no safe level of lead exposure 2 even low levels of lead exposure in children can interfere with the brains ability to develop resulting in neurological and developmental delays 134 childhood lead exposure can cause irreversible brain damage and is associated with various adverse physical mental and behavioral outcomes 34 environmental conditions that contribute to childhood lead exposure are spatially patterned childhood lead exposure disproportionately impacts neighborhoods with low socioeconomic characteristics 5 6 7 8 9 older housing stock 710 neighborhoods of color 5 6 7 11 and neighborhoods in geographic proximity to industrial lead emissions 1213 older metropolitan areas in the us such as milwaukee county wisconsin share a disproportionate burden of lead exposure due to housing stock age and the legacy of infrastructure material choices made a hundred years ago according to 5year american community survey estimates between 2012 and 2016 84 of occupied housing in milwaukee county was built in 1979 or before and 40 was built before 1950 14 additionally more than 75000 homes are serviced by lead water laterals 15 however the presence of lead in homes and infrastructure alone do not determine whether children are exposed to lead childhood lead exposure is influenced by neighborhood social context driven by power differentials and institutional racism neighborhood racial and economic inequality is actively maintained through racist housing and economic policies and practices at local state and federal levels milwaukee is commonly ranked among the most segregated major metropolitan areas in the united states 16 has areas of intense socioeconomic deprivation 17 and faces challenges combating childhood lead exposure indeed according to the wisconsin department of health services in 2016 among children under the age of six that were tested for blood lead levels 88 of children in milwaukee county the most populous county in the state had blood lead levels greater than or equal to 5 μgdl as compared to 50 of children in wisconsin 18 identifying social determinants of childhood lead exposure that cooccur guides primary prevention efforts by understanding holistically the characteristics of neighborhoods most atrisk exploring the contribution of single sociodemographic neighborhood risk factors on health inequities is methodologically complex due to the spatial patterning of racial and economic segregation and the numerous pathways segregation operates through to influence health 19 20 21 further this study examines upstream social drivers of childhood lead exposure because case management and environmental assessments to mitigate lead exposure for children residing in the city of milwaukee are rationed to children with one venous blood lead test � 20 μgdl or two venous blood lead tests � 15 μgdl drawn at least 90 days apart 22 socioeconomic and racial inequities in childhood lead exposure have been well documented 5 6 7 8 9 10 11 23 24 25 26 27 however drivers of childhood lead exposure in milwaukee is understudied milwaukee is uniquely positioned to evaluate synergistic effects of neighborhood sociodemographic characteristics on childhood lead exposure due to the socioeconomic and racial patterning exacerbated by the lack of formal lead prevention infrastructure as a segregated rustbelt metropolitan area with childhood lead exposure concerns milwaukee is unfortunately wellsuited to examine the intersection of home ownership poverty and racial ethnic composition on neighborhood childhood lead exposure risk using surveillance data from the wisconsin department of health services division of public health and the us census bureau this crosssectional study tested the hypothesis that the combined effect of low home ownership high poverty and majority nonwhite racialethnic composition would result in the highest risk for childhood blood lead levels in milwaukee county neighborhoods materials and methods data individual blood lead level surveillance data for children six years old or younger residing in milwaukee county wisconsin were obtained from the wisconsin department of health services division of public health for 20142016 individual blood lead levels were aggregated to generate milwaukee county census tract mean childhood blood lead levels census tract mean childhood blood lead level data was merged with socioeconomic and demographic data obtained from the us census bureau using census tracts census tracts with no socioeconomic or demographic data available were subsequently dropped from the analysis resulting in 48393 individual blood lead levels aggregated to the final census tractlevel analytical sample of 215 the average number of individual childhood blood lead observations contributing to census tractlevel means was 225 the minimum number of individual childhood blood lead observations contributing to a census tractlevel mean was six this study was approved by the university of wisconsinmilwaukee institutional review board blood lead level data blood lead level surveillance data were obtained from routine healthcare appointments data included individuals sex age raceethnicity maximum blood lead level from their highest value blood test between 2014 and 2016 the type of blood sample taken the month and year the test was administered and the census tract in which the individual resided at the time of the blood test to account for variation in detection levels of testing methods all individual blood lead levels of 10 μgdl were divided by the square root of 2 before aggregating to the census tract level 5628 for descriptive statistics census tract mean childhood blood lead levels were categorized as less than 5 μg dl or � 5 μgdl consistent with the centers for disease control and preventions reference level for childhood lead exposure 2 all remaining analyses utilized continuous mean census tract childhood blood lead levels neighborhood socioeconomic and demographic characteristics data on home ownership poverty and racialethnic composition were obtained from the us census bureau american community survey 20122016 5year estimates for each milwaukee county census tract 29 30 31 this study emulates previous research on childhood lead exposure using census tracts as a proxy for neighborhoods 568 the optimum size of a single census tract is approximately 4000 people representing small relatively permanent statistical subdivisions that provide stable geographic units for presenting statistical data 32 additionally census tracts have been utilized to monitor area based socioeconomic characteristics and health to illustrate the context of social patterning 3334 home ownership was measured using the percent of owneroccupied housing units in each census tract poverty was measured using the percent of families in the census tract whose income in the last 12 months was below the united states poverty level threshold determined by the us census bureau incorporating the number of people in family age of its members and number of children under 18 years related to householder home ownership and poverty levels were dichotomized into low and high according to the mean value among census tracts high ownership was categorized as census tracts with � 40 of occupied housing owned and low ownership was categorized as census tracts with 40 of occupied housing owned high poverty was categorized as census tracts with � 25 of families living below the poverty level and low poverty was categorized as census tracts with 25 of families living below the poverty level dichotomizing the poverty level data at the mean split value of 25 falls directly between the us census bureaus categorization of concentrated poverty as census tracts with a poverty rate of 20 or more 35 and the commonly utilized cutoff of 30 for areas of extreme concentrated poverty 3637 majority white and majority nonwhite census tracts were categorized using census tract racial demographic estimates census tracts with � 50 of residents who identified as nonhispanic white were classified as majority white and census tracts with 50 of residents that identified as nonhispanic white were classified as majority nonwhite the categorization of majority nonhispanic white vs majority nonwhite neighborhoods is supported by previous literature 3839 and the bifurcation model which posits that neighborhoods adhere to a whitenonwhite color line as a means to reinforce racial hierarchy 40 covariates several variables were used to characterize census tracts in this analysis including census tract educational attainment housing age and number of children data on educational attainment and housing age were obtained from the us census bureau acs 20122016 5year estimates for each milwaukee county census tract 1441 neighborhood educational attainment was dichotomized into census tracts with � 50 of the population 25 years and older with a high school diplomaequivalent or less education or census tracts with 50 of the population 25 years and older with a high school diplomaequivalent or less education housing age was dichotomized into census tracts with � 50 of the housing built prior to 1950 or census tracts with 50 of the housing built prior to 1950 data from the us census bureau 2010 decennial census were obtained to estimate the number of children age six years and under that resided in milwaukee county census tracts 42 the estimates for the number of children per census tract was treated as a continuous variable for analysis childhood lead testing penetrance estimates were calculated using the number of children six years of age and under tested in each milwaukee county census tract between 2014 and 2016 divided by the number of children six years of age and under residing in each census tract as reported in the 2010 decennial census statistical analysis descriptive statistics were conducted to evaluate characteristics of milwaukee county census tracts by elevated mean childhood blood lead level status and by housing tenure and poverty levels differences in observed distributions of characteristics were evaluated using twotailed ttests wilcoxon twosample tests and ftests for average tract continuous variables and chisquare tests for categorical variables we further limited the analysis to census tracts with high poverty low home ownership and low poverty high home ownership for regression analysis the intersectional effect of home ownership poverty and raceethnicity on census tract mean childhood blood lead levels was estimated using linear regression covariates were selected for model inclusion based on a priori knowledge of potential confounding variables and the covariates association with the exposure and outcome the final covariates were census tractlevel housing age and number of children a twosided pvalue 005 was considered statistically significant all analyses were conducted in sas 94 results utilizing 2010 decennial census child population estimates the mean childhood lead testing penetrance for the 215 milwaukee county census tracts analyzed was estimated to be 6868 the mean childhood lead testing penetrance for census tracts within the city of milwaukee was higher than the childhood lead testing penetrance for census tracts outside the city of milwaukee among all 215 milwaukee county census tracts the average census tract mean childhood blood lead level was 433 μgdl descriptive statistics for milwaukee county census tracts by dichotomized census tract mean childhood blood lead levels are displayed in table 1 sixty of the 215 census tracts in milwaukee county had a mean childhood blood lead level at or above the 5 μgdl center for disease control and prevention level of concern and were classified as elevated these elevated census tracts had on average a higher proportion of nonhispanic black or african census tracts with 25 of families living below poverty level f census tracts with � 40 of occupied housing that is owned g census tracts with 40 of occupied housing that is owned h census tracts with � 50 of the population 25 years and older with a high school diplomaequivalent or less education i census tracts with or 50 of the population 25 years and older with a high school diplomaequivalent or less education j census tracts with � 50 of the housing built before 1950 k census tracts with 50 of the housing built before 1950 american residents residents who rent and residents who live below the federal poverty line compared to census tracts with mean childhood blood lead levels less than 5 μgdl among elevated census tracts an average of 67 of residents identified as nonhispanic black or african american 22 identified as hispanic or latino or other and 11 identified as nonhispanic white ninetyseven percent of elevated census tracts were categorized as majority nonwhite while only 3 of elevated census tracts were categorized as majority white eightyeight percent of elevated census tracts were categorized as high poverty census tracts while 69 of not elevated census tracts were categorized as low poverty census tracts eightyfive percent of elevated census tracts were categorized as low home ownership census tracts and 61 of not elevated census tracts were categorized as high home ownership census tracts in addition 93 of elevated census tracts had the majority of housing stock built before 1950 and 87 of elevated census tracts were categorized as low educational attainment descriptive statistics for milwaukee county census tracts by intersection of housing tenure and poverty levels are displayed in table 2 census tracts with high home ownership and low poverty had the lowest mean childhood blood lead level while census tracts with low home ownership and high poverty had the highest mean childhood blood lead level sixtytwo percent of high home ownership low poverty census tracts were majority white and 94 of low home ownership high poverty census tracts were majority nonwhite elevated census tracts were predominantly low home ownership high poverty and majority nonwhite among the 58 majority nonwhite census tracts with a mean childhood blood lead level � 5 μgdl 81 were low home ownership and high poverty census tracts milwaukee county mean census tract childhood blood lead levels were highest among majority nonwhite census tracts with high socioeconomic disadvantage and lowest among majority white census tracts with low socioeconomic disadvantage linear regression results are displayed in table 3 among high home ownership and low poverty census tracts majority nonwhite census tracts had a 085 μgdl higher average childhood blood lead level than majority white tracts after adjusting for census tract housing age and number of children further among majority white census tracts low home ownership and high poverty census tracts had a 037 μgdl higher mean childhood blood lead level than high home ownership and low poverty tracts after adjusting for average census tract housing age and number of children when the three exposures were assessed jointly low home ownership high poverty and majority nonwhite census tracts had a 178 μgdl higher mean childhood blood lead level than high home ownership low poverty and majority white census tracts after adjusting for average census tract housing age and number of children discussion childhood exposure to lead continues to be a significant environmental public health concern national data documents that lead exposure disproportionately burdens nonhispanic black children children in families living below the federal poverty level and children living in older housing 23 our study revealed that milwaukee county neighborhoods do not have equal risk of childhood lead exposure consistent with previous studies 5 6 7 8 9 10 11 23 24 25 26 27 we document socioeconomic and racial inequities in childhood lead exposure at a neighborhood level however our results also reveal that risk of elevated blood lead level is greatest in neighborhoods with multiple risk factors including high poverty low home ownership and majority nonwhite residents our study illustrated a neighborhood level socioeconomic inequity in mean childhood blood lead levels exacerbated by racialethnic composition demonstrating that community lead prevention efforts should be informed by the intersection of multiple indicators of sociodemographic disadvantage including home ownership poverty and race ethnicity current childhood lead prevention efforts in milwaukee are limited by several factors wisconsin has a decentralized public health system with 92 local city and county health census tracts with � 25 of families living below poverty level e pvalue from ftest or chisquare test f census tracts with � 50 of nonhispanic white residents g census tracts with 50 of nonhispanic white residents h census tracts with � 50 of the population 25 years and older with a high school diplomaequivalent or less education i census tracts with or 50 of the population 25 years and older with a high school diplomaequivalent or less education j census tracts with � 50 of the housing built before 1950 k census tracts with 50 of the housing built before 1950 these factors contribute to the limited and fragmented lead prevention services available to milwaukees children indeed from 20142016 10004 children in the city of milwaukee had elevated blood lead levels according the cdc but were below the city of milwaukees level of action and did not receive case management or mitigation services despite knowing that no level of lead is safe the inequity in risk of childhood lead exposure is compounded by lack of equal access to case management and mitigation services for affected children in milwaukee that but for their location of residence they would have received this underscores the importance of identifying upstream social determinants of lead exposure to be targeted by primary and primordial prevention efforts in milwaukee and other cities struggling with the dual problem of high prevalence of lead exposed children and scarce resources further milwaukees old housing stock and stark segregation poses a challenge for lead exposure prevention 1416 while the age of housing stock is an important risk factor for lead exposure old housing is distributed throughout milwaukee county but socioeconomic disadvantage and raceethnicity are not areas with high poverty and low home ownership represent neighborhoods where residents may lack the ability and agency to remediate sources of lead exposure in their homes renters living in poverty may face barriers in testing lead sources or receiving lead remediation due to financial costs but also may be less likely to initiate testing or remediation with their landlord due to inherent power differentials rental contract restrictions or threat of eviction in wisconsin landlords of rental properties built before 1978 are not required to test for leadbased paint and are only required to disclose known leadbased paint hazards to potential tenants 45 wisconsin property owners are only required to eliminate leadbased paint hazards if the department of health services initiates a property investigation report to do so upon notice that the property is home to a blood lead poisoned child under the age of 6 46 alternatively homeowners not living in poverty may have the financial means and agency to test and remediate lead sources in their home milwaukee neighborhood racialethnic composition magnify socioeconomic disparities in childhood lead exposure our results revealed that 56 of majority nonwhite census tracts in milwaukee county were classified as high socioeconomic disadvantage whereas only 7 of majority white census tracts were classified as high socioeconomic disadvantage since economic security is inherently linked to the historical legacy of racial discrimination within the housing market understanding how these power dynamics operate within the housing market to influence childhood lead exposure is a key area for future research table 3 adjusted linear regression estimating association of socioeconomic disadvantage and racial ethnic composition on mean childhood blood lead level among milwaukee county census tracts change in census tract there are some limitations to the generalizability of the study results census tract mean childhood blood lead levels are only representative of the children who were tested between 2014 and 2016 while the mean childhood blood lead testing penetrances are to be interpreted with caution due to the limitations in using the 2010 us census bureau child population estimates the mean childhood blood lead testing penetrance estimated for the census tracts within the city of milwaukee is comparable to the 12 to 35month testing rate reported by the city of milwaukee in 2016 47 the large sample size and relatively high screening rate increases confidence that the average childhood blood lead levels analyzed in this study are representative of milwaukee children tested for blood lead levels another limitation is the potential for measurement error from capillary blood samples as 70 of individual childhood blood lead level data points analyzed were recorded as capillary blood samples while capillary tests are sensitive to environmental contamination there is no way of knowing the direction of bias from capillary samples capillary sampling has been shown to have slightly lower sensitivity to venous sampling although its specificity is comparable to venous sampling and its convenience has enhanced screening efforts 48 however due to the limitations of capillary samples we performed a sensitivity analysis to quantify the impact of potential environmental contamination by subtracting 1 μgdl off of all individual blood lead levels obtained from capillary tests the sensitivity analysis estimates were only slightly attenuated suggesting that our study inferences remain unchanged even if capillary blood lead levels were affected by environmental contamination due to the crosssectional nature of the data it is possible that children were exposed to lead in different geographic locations than the neighborhood reported at the time of the blood sample however blood lead levels are an accurate snapshot of current lead exposure reducing the threat to temporality additionally the ecological design of the study limits the ability to assess individuallevel associations however lead is a neighborhood exposure because of its social and geographic concentration 49 thus it is necessary to document neighborhoodlevel inequities in lead exposure to understand the spatial context of its social determinants finally census tracts were utilized as a proxy for neighborhoods for this analysis which may not accurately represent informal neighborhood boundaries future research should explore smaller geographic levels of analysis that may more closely align with informal neighborhood boundaries in milwaukee county to further tease apart residential segregation and childhood lead exposure additional multilevel analysis could be conducted to explore the associations between individual and neighborhood socioeconomic and racial characteristics in relation to childhood lead exposure despite these limitations this study utilized large surveillance datasets to estimate the intersectional effect of social determinants of childhood lead exposure documenting neighborhood factors that cooccur and interact to influence childhood lead exposure showing the synergistic effects of social determinants on childhood lead exposure at a neighborhood level strengthens the public health knowledge base on the social patterning of environmental exposures and informs primary prevention efforts to reduce childhood lead exposure secondary prevention of childhood lead exposure the identification and management of childhood blood lead levels after a child has already been exposed to lead is not sufficient to eliminate the disproportionate burden of childhood lead exposure in vulnerable populations 23 primary prevention of childhood lead exposure targeting the conditions that cause lead exposure before a child is exposed is the most effective approach to mitigating inequities in lead exposure 23 while milwaukee is one of many rustbelt metropolitan areas with lead concerns it has yet to establish a formal infrastructure that builds the capacity for primary lead prevention through policy change and coalition like the city of rochester new york has done 50 to tackle the link between neighborhood racialethnic composition and childhood lead exposure that this study illustrates lead prevention efforts must align with equityfocused housing and economic policies leadhazard reduction initiatives in residential housing have mandated lead safe certifications for rental units additional lead disclosures and expanded tenant rights 5152 these serve as models for local communities to implement primary prevention policies to mitigate childhood lead exposure particularly in neighborhoods that are disproportionately burdened by childhood lead exposure however action to strengthen tenant protections or efforts to increase home ownership must also address the legacy of policies and practices that have historically marginalized lower income communities of color conclusions poverty home ownership and raceethnicity at the neighborhood level cooccur and interact to produce inequities in childhood lead exposure the risk of elevated childhood blood lead levels is greatest in majority nonwhite milwaukee county neighborhoods with high poverty and low home ownership by illustrating the intersection of neighborhoodlevel social patterns associated with childhood lead exposure this study provides support for lead prevention efforts to align with equityfocused housing and economic policies to target primary prevention in neighborhoods disproportionately burdened by childhood lead exposure data cannot be shared publicly by the authors due to legal restrictions on surveillance data and data use agreement sharing restrictions childhood lead data was obtained from the wisconsin department of health services division of public health the data included sex age raceethnicity maximum blood lead level from highest value blood test between 2014 and 2016 the type of sample taken the month and year the test was administered an the census tract in which the individual resided data requests can be made to the wisconsin department of health services environmental public health tracking program at census tractlevel sociodemographics are publicly available from the american community survey 5year estimates at the us census bureau website supporting information s1 table descriptive statistics of milwaukee county census tracts by childhood blood lead levels milwaukee county census tractlevel distributions were averaged across all census tracts displaying the average percent or mean value by childhood blood lead levels s2 table descriptive statistics of milwaukee county census tracts by intersection of housing tenure and poverty level milwaukee county census tractlevel distributions were averaged across all census tracts displaying the average percent or mean value by intersection of housing tenure and poverty level s3 table socioeconomic and racialethnic composition of milwaukee county census tracts by average childhood blood lead level n 215 socioeconomic and racialethnic characteristics of milwaukee county census tracts with mean childhood blood lead level � 5 μgdl elevated and 5 μgdl not elevated s1 file linear regression analyses results estimated regression coefficients standard errors pvalues confidence intervals and rsquare for linear regression models

environmental conditions that contribute to childhood lead exposure are spatially patterned socioeconomic and racial inequities in childhood lead exposure have been well documented however childhood lead exposure in milwaukee is understudied as a segregated rustbelt metropolitan area with childhood lead exposure concerns milwaukee is uniquely positioned to evaluate the synergistic effects of racial and economic drivers of childhood lead exposure using surveillance data from the wisconsin department of health services division of public health and the us census bureau this crosssectional study determined the intersectional effect of poverty home ownership and racialethnic composition on childhood lead exposure in milwaukee county neighborhoods using linear regression adjusting for average census tract housing age and number of children the final analytical sample consisted of 48393 individual childhood blood lead levels aggregated to 215 milwaukee county census tracts census tracts with mean childhood blood lead levels greater than or equal to 5 μgdl were predominantly low home ownership high poverty and majority nonwhite census tracts the effects of low home ownership high poverty and majority nonwhite census tracts were synergistic producing 178 95 ci 144 211 μgdl higher mean childhood blood lead level than high home ownership low poverty and majority white census tracts referent this research reveals that social determinants at the neighborhood level cooccur and interact to produce inequities in childhood lead exposure lead prevention efforts should align with equityfocused housing and economic policies that target primary prevention in neighborhoods disproportionately burdened by childhood lead exposure

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and her flowers the sun and her flowers the sun and her flowers ankara orcid id 0000000172317523 introduction this paper aims to analyze and criticize the turkish translation of the english poems in the sun and her flowers written by the canadian poet rupi kaur even though criticizing translated poetry seems rather challenging the guidelines constituting the theoretical and methodological design of this study will be quite helpful in the evaluative process in this respect the analysis will be carried out by taking into consideration drydens three translation types which consist of metaphrase paraphrase and imitation and the macromicromacro methodological design the poems translated into turkish in chapter will be classified by three interraters based on their translation type on the macroand microlevels the macrolevel will form the final agreement of interraters on the type of the translated poem as a whole on the other hand the microlevel is targeted at finding out any distinct lines within the poem that fit into another translation type unlike its macro type the study aims to answer the questions of which and to what extent translation types of dryden are applied by the translator on macroand microlevels and the agreement rate of the three interraters and to display them as numeric data additionally the dominance of one of the translation types will also be discussed upon the clarification of results review of the literature even though most literature rest upon the first book of rupi kaur milk and honey a limited number of reviews on the sun and her flowers also exist in this regard the book review by ion family womanhood and on the other hand shares her realinternet resources also de regarding poetry translation and translatability of poems various scholars who have expressed their ideas on literary and poetic works are worth mentioning jakobson for instance defines poetry values such as paronomastic value may be lost for example the punning effect in the saying jakobson also introduces poetic language with two influential factors in sound selection and constellation of phonemes and constituents these factors should also be taken into account while evaluating poetry and its translation for schopenhauer poems cannot be translated either but can only be transposed therefore he believes that translatability and equivalence are not possible he also defends the idea that transposition is only possible by embracing the culture of the foreign language in use in contrast to schopenhauer goethe also accepts the translatability of poetry and he goes on to suggest the following three types of translation plain prose translation where there is a neutralization of the formal characteristics of poetic art the reader becomes familiar with foreign cultures and the meaning is made simple parodistic translation which applies to all poetic works and involves the transference of foreign content with the help of the style of the translator in this one there is reconstruction and assimilation by the translator which can be considered as domestication the final phase where the known and the unknown consequently come together to achieve a perfect identity with the original it can be inferred from such categories once again that goethe believes in the translatability of literary and poetic works another scholar paz focuses on poetry translation in his translation literature and letters for him translation is a universal activity among all cultures he suggests that the translators activity is parallel to that of the poet and the result of poetry translation is the reproduction of the original poem in another poem paz also thinks that poetry translation is difficult but not impossible and poetry should be translated by poets however poets can rarely be good translators therefore a very qualified translator should translate poetry similarly nabokov does not think that poetic texts are easy to translate for the following characteristics of language and prosody that russian poetry is particularly affected by number of rhymes length of words polysyllabic words all syllables are pronounced inversion and russian poems having a larger number of modulated lines rather than iambic ones for such reasons nabokov does not call the 131 believes that poetry can be translated but the readability will be lost in translation therefore poetry translation is only possible by a literal method methodology the theoretical framework of this paper is based on the translation types defined by dryden he introduces three types of translation metaphrase paraphrase and imitation dryden chooses paraphrase as his ideal method he negatively criticizes those who choose imitation as a way of translation for the type of paraphrase he says that the spirit of lation can be considered a sort of transfusion for him since a translator should not alter the characteristics of the work but make it similar to the original furthermore a translator needs to transport the spirit that gives the work life to keep the character of the author over the years he tends to use imitation though the theorist thinks that poetry is also translatable over time and suggests that translation is both an art and lost in transfusion dryden believes that the sense will be kept and moves from the prescriptive and normative approach to translation to the one with more latitude as well as indirectly involving culture within translation in this study b final charts this research follows a qualitative method in order to express the most used translation types qualitative data will be quantified and revealed as numeric data the qualitative data will be provided the sun and her flowers by rupi kaur the analysis of the translation is limited only to the aforementioned chapter because the analysis of the whole book will exceed the borders of this study and thus will be subject to further analysis to ensure the reliability of the numeric data 27 poems will be evaluated by three interraters who are native in turkish highly competent in english and working as academics in the field of translation studies the number of the most frequently used translation types will be presented and discussed in percental charts in this respect the following questions will be addressed to the interraters for the evaluation of the poem translations into turkish 1 which translation type of dryden does this poem translation in turkish fit into on the macrolevel metaphrase paraphrase or imitation 2 did you observe exceptional lines in the poem translation type you chose in other words do some of the lines of this translation fit into a different translation type on the microlevel unlike the type on the macrolevel the analytical process of the translated poems will present an eclectic method in which evaluation methodological framework for translation criticism hewson divides the process of assessment into four major stages which are shortly composed of preliminary data critical framework microand mesolevel analysis and finally macrolevel analysis the preliminary data will cover the basic information about the original work and its translation as well as the author and the translator to give more insights about the authortranslator profiles the translation method used by the translator and the quality of the final product the critical framework will include the identification of the poems to be analyzed with the purpose of determining the characteristics of the book and also examining the interpretative aspects this phase in this regard will mostly focus on the aspects of the source text at the next microand mesolevel analysis level the source and target texts will be brought together and the critic will analyze the choices taken by the translator and also give reflections on their potential effects some examples with a 100 interrater agreement rate among 27 translated poems in the translation with a lower agreement rate will be displayed and assessed in terms of its disagreed aspects along with the explanations of the interraters among the five chapters in the original methodological framework of hewson he categorizes the translations in four sections as centred classification analysis in this analytical section the design of translation criticism by hewson will be applied accordingly the preliminary data critical framework microand mesolevel analysis and macrolevel analysis will be presented below as part of the analysis of the translations of 27 poems into turkish in the sun and her flowers by kaur preliminary data in this part some basic information about the poet3 and translator as well as the original work and its translation into turkish will be given critical framework the original book has thematic chapters divided based on the life cycle of a flower wilting falling rooting rising and blooming the themes are more related to femininity love motherhood loss healing and migration the rooting chapter the focus of this study particularly emphasizes the concepts of migration language family and motherhood in minds it shoots a short movie of all the struggles that a migrating family undergoes on their journey from a distant land to a completely foreign one it also talks about the cultural boundaries such as traditions and language that the first generation of immigrant families are exposed to kaur expresses in her own words in one of her facebook posts6 that her poems are written in lowercase to give equality to all letters as one more representation of her feminist side often i am asked why i only use lowercase letters and periods in my poetry although i can read and understand my mother tongue i do not have the skill set to write poetry in it to write punjabi means to use gurmukhi script and within this script there are no uppercase or lowercase letters all letters are treated the same i enjoy how simple that is how symmetrical and how absolutely straightforward i also feel there is a level of equality this visuality brings to the work a visual representation of what i want to see more of within the world equalness and the only punctuation that exists within gurmukhi script is a period which is represented through the following symbol criticizing the turkish translation of the english poems in the sun and her flowers translation types kocaevliso in order to preserve these small details of my mother language i include them within this language no case distinction and only periods a world within a world which is what i am as an immigrant as a diasporic punjabi sikh woman it is less about breaking the rules of english but more about tying in my own history and heritage within my work her simple but meaningful drawings accompanying most of the poems also make her poetry easy to revive in minds in short through her poems she tries to deconstruct the conventional societal understanding and approach to women stylistically her poems are not bound to any rhythmic or metric structure so she is using free verses in general apart from poems she also writes prose from time to time at the end of almost every poem she writes in italics the content or the message she wants to give it is also of significance to mention that the turkish translation of the sourcebook completely preserves the original form it can be inferred from this conservation of the form of the book covers accompanying drawings and even the page numbers that this translation could also be considered as the formbased text type defined by reiss microand mesolevel analysis this section is reserved for a closer analysis of some of the poems and their translations randomly to note that three interraters have already been asked to analyze and categorize all 27 poems and their translations at macroand microlevels by considering the three translation types defined by dryden hewson explains the microand mesolevel analysis as target texts will hereby be presented and evaluated on microand mesolevels translations with completely agreed translation types will be randomly and limitedly demonstrated hereby for evaluation all translations on whose type the interraters could not agree by 100 will also be displayed under this section for the assessment of reasons given for disagreement in this respect the analysis begins with the following example st1 tt1 they have no idea what it is like to lose home at the risk of never finding home again to have your entire life split between two lands and become the bridge between two countries immigrant bir daha bulamama ihtimaliyle iki example 1 the turkish translation of this english poem is made in such a way that the meaning and the form of the original are completely kept in the tt if one analyzes this poem line by line she will see that there is no big deviation from the original meaning or the form for this reason all three interraters have accepted this translation type in the category of paraphrase both at macroand microlevels the paraphrastic clues are observable in the way the translator changes the style of wording for example 1 are translated as similarly the text in st2 keeps the exact form and meaning in its transfer into turkish it is observed that there is no concern by the translator to add more artistic or aesthetic effects in translation for instance s are to demonstrate paraphrastic features as a result all three interraters have again categorized this translation as paraphrase at macroand microlevels however the following examples will show some differences in terms of the disagreement among the interraters these disagreements are only at the microlevel though st3 tt3 i wonder where she hid him her brother who had died only a year before as she sat in a costume of red silk and gold on her wedding day she tells me it was the saddest day of her life how she had not finished mourning yet a year was not enough there was no way to grieve that quick it felt like a blink a breath before the news of his loss had sunk in the decor was already hung up the guests had started strolling in the small talk the rush all mirrored his funeral too much it felt as though his body had just been carried away for the cremation when my father and his family arrived for the wedding celebrations amrik singh y amrik singh example 3 this is one of the examples of the prose style of rupi kaur the translator utilises a paraphrastic way to she was still mourning in ttwith the two other interraters in terms of its type on the microlevel r2 categorizes some of the lines as imitation while the others see no difference with the macrolevel type they accepted as 3 original text might refer to both the goldwork on indian traditional red wedding dresses and the golden jewellery traditionally worn by the indian brides at this point the translator must have made turkish also gives the clue of adaptation to the target culture given this explanation for choosing the relative line as imitation an even more imitative attempt for the texture is usually red velvet and adorned with gold patterns another disagreement is displayed below st4 tt4 despite the categorization of this translation as paraphrase on the macrolevel by all interraters r3 detects imitative lines on the microlevel it is noted that the italic form as well as the simple format in 4 is transferred to tt4 as it is the reason that r3 gives for the line that 4 which is a more local and dramatic kept in the translation of this poem at all levels what st5 tt5 given my mother on her wedding day 1 you are allowed to say no 2 years ago his father beat the language of love he will never know how to say it but his actions prove he loves you 3 go with him when he enters your body and goes to that place sex is not dirty 4 no matter how many times his family brings it up lock the relatives out and swallow the key he will not hate you 5 take your journals and paintings across the ocean when you leave these will remind you who you are when you get lost amid new cities they will also remind your children you had an entire life before them 6 when your husbands are off working at the factories make friends with all the other lonely women in the apartment complex this loneliness will cut a person in half you will need each other to stay alive 7 your husband and children will take from your plate we will emotionally and mentally starve you all of it is wrong at sacrificing yourself is how you must show love 8 when your mother dies fly back for the funeral money comes and goes a mother is once in a lifetime 9 you are allowed to spend a couple dollars on a coffee i know there was a time when we could not afford it but we are okay now breathe or operate a computer or cell phone we did that to you it is not your fault you are not any less than the other mothers with their flashy phones and designer clothing we confined you to the four walls of this home and worked you to the bone you have not been your own property for decades 11 there was no rule book for how to be the first woman in your lineage to raise a family on a strange land by yourself 12 you are the person i look up to most resimleri seni para gelir gider ama bir kez veda edersin annene rahat ol criticizing the turkish translation of the english poems in the sun and her flowers translation types kocaevli13 when i am about to shatter i think of your strength and harden 14 i think you are a magician 15 i want to fill the rest of your life with ease 16 you are the hero of heroes the god of gods example 5 in this poem in a listing format the translation type on the macrolevel is accepted as paraphrase the translation appears to have been conducted based on the explanatoryinterpretative sense for instance er of my father children will take from your p as your husband and children join your table in tt5 also serve as the paraphrastic features of the translation the translator makes a translational choice of using positive connotations instead of negative ones by also keeping the sense on the microlevel on the other hand r1 marks the translation of certain lines as imitation with the explanation as follows st5 demonstrates imitative clues adaptation to the target culture even though the corresponding or the equivalent word 5 could have been lira 5 the translational choice is made for the equivalent of cent in tt5 it gives this line a more turkish context in this sense this microunit in this poem displays imitative tendencies unlike its macro type the next one is also another example of a longer poem st6 tt6 broken english two university degrees that meant nothing one mother tongue that was broken now one swollen belly with a baby inside a father worrying about jobs and rent cause no matter what this baby was coming and they thought to themselves for a split second was it worth it to put all of our money into the dream of a country that is swallowing us whole and sees loneliness living where the iris was wants to give her a home in a country that looks at her with the word visitor wrapped around its tongue on their wedding day she left an entire village to be his wife now she left an entire country to be a warrior and when the winter came they had nothing but the heat of their own bodies to keep the coldness out like two brackets they faced one another to hold the dearest parts of them their children close they turned a suitcase full of clothes into a life and regular paychecks to make sure the children of immigrants immigrants they worked too hard you can tell by their hands their eyes are begging for sleep but our mouths were begging to be fed and that is the most artistic thing i have ever seen it is poetry to these ears that have never heard what passion sounds like and my mouth is full of likes and ums when i look at their masterpiece cause there are no words in the english language that can articulate that kind of beauty wentysix letters and call it a description i tried once but the adjectives needed to describe them so instead i ended up with pages and pages full of words followed by commas and more words and more commas translations however he favours the use of paraphrase as the dominant type in most of his poetry translations this draws a correlation between drydens and the translators choices in the translation of poems nevertheless the possibility of the impositions by the publishing house on the translator for this particular choice should always be born in mind conclusion the sun and her flowers hold 100 of paraphrastic translation style on the macrolevel while there is a slight difference on the microlevel some of the lines within the poems analyzed and criticized by the three interraters show that it is not under the category of paraphrase but imitation this translation type deviation on the microlevel is only by 370 in the entire poems under evaluation the agreement rate of 90 also proves high reliability for the assessment of the poems by the experts in the field the percentages in the final charts in this analysis of the book consequently affirm the ideal translation type paraphrase that dryden had favoured and used particularly in his translations of poetry therefore it can be concluded that the turkish translator of the sun and her flowers like dryden has followed and adopted the paraphrastic way of translating poems from english to turkish to a great extent criticizing the turkish translation of the english poems in the sun and her flowers translation types kocaevlionly to realize there are some things in the world so infinite they could never use a full stop so how dare you mock your mother when she opens her mouth and broken english spills out she split through countries to be here cross a shoreline her accent is thick like honey hold it with your life instead hang it up on the walls of museums next to dali and van gogh her life is brilliant and tragic kiss the side of her tender cheek she already knows what it feels like to have an entire nation laugh when she speaks she is more than our punctuation and language we might be able to paint pictures and write stories but she made an entire world for herself how is that for art example 6 the translation type on the macrolevel is selected as paraphrase since it is easy to read and understand stthe translator first interprets and fits them into the turkish phrasal patterns however there is one interrater again who finds some of the lines that fit into imitation the interrater gives the following explanation for categorizing certain lines as imitation what see full of likes and ums in tt6 at first glance the literal likes and ums 6 in its essence add if she gave up on her homeland to be here in tttakes the initiative of focusing on the sacrifice the mother makes rather than mentioning the comfort of her offspring for not having to go through the same struggles for such reasons these lines display imitative features r u m e l i d e 1 6 1 7 the sun and her flowers kocaevlirezgui given the explanation of r3 there is both stylistic and semantic loss in tt6 considering particularly the omissions made in the abovementioned lines while transferring the feeling of the original lines therefore these comments lead to the existence of imitation on the microlevel of this poem the evaluations of the extracted poems above will be further discussed on the macrolevel in the next types macrolevel analysis it is observable in all the poems that the overall structure both in meaning and form encompasses a paraphrastic nature even though there are some slight differences detected by the interraters on the microchapter of her book the sun and her flowers is found to be paraphrase the form of the poems is also kept in the same position the following section will present more numeric data about the final result of the assessment of all poems on both macroand microlevels results and discussion the sun and her flowers has been analyzed based on drydens translation types by three interraters at the macrolevel all poems are found to be translated as paraphrase however only one poem has been categorized under imitation on the microlevel analysis there are four poems on which there are certain disagreements among the interraters even though it is rather a weak difference it is of importance to note that the interrater reliability proves high by 90 calculated based on the percent agreement formula 7 the results are demonstrated in percentages as follows figure 1 figure 2 these figures can be interpreted in such a way that the translation type of paraphrase is by no exception the dominant type which shapes the translation of kaurs poems metaphrase type is not observable in any of the levels therefore these poems can be considered as meaningbased but imitationdeficit type on the microlevel the small percentage of imitative tendency shows that there are tiny deviations from the mainstream use of paraphrastic type just as dryden would apply in his own

the canadian poet rupi kaur a child of an immigrant family is a rising figure in contemporary poetry which particularly focuses on immigration and womanhood the english poems in the the sun and her flowers 2017a reflect what she has experienced as a firstgeneration female immigrant to analyze this experience in the target culture this study concentrates on the poems translated into turkish in 2017b by gizem ald is based on john drydens three translation types 1992 metaphrase paraphrase and imitation for the data analysis the original and the translated poems are classified in terms of hewsons macromicromacro methodological design 2011 interrater reliability is ensured with the participation of three field experts during the data analysis the macrolevel analysis represents the final agreement of the field experts on the overall type of the translated poems in the defined chapter the microlevel analysis on the other hand aims at finding out any unusual lines within a specific poem that fits into a translation type different from its macrolevel type the findings of the study show that the turkish translations of kaurs poems hold 100 paraphrastic translation style on the macrolevel while there is a slight deviation on the microlevel

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introduction gender stereotypes reflect general expectations about typical men and typical women and a central claim in social role theory is that stereotypes change in time and when social context changes more specifically the changes in the content of stereotypes follow the changes of typical activities associated with a particular social role for example as women participation in the workforce substantially increased in the last decades the content of socially shared gender stereotypes changed as well and modern women tend to be described as more masculine than women of the past a typical procedure used to explore dynamic stereotypes is to ask participants to describe people as they were typical in the 50s 70s or current time although informative on the difference in gender related attributes ascribed to women and men across various time frames this method is subject to recollection biases and it does not allow an accurate evaluation of the real stereotypic content associated with men and women moreover empirical research rarely captures simultaneously the effect of historical changes gender and age on the dynamics stereotypes content historical effects can be attributed to how specific social roles change in different historical periods while age effects reflect the change that can be attributed to specific role changes across the lifespan of individuals in other words change in the content of gender related stereotypes can be attributed to the fact that in time the generic content of the gender social roles changes or to the specific difference in the social roles of individual members in a community across their lifespan these crosstemporal and crossdemographic comparisons are also restricted due to limited data availability we suggest that the use of a historical approach that rates the content of gender stereotypes in cultural artifacts can be a useful approach to investigate the content of dynamic gender stereotypes such cultural artifacts are rich repositories of valuable social knowledge that can be used to make inferences on the dynamics of social cognition moreover previous research using noninvasive historical approaches shows that obituaries as short biographical descriptions can be used to capture the way in which the content of stereotypes changes in time we therefore set out to explore using this novel historical approach gender stereotypes recorded in a cultural artifact claimed to be a social knowledge repository in a small romanian community the epitaphs written on the bluepainted crosses of the merry cemetery of sȃpânţa summarize the identities of deceased community members dating back to the 1930s examples of painted crosses with the written epitaphs are presented in figure 1 in this paper we answer the call for more ecological investigations of how stereotypes actually change over time and we aim to investigate the way in which age the social roles and historical periods influence the content of gender stereotypes used in the epitaphs to describe the deceased community members this ecological and historical perspective allows us to capture timebounded snapshots of personal biographies and isolate the historical period effects from age or social rolesrelated effects on stereotype change dynamic gender stereotypes initial research on the content of gender stereotypes claimed that the beliefs related to gender differences are stable across life stages and rather stable in time recent approaches theorized gender stereotypes as dynamic constructs and show that some of the gender specific attributes associated with men and women might change in time due to the inherent changes in societal dynamics and social roles as diekman and eagly claim these results are aligned with the conception of individuals as implicit social role theorists that observe transitions in gender related expectations that are closely related to social changes people act as implicit role theorists and make inferences about the typical attributes of men and women depending on the dominant social roles each social category tends to fulfill in the past women were mostly observed in domestic householdrelated roles and as such were attributed more communal traits while men were observed more in breadwinner roles and were ascribed more agentic traits as the social and historical contexts are changing these changes are expected to reshape the roles men and women take using a typical design for studying dynamic gender stereotypes banchefsky and park show that mothers and fathers of the future tend to be seen as more similar than they were seen in the past these changes are explained by the fact that men and women are expected to assume more similar social roles in the future in other words a key tenet of dynamic gender stereotypes is that the change in the social context is associated with changes in the descriptive norms and attributes ascribed to men and women at least three perspectives coexist with respect to the change in the social context a historically driven change in the content of gender stereotypes as a consequence of changes in the differential access to specific social roles that men and women have across different time periods a change associated with the accumulation of various roles during the lifespan and a change in the adoption of specific social roles by various individuals gender influences gender schema theory posits that social categorization processes trigger gender schematic information processing leading to specific stereotypical attributes being associated with men and women individuals belonging to the same social category tend to share more similar attributes than they do with individuals that belong to different social categories in line with the depersonalization principle in social categorization while organizing the information about their social world people use generic gendertyped schemas to attribute gender specific characteristics to individuals they categorize as men or women according to these social categorization claims the gender schema theory states that men should be described more in terms of masculine traits while women should be described using feminine attributes in romanian rural communities men are seen as more inclined to take public roles while women are seen as being more active in the familyrelated roles the specific context in which we could explore the content of the cultural artifacts is a rural community in which the gender roles still follow a traditional distinction with women more present in domestichomemaker roles while men are more present in publicbreadwinner roles in line with these theoretical arguments we expect that in the epitaphs of the merry cemetery of sȃpânţa the incidence of feminine attributes will be higher for women than for men while the incidence of masculine attributes will be higher for men than for women influences of historical periods social events that unfold during history bring forth changes in the way individuals experience life and ultimately impact on their individual attributes personality and identity moreover sewell argues that major historical events trigger changes in social structures and institutions as individuals live their lives in intricate social structures and comply with various institutional norms the change of these social structures and institutions triggers changes in personal identity as well we build on these theoretical concepts that tie personal development to historical changes and argue that gender attributes as prototypical representations of social roles attributed to men and women change as a function of major historical events in particular critical social events such as wars tend to favor masculine attributes therefore the use of masculine traits is expected to dominate during times of social unrest such as wars and social conflicts while feminine attributes are expected to be associated with social stability starting with the 1930s when the practice of writing epitaphs on painted crosses at sȃpânţa was initiated by ioan stan pãtras ˛ three major historical events in the sense described by sewell can be identified the first one is the period surrounding the world war ii a time of social unrest and conflict that affected virtually the whole romanian territory the second major historical change is the instauration in the late 1940s and domination until 1989 of the communist regime previous research explored the implications of communism ideology for gender discrimination and sexism the communist era in romania was initially marked by social unrest and resistance against the new regime and then after 1967 during the ceaus ˛escu regime marked by a pervasive propaganda focused on social equality and nationalism this period was also influenced by the propagandistic image of the heroic mother and the marked public presence of ceaus ˛escus wife as idealized image of the mother of the nation finally after 1989 the postcommunist era reflects a transition to a market economy and adoption of capitalist values and social practices in line with these historical events we expect that masculine and instrumental attributes will dominate in the period surrounding wwii and the early turbulent years of the communist regime while during ceaus ˛escu regime under the intense propaganda that favored feminine attributes and equality we expect feminine attributes will become more prevalent in the epitaphs of the mcs in other words we expect a positive association between femininity and year of death social roles influences social role theory posits that people describe themselves and are described by others in line with the social roles they occupy previous research has shown that the increase in participation of women in the paid labor force fosters the ascription of masculine attributes to women moreover in general employees tend to be characterized by masculine rather than feminine attributes when compared with homemakers this effect was gender insensitive in that both men and women with a paid profession were described using masculine rather than feminine traits in rural communities employed people have to often combine their professional roles with household activities and additional social roles therefore we also expect a role accumulation effect for people with paid professions in line with these arguments and also in line with the claims of dynamic stereotypes perspective we argue that people engaged in paid work will be described as being more masculine and androgynous than homemakers age influences role accumulation across the lifespan was conceptualized as a source of gratification as various roles assumed simultaneously by individuals bring multiple role privileges offer multiple resources for building and maintaining social status and contribute to the personality and ego enrichment in line with these role accumulation arguments as individuals may take multiple roles simultaneously another hypothesis derived from the social roles theory is that the number of attributes used to describe a particular person proportionally increases with the number of roles that a person takes in a developmental perspective as they grow older individuals accumulate various roles and as roles and life experiences accumulate during ones lifespan it is also more likely that androgyny increases with age in line with these arguments we therefore expect that the incidence of both men specific and women specific attributes in the epitaphs of the mcs will increase with the age of the deceased person literature to date explored the interplay between societal changes and the changes in the content of gender stereotypes societal changes bring forth changes in typical gender roles as well as changes in social status for men and women diekman et al compared the content of dynamic stereotypes in us chile and brazil their results show a steady increase in womens perceived masculinity in all three cultures while for men this increase was observed in chile and brazil and was associate to the societal changes specific to these countries in another study on the dynamics of power in relation to gender diekman et al show that the perceived power increases steadily for women while for men remains relatively stable for a nonwestern cultural context bosak et al show gender differences in the historical period effects such that in time ghanian women tend to be perceived as being more masculine while men are perceived as gaining in femininity in a crosstemporal metaanalytic investigation of bem sex roles inventory scores twenge reports gender specific and significant cohort effects for masculinity a more recent metaanalysis on the crosstemporal dynamics of the bsri scores shows a decline in womens femininity between 1993 and 2012 while their masculinity did not increase in this time interval to summarize the results to date suggest that gender might qualify the effect of age profession and historical period as they were hypothesized earlier however as the moderating role of gender is closely related to the specific societal historical and cultural context in which it is investigated we set out to explore this moderating role without formulating specific hypotheses ethics statement this study is based on artifact analysis and it involved the analysis of public data although the data reflects individual biographies none of the participants were alive at the time of the study in the data sets on which analyses were carried out participants were anonymized and because no additional harm was inflicted on the participants we did not seek an irb approval for this study materials and methods gender stereotypes evaluation to evaluate genderrole stereotypes we have adapted items from the bem sex role inventory because this measure was extensively used in various cultural contexts although bsri was previously used to evaluate both gender identity and gender stereotypes given that the content of the items largely overlaps with the content of gender stereotypes we used the bsri attributes as indicators of gender stereotypes present in the epitaphs moreover because in our study we have analyzed the content of a cultural artifact consisting of short biographical sketches made by third parties and we do not rely on selfreports the results based on the bsri reflect stereotypes contents and not gender identity we have used research on gender stereotypes carried out in romania to find gender specific attributes for men and women identified in this particular cultural context we started by exploring previous analyses using the bsri on romanian samples and selected the most representative items for the malefemale role description as previous research points out that in traditional romanian communities women are perceived as being strongly involved in the familyprivate domain while men as being strongly involved in the public sphere we also included two attributes devoted to family and devoted to community to the items selected from the bsri some of the items used in the short form of bsri were adapted for example leadership ability does not differentiate among men and women in the romanian context as incidence of women leaders was rather high during the communist regime and both men and women specific attributes are associated with effective leadership styles we therefore used takes the initiativeleads as a male typical attribute moreover in traditional romanian communities women are perceived as being more religious than men are therefore religious was added as a typical feminine attribute the final selection of items included 15 male and 15 female typical attributes the attributes and their respective factor loading in the first two dominant factors are presented in table 1 epitaphs sampling and coding we have used a stratified selection procedure to compile the list of epitaphs to be coded and further analyzed we selected 197 epitaphs of community members deceased between 1935 and 2010 with ages up to 96 years old a problematic category was the preadolescence age group that was underrepresented in the final sample of epitaphs yet the sample also included deceased newborn infants we however deemed relevant to include adolescence and preadolescence as well in order to have a more complete picture of the lifespan variation of gender stereotypes an independent coder unaware of the specific hypotheses of the study coded each of the epitaphs using the bsri attributes we have used an integrative coding procedure such that synonyms for the bsri attributes or implied attributes from selected biographical facts were also considered in the coding scheme each attribute from the list that was deemed to be present in the epitaph was coded with one and the ones that were not present in the epitaph were coded with zero results preliminary analyses as the metaanalytic investigation of choi and fuqua showed that the factorial structure of the bsri might not be stable across contexts we started by analyzing the factorial structure of the bsri for our study we have used paf that revealed two dominant factors that cover together more than 47 of the variance in the scores the first dominant factor had an eigenvalue of 162 and covers 278 of variance in scores while the second dominant factor has an eigenvalue of 112 and covers 1928 of variances in scores we have used the results of the factor analysis to compute two dominant factor scores and in order to obtain scores as close as possible to the true factor scores we have used the bartletts approach although in the bartlett approach the extracted factors may still be correlated the scores are indicative of the true factor evaluated by the items included in the scale the two dominant regression factor scores obtained in our analyses were uncorrelated and the item loadings in the two dominant factors are presented in table 1 most of the items load as expected on their respective factor score the masculine items load in the first factor while most of the feminine items load on the second one the two resulting dominant factor scores were saved as variables and used as indicators of masculinity and femininity in subsequent analyses as they are accurate factor estimators to which each of the bsri items contribute with its individual factor load in line with previous research we have used three main indicators derived from the bsri masculinity was evaluated using the first dominant factor score that resulted from the factor analysis while femininity was evaluated using the score of the second dominant factor as bartlett scores are likely to be indicative of the true factor scores in what follows we will report the results of the analyses using the bartlett dominant factors scores derived from covariance matrix in the factor analyses using pfa however because the regression procedure for computing the dominant factor scores maximized the validity of the estimates we also used this procedure for computing the factor scores in order to cross check the results androgyny was computed using the procedure described by donnelly and twenge namely we subtracted the value of the absolute difference between masculine and feminine attributes that loaded in their respective factor from the total number of attributes androgyny mf to compute the androgyny score we kept the scores for the items presented in bold in table 1 and a high score for androgyny reflects the coexistence of both masculine and feminine traits in order to make sure that the coding of the epitaphs was accurate we asked a second coder to evaluate forty epitaphs coded by the main coder and we have computed the intraclass correlation coefficient in order to correct for agreement by chance for the masculinity attributes the intraclass correlation coefficient was 087 and the chisquare was 596 while for the femininity scores the intraclass correlation coefficient was 084 and the chisquare was 359 showing evidence of substantial agreement between the two coders based on this substantial intercoder reliability we have used for further analyses the coding of a single independent coder the resulting codes were further checked for consistency and for the masculinity scale cronbachs alpha is 090 while for the femininity scale cronbachs alpha is 083 we can therefore conclude that the coding procedure resulted in reliable estimates of masculinity and femininity ols regression analyses means standard deviations and correlations for the variables included in the study are presented in table 2 in order to test the hypotheses we have used ols regression analyses with femininity masculinity and androgyny as dependent variables as predictors we have entered in the first step gender paid profession year of death based on a suggestion received during the review process we accounted in the second step for the plausible nonlinear effect of age as well as for the interaction between gender and age year of death and paid profession it is likely that role accumulation reaches a maximum in the late adult life and as such androgyny reaches a plateau around the age of 60 moreover the effect of historical periods age and profession might show a gender dependency as mentioned in the theoretical arguments in order to account for these potential effects we have entered the squared term for age and the interaction term between gender and all the other between subjects variables in the second step of the analyses age and year of death were grand mean centered before computing the crossproduct terms and the squared term for age the results of these analyses are presented in table 3 for illustrative purposes we also depict in several figures the slopes for masculinity femininity and androgyny gender had a negative and significant effect on masculinity β 028 and a positive and significant effect on femininity β 045 showing that in line with hypothesis 1 women were characterized by more feminine than masculine attributes and the opposite is observed for men therefore we can conclude that hypothesis 1 was supported gender differences were however not significant for androgyny β 002 therefore men and women did not significantly differ on androgyny moreover the historical period had a positive and significant effect on femininity β 024 but not on masculinity β 006 showing that femininity increases in time while masculinity did not show a significant increase in time therefore we can conclude that hypothesis 2 was also supported the results are depicted in figure 2 as indicated in figure 2 masculine attributes dominated during the period around the wwii and initial communist years while the feminine attributes dominated in the late communist period the results presented in table 3 showed that also androgyny had a significant positive association with the time passage β 021 the positive and significant effect of historical period on androgyny is therefore likely to be explained by the increase in feminine attribute used in more recent years because the effect of profession on masculinity was positive and significant β 020 and as depicted in figure 3 people with a paid profession were described with masculine rather than feminine traits we can conclude that hypothesis 3 was also supported moreover gender moderated the effect of paid profession on masculinity β 027 in such a way that for women the difference between homemakers and the ones with a paid profession was larger than for men finally the main effect of age on masculinity was significant β 051 and as depicted in figure 5 masculinity scores increased with age while femininity scores did not show a stable increase with age moreover our results show that the androgyny increased with age as indicated in model 1 presented in table 3 therefore we can conclude that hypothesis 4 was also supported as illustrated in figure 6 this effect was stronger for women than for men we further analyzed the effect of gender for the two bsri dimensions separately and as indicated in table 3 age had a positive association with masculinity and not femininity moreover although age had a significant association with androgyny β 024 this effect was significantly moderated by gender β 024 after adding the crossproduct term in model 2 the main effect of age became not significant β 007 while the interaction term between gender and age remained positive and significant as depicted in figure 6 androgyny increased with age for women but not for men role accumulation seems therefore to go hand in hand with masculine traits as only these showed a significant positive association with age although the squared term of age was not significant β 012 the graphical depiction of the relationship between androgyny and age seems to reach indeed a plateau around the age of 60 as illustrated in figure 7 discussion in our study we have sampled the epitaphs of the merry cemetery of sȃpânt ˛a and analyzed the short biographies of 197 community members deceased between 1935 and 2010 both masculine and feminine traits were coded for each of the sampled epitaphs as most of the current research on the dynamic gender stereotypes stems from western urban contexts our study extends current research and calls for further exploration of dynamic gender stereotypes in a variety of social and historical contexts given the comprehensive nature of our data set we could explore the dynamic nature of gender stereotypes by simultaneously investigating three sources of change historical periods social roles effects and role accumulation across the lifespan gender is coded as a dummy variable with 1 women and 0 men paid profession is coded as a dummy variable with 1 has a paid profession and 0 does not have a paid profession historical periods first we have investigated the influence of major historical events on the use of masculine and feminine traits and we have found that in situations of social unrest community members were described using more masculine traits while during the late communist period the feminine traits dominate an important observation emerges from the analysis of the interaction effect depicted in figure 2 namely that during the first years of communism masculine attributes seemed to be also dominant fact that was probably associated with the resistance to the instauration of the new political regime during the wwii and the first communist years both men and women are predominantly described using masculine attributes the social unrest that governed these historical periods probably pushed people to take more agentic and active roles on the one hand men were actively involved in the conflicts in the public sphere while probably women had to take active roles and assume masculine attributes on the home front we argued that historical events change stereotypes via two mechanisms on the one hand critical events change the very nature of life in communities and as the actions and behaviors change so do the genderrelated attributes on the other hand critical events change the social structure and the institutional norms that are governing social behavior with the change of social structure comes a change in specific role prescriptions and role expectations our results show that for example during the late communist era as the social equality propaganda and the myth of the heroic mother became widely spread after the 1970s the use of feminine attributes increased substantially and almost overruled the use of masculine ones that dominated during the previous times marked by war and social unrest our study is among the first to directly test the role of historical events on the dynamic nature of stereotypes and we call for more research that investigates the way in which critical events shape the content of gender stereotypes social roles effects second we investigated the extent to which being employed impacts on the use of masculine traits and in line with previous research we have found that employed people are described using more masculine traits than homemakers this result is in line with the social role theory stating that the ascription of gender attributes is dependent on the social roles fulfilled by individuals according to our results employed individuals are described by masculine rather than feminine traits while the opposite is valid for homemakers as illustrated by the positive effect of paid profession on androgyny the role accumulation hypothesis is also supported by the fact that in general employed members are described by more attributes than unemployed individuals women had traditional professions like weaving and spinning and an illustrative example is presented in the following epitaph here i take my final restih is my namealready from my early childhoodi was very creativemy work made my exhibitions famousthroughout the whole countryfrom craiova to bucurestii went to show my creationstraditional rugs from sȃpânţai have made weaving and spinning an artand i taught many girls to do it as welli have made beautiful thingswhich i sold throughout the countryand death found me in the capitalwhere i came to sell my traditional rugsmaybe i could have lived longerbut with sorrow i am telling youmy days were numberedand my life faded awayi was taken from my dear onesmy husband is now alonetwo sons daughters in law and grandchildrenwill all certainly miss mei would also like to tell my colleaguespreserve your traditional artdont let it go to waste men on the other had had a wider range of professions from tractor drivers to engineers as illustrated by the following two epitaphs excerpts here i lie to take my restand sm is my namenobody should have the bad luck i hadi was a tractor driveri death found me at my workfar away from my villagei had to leave this life at a very early agemy poor motherwill never forget meand she will grief me as long as she will live and as long as i livedi have studied a lotgraduated university with honorsbecame a civil engineeri had a good job at the municipality in baia marebut the bad and ruthless death put me to restand did not forgive metook my young life only 50 epitaphs in our sample made explicit reference to paid professions therefore a further clustering of the epitaphs using professional categories would have reduced the sample size for the professional categories although women had more traditionally feminine occupations the ones that had a paid figure 6 the interaction effect between age and gender on androgyny profession were described in more masculine terms than men having paid professions we believe this result is in line with the role accumulation argument because in rural communities such as sȃpânt ˛a the paid employment comes often on top of other social roles fulfilled in the household and community women with a paid profession are described as being masculine and given that older women are also more androgynous these results indicate a significant role overload experienced by women in rural romania one epitaph excerpt clearly illustrates this dual role constraint here i lie to take my restand is is my nameas long as i livedi was blessed with golden handsi sew blouses for girlsand i worked hard for many of themso i could earn a livingand raise my five childreni raised them wellwith gods helptwo of my daughters married welland also one of my sonsmy kids were my joy in lifeand i had to leave them too soon age effects we also show that as social roles accumulate during ones lifetime so does the number of attributes used to describe the community member young infants were described by a rather small number of attributes and most certainly at young ages the feminine traits are dominant a clear trend illustrated by our data is that masculine traits systematically increase with age we believe this trend is aligned with the role accumulation hypothesis as individuals start taking active roles in the family and community they are described using more masculine traits an interesting observation emerges from the additional analysis of the nonlinear association between age and androgyny as indicated in figure 7 the role accumulation effect fades away after the age of 60 and it is conditional on gender androgyny seems to become more apparent for women as they grow older but not for men in other words in this rural community masculinity increases with age especially for women and this explains the interaction effect between gender and age on androgyny implications we answer the call for more ecological investigations of how gender stereotypes really change in time and our key contribution is that we explore a cultural artifact and consider simultaneously various sources of stereotype change by including gender age historical period and profession simultaneously as predictors we could partial out their separate main influences moreover as indicated by the regression analyses masculinity is predicted by age and paid profession while femininity by passage of time the historical perspective taken here allows us to disentangle the role of ontogenesis and historical events in shaping the content of gender stereotypes by including passage of time and the effect of age simultaneously in our analyses we disentangled the effect of ontogenesisrelated factors versus social changes emerging during various time intervals our study extends the research on the dynamic nature of stereotypes and opens valuable research venues especially geared toward using secondary data or cultural artifacts for the exploration of how the content of gender stereotypes changes under the influence of various factors first we show that it is important to disentangle the historical period effects from the other factors that impact on the content change in stereotypes these historical period effects however capture the implications of various societal historical and cultural characteristics therefore our results point to the need of exploring various specific contextual variables like major social events and their direct effect on the content of gender stereotypes the increased availability of secondary data in recent years through the internet and social media could in principle generate ample opportunities to analyze and capture the interplay between contextual changes the gender stereotypes in different cultures and societies second our study shows the relevance of evaluating timebond biographical snapshots as indicators of gender stereotypes previous research on gender stereotypes in management used obituaries to explore differences in the way successful managers were described in western european countries as well as in communist and postcommunist romania as the content of the epitaphs and obituaries are likely to be influenced by social norms that also impact the stereotyping process in real social interactions these artifacts are accurate reservoirs of stereotypes similar approaches can be adapted to explore the way in which for example political regimes with their specific social structures and institutional profiles shape the content of gender or other social stereotypes limitations although we believe our study contributes to the research on dynamic stereotypes it also has several limitations first the data used in this study is restricted to a particular community and it cannot be easily generalized second the research is nonexperimental and noninvasive therefore no causal claims can be derived from our results third although we have considered various factors that could impact on the use of feminine or masculine traits the content of the epitaphs could have been shaped by other factors as well we could not account for the process of writing the epitaphs these are stylized summaries of ones life and the artist who designed the cross and the family of the deceased member could in principle decide on the content of the epitaphs one could argue that the epitaph contents are idealized depictions of ones life yet as clearly illustrated in the analyses reported in curşeu and popcurşeu an important cluster in the epitaph contents are the negative attributes therefore we cannot but assume that the epitaphs capture the quintessential attributes of the community members the type of profession for example could be another relevant factor that could drive the content of gender stereotypes due to the rather small sample size for participants with a paid profession this analysis was not deemed appropriate in the context of our study conclusion our study uses a novel historic approach to investigate the dynamic nature of gender stereotypes in a small romanian community we have analyzed the gender stereotypes used in the epitaphs written on the bluepainted crosses of the merry cemetery of sȃpânţa our results support the effect of social roles on stereotypes showing that people with a paid profession tend to be described with masculine attributes moreover our results support the role accumulation across the lifespan showing that androgyny increases with age especially for women who are described as having more masculine attributes in late adulthood while young children are mostly described using feminine attributes in late adulthood masculine attributes are dominant for both genders finally our results open new venues for exploring the link between social change and the content of gender stereotypes by showing that during historical periods marked by social unrest masculine traits are dominant while in nonconflictual historical periods feminine traits dominate especially for women conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

gender stereotypes are shaped by the roles men and women fulfill in society our study uses a cultural artifact analysis and explores the way in which remunerated jobs development across lifespan and historical time frames influence the content of gender stereotypes we coded the feminine and masculine attributes in a selection of epitaphs written on the painted crosses of the merry cemetery of s ȃpânţa romania between 1935 and 2010 this novel historical approach allowed us to explore the dynamic nature of gender stereotypes and the extent to which changes in the social context or the social roles have transformed the content of gender stereotypes we show that during years of social unrest associated with the world war ii and the early communist years the masculine attributes are dominant while during the last decades of the communist regime and the postcommunist period the feminine attributes become more prevalent moreover people having paid jobs are described as being more masculine than the homemakers finally our results show an increase of masculinity during the lifespan for both male and female as well as an increase of androgyny with age for women and a slight decrease with age for men

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introduction truth manipulation through social media platforms impacts negatively or positively a wide array of our socioeconomic life digital technologies shape our identities social relationships and perceptions of the world around us gallese highlights how mediascape has shaped the world and influences meaningmaking or building perceptions and social cognition our ways of meaningmaking from words and images are changing due to the digitally mediated reality social media platforms have become a crucial political tool for public diplomacy at home and abroad netizens interpret policy declarations and opinions on social media as official statements hansen and lim argue that social media can influence the cognition and behavior of voters ultimately diverting the trends in democracy and political order the information trends on social media platforms can leverage social and political cognitions for changing policy preferences the political cognition of people is strongly influenced by the language and images used in the content on media platforms social media is heavily used by those who want to manipulate the truth intentionally or otherwise to propagate theories for their benefit social media gives such people or groups the platforms to fabricate information allowing them to plan deceptive conduct hameleers et al argue that the restricted inclination of factchecking and the intentional use of images in social media have made the digital environment prone to the unchecked spread of disinformation the truthmanipulative groups employ a variety of visual content including games and movies to spread their ideology among the masses since social media users place a higher value on visual or graphic information than textual information abdelraheem and alkhammash concluded that framing of content influences how people react to certain incidents or news stories on the political front there is a significant increase in using cyberspaces for statesponsored operations against foreign political actors and institutions and domestic political oppositions political misuse of social media platforms deeply affects online contents modesty and influences netizens perceptions and cognition during the 2016 us presidential election swire et al looked examined how people processed real and incorrect political information in their minds the results of such corrective measures are limited notwithstanding the possibility that factchecking news or information online might lead to more accurate political knowledge amidst significant events such as the covid19 pandemic people mainly rely on information from social media platforms in many cases their wish to stay informed about that event caused the instant spread of misinformation su et al revealed that informationseeking activity on social media was the major driver of false beliefs regarding the coronavirus such platforms must persuade users to verify online informations veracity for them to be effective kelly constructed a framework for selecting news based on perceptions of objectivity and trustworthiness discovered that when information from untrusted sources accords with preexisting ideas it is regarded as being more trustworthy and less biased algorithmically curated material online such as on social media impacts public opinion since the online ecosystems primary goal is to catch the audiences attention the truth by repetition effect as described by corneille et al is the tendency for people to place greater trust in recurring assertions or ideas than in novel ones the idea of reasoning supports identityprotective cognition which is utilized to explain the material fitting with ones political viewpoint and is frequently cited as a push factor for individuals believing in fake news despite the availability of tools for examining the veracity of internet information not everyone has access to or knowledge of using online sources for information it is necessary to make crosssectoral and interdisciplinary efforts to comprehend false news as well as to develop measures to reduce the hazards associated with behavior modification through social media networks despite the growing literature on the believability of manipulative truth over social media platforms there are still gaps in the empirical research about the degree to which malicious actors can use social media to affect behavior covertly since even limited exposure to fake news can modify ones unconscious behavior current approaches to mitigating fake news or disinformation online are insufficient to protect social media users from being manipulated human cognition has been altered with the increased use of technology and social media which requires reconfiguring our approach to ethically and correctly disseminating information online research questions there is a need to understand how people get information make sense of it and shape their attitudes based on their interactions with technologically mediated information sources scholarly work on truth manipulation through social media and strategies to prevent or counter that is becoming more prevalent amidst increased misinformation and propaganda online amidst the dearth of systematic reviews of published scholarly work on disinformation and truth manipulation through social media this study aimed to synthesize what aspects have already been studied and what should be taken into account for future research hence the research question guiding this study was to synthesize the major causes reported about disinformation and truth manipulation through social media and how that can be prevented or countered following the recommendations of scholarly research by undertaking a thorough content analysis and bibliometric analysis to show how different facets of truth manipulation through social media have been researched and discussed throughout time this study sought to complement previous studies and jot down the existing knowledge the motivation of this study is to stimulate more scientific work aimed at expanding the understanding of truth manipulation and identifying frameworks and approaches for monitoring reporting and dealing with disinformation misinformation and manufactured news on social media utilizing bibliometric and informetric analyses this paper also highlights various solutions suggested by scholars for preventing and countering truth manipulation on social media finally the article discusses research trends and highlights research gaps definitional aspects social communication started on may 24 1844 when a telegraph operator manually typed a string of electronic dots and dashes according to the technology news website digital trends the development of the internet allowed the launch of online communication services like compuserve america online and prodigy in the 1980s and 1990s these services exposed consumers to digital communication through email message boards and live online chat hence the existence of the forms of online social media communications can be rooted back in the 1990s the time when the internet was just emerging this section provides a definitional understanding of key concepts used in this study gibbons and carson studied the definitional aspects of misdisinformation and fake news they noted misinformation as false information that is spread regardless of whether there is intent to mislead and when there is no intention to cause any harm european commission named disinformation the main reason for online falsehood and defined disinformation as verifiably false or misleading information that is created presented and disseminated for economic gain or to intentionally deceive the public and may cause public harm they further defined fake news as a nebulous term that some see as a short form to include misinformation disinformation and other false content hyzen defines propaganda as the tangible expression of ideology in communication … to enforce ideological goals manage opinions and consolidate loyalties … to further ideological agendas salgado highlights that the developments in media such as the emergence of social media have obscured the difference between news and propaganda which has increased the spread of false and manipulated truth the space for information manipulations on social media platforms has polarized public opinions as they tend to believe in an information version that aligns with their ideologies it causes believing in the manipulated truth as fake information which is deliberately being spread by those seeking political interests salgado views that social media is highly vulnerable to manipulated facts where some political factions present fake information as reality and as in public interest such propagandists deliberately aim to deceive and conceal the truth … to direct public opinions in a particular way through manipulative tactics devices and strategies furthermore critical media literacy expands the notion of literacy to include different forms of mass communication and popular culture as well as deepens the potential of literacy education to critically analyze relationships between media and audiences information and power bergstrom et al view that critical social media literacy cultivates skills to analyze social media conventions abilities to criticize stereotypes dominant values and ideologies and competencies to interpret the multiple meanings and messages generated by media texts mobile or cell phone technologies can be used to build authentic learning environments online via meaningful knowledge construction method the bibliometric analysis was used to review the selected research articles systematically the goal was to outline the relationship between social media cognition disinformation misinformation manufactured news propaganda and other related concepts the systematic literature review establishes themes and trends and highlights the research gaps and promising study fields a systematic review process is shown in fig 1 the web of science core collection database was used to find scholarly published articles in the initial phase the search string comprised of social media disinformation misinformation fake news propaganda and cognition was used to identify the relevant studies from 1970 through september 2022 three indexes were chosen science citation index expanded social sciences citation index and the arts humanities citation index peerreviewed englishlanguage publications were the focus of the search a review of the 251 articles found during the initial search was part of the second step all the papers were vetted at this point by reading the title abstract and rest of the article after a thorough screening 89 articles were disregarded because they were irrelevant or did not fit the studys focus the total number of published articles chosen for a systematic review was 162 the information of selected research articles were organized manually using ms excel by specifying the author publication year citation details research objectives and questions context and methodology the third phase comprised informatic analysis using vosviewer software version 1616 for bibliometric analysis which is freely available according to lee and su keywords display the fundamental information included in publications and highlight distinct knowledge areas therefore 162 articles imported to vosviewer for the bibliometric analysis provide a clear picture of the research domain and its recognized patterns the information for the articles was taken in txt format from the wos core database collection wos offers two kinds of keywords one that authors provide and another known as keyword plus that is taken from the titles of cited references in the dataset of 162 articles according to lee and su keywords plus use a cooccurrence network to identify new topics normalization using fractional counting was carried out to examine published papers bibliometric offers a mathematical view of the dataset including regional affiliation authorship sources institutions and timeline it includes mapping and visualizing datasets extracted for systematic reviews in a scientific manner three different bibliometric analyses were carried out for this study a cooccurrence of keywords b cocitation of cited sources and c citation of countries the bibliometric analysis technique has been used in past research conducting systematic reviews hence utilized in this study as well the review process took three steps identification or search of the papers evaluation or selection of the papers as per review criteria and analysis for bibliometrics and themes fig 1 prisma chart that demonstrates the systematic review process content analysis was conducted using nvivo version 12 all 162 articles were imported into nvivo where the inductive coding framework was applied the articles were read thoroughly to generate and assign codes which were later grouped into themes and categories the presentation of findings from content analysis gleaned from a systematic review was included in the fourth step sorting the data into categories or open codes was the initial stage in content analysis mainly two researchers were involved in the coding of the selected articles a third researcher validated interrater reliability to assure the degree of agreement among separate observers who rate code or analyze the same phenomena the content analysis technique allows codes to be phrases or complete sentences instead of offering further guidance on how these themes and categories should be constructed the analytical approach urges researchers to interpret with the overarching purpose of reducing initially identified codes analysis the analysis of this study is divided into two sections the first section is a bibliometric analysis of selected articles it focuses on truth manipulation through disinformation misinformation and manufacturedfake news on social media bibliometric analysis was conducted using vosviewer software the second part presents the results of the content analysis of 162 selected articles from the wos database considering thematic descriptions bibliometric analysis based on the bibliographic information retrieved from wos vosviewer generated a cooccurrence map the cooccurrence of keywords is only processed through the wos txt file due to the mapping tools inherent limitations the frequency of keywords and overall link strength are shown in table 1 it indicates the distance between nodes based on proximity and outputs a cluster diagram word font size simultaneously indicates the degree of focus on a certain topic the threshold for cooccurrence keywords was set at a minimum of five times to produce a map having 48 keywords appearing inside eight clusters satisfying the minimal level a higher number would result in fewer keywords making meaningful analysis more difficult fig 2 displays bibliometric mapping based on all term cooccurrences through time from 2014 to 2022 when scores were derived on average normalized citations the network depiction was based on the strength of linkages the word font size denotes the number of occurrences of a certain keyword the higher the size the more influential the phrases the most recurring keywords were misinformation followed by fake news disinformation social cognition and false memories citation analysis based on the 162 chosen studies is shown in fig 3 a cocitation analysis was carried out by providing a weighted percentage of cited papers using fractional counting an annotated bibliographic map with a minimum of six criteria was made a highly referenced item is represented by its size in nodes and the thickness of linkages shows how strongly articles are associated with one another according to the number of citations the various color intensities display the strength of the linkages it indicates citations from 2005 to 2022 fig 2 cooccurrence network of all keywords fig 3 cocitation analysis fig 4 shows the location of research on truth manipulation through social media as well as a country analysis subject to author affiliation this data is gathered to direct academics decisionmakers strategists and researchers toward such centers of excellence to achieve this finding created a bibliometric map and displayed the connection strength the big node and bold text from the displayed countries show greater research contributions on truth manipulation through social media with its larger contribution to the advancement of studies on truth manipulation the usa seems to be the most prominent node a strong link occurred between the usa and england china australia israel and new zealand for collaboration on the research on truth manipulation fig 4 country analysis subject to authors association and research produced from 1990 to september 2022 fig 5 shows the yearly publishing trend of research on truth manipulation through social media social media has become a strong presence since the launch of facebook and twitter earlier there were different means of communication such as online chatting platforms news organizations extensive use of social media brought a sharp rise in publication trends another key factor was the presidential term of 20162020 in the usa when social media was heavily used for domestic and international politics as a result academics focused more on discussing this subject however there is a need for more research on disinformation from various angles the top 10 journals with the most papers published on truth manipulation through social media are listed in table 2 according to the wos database pennycook et al is among the top 10 referenced publications in table 3 content analysis since the online ecosystem mainly aims to capture the audiences attention algorithmically curated content online such as on social media shapes public opinion the heavy influx of information on social media platforms facilitates truth manipulation and the spreading of false information such influx of manufacturedfalse information on social media increases during the pandemic such as covid19 many scholars labeled the pandemic as an infodemic due to the spread of misinformation at its peak su et al found that misperceptions about coronavirus were mainly fueled by informationseeking behavior through social media the content analysis revealed that the selected articles were around two major categories as in table 4 below along with major causes of truth manipulation online this study mainly focuses on the ways of preventing or countering truth manipulations to ensure it is a source document for remedial actions shift to cyberwarfare analyzing the shift of cyberspace weapons from the physical network to the cognitive information domain chen et al argue that technologies are becoming the key players in cyber warfare such as shaping public opinions through social media they are concerned that the emergence of social media networks may cause threats to the security and stability of the national and international community social network warfare is a new field and the confrontation of opponent countries can be observed on their social media profiles states use social media platforms to penetrate their narratives whereas the internet helps them to monitor the trends and build defenses accordingly countries use social media to spread their political propaganda by influencing the digital information ecosystem amidst increased weaponization of social media countries have started to research fundamental cognitive theories to understand how netizens are influenced manipulations of beliefs and perceptions people believe more in the repetitive statements or content than the new ones which corneille et al call the truth by repetition effect they argue that repetition of content reduces the perception of falsehood especially when the context is unspecified which helps spread fake news hale shevel and onuch studied the belief formation of people about the factual content of significant events amidst challenged geopolitical orders they found that identities influence cognition and how we receive perceive and process information often a debate or discussion serves as a push factor for people believing in fake news because the notion of reasoning helps identityprotective cognition which is used to rationalize the content aligning with ones political ideology people ineffectively distinguish between true and false news headlines when they rely on their personal or political perceptions shortland et al assessed the association between exposure to extremist propaganda and violent cognition they found that participants with low and medium trait aggression became more prosocial after exposure to extremist propaganda preventing and countering truth manipulation online factchecking misinformation and fake news various factchecking initiatives have been launched to prevent or counter truth manipulation on social media platforms the effectiveness of such platforms requires them to be persuasive in checking the facts about information online for example facebook started flagging fake or vague articles in 2017 but had to remove that feature from its platform due to its ineffectiveness factchecking misinformation has become important amidst political communications at new media outlets such as social media platforms although there are tools to check the authenticity of information online there is no access or understanding of everyone using online sources for their information though factchecking information or the news online may provide more accurate political knowledge the effects of such corrective measures are limited cognitive responses to identify and counter disinformation to reduce the influence of manufacturedfake news on social media users moravec et al examined how ones cognition processes manufactured news and found that the factor of believability influences the engagement of social media users with the information they encounter online kožuh and čakš provided a model utilizing cognition and news engagement to explain the trust in news on social media platforms based on the concept of social cognition freeze et al found that valid and accessible mechanisms can help individuals counter misleading and false information online it needs to be ensured that such tools are effective otherwise they may wrongly label accurate information as false which reduces the credibility of genuine news stories and their sources deliberation while engaging humans are influenced by their social environment which can sometimes be misleading edelson et al proposed a mediationbased model combined with brain imaging to correct and counter the misinformation the dynamic social environment allows learning new things from others while unlearning those having no or invalid influence on cognition lenzi studied how biased cognition and polarization about climate change influence the effectiveness and legitimacy of climate policies since people lack the skills to distinguish between reliable and false pieces and sources of information deliberation may help reduce polarization about social issues such as climate change it can further provide a platform for healthy debates and consensus building on the scalability and reality of the social problems of ones concern how online technologies can help the past few years have witnessed an increase in the manipulation of truth through social media moravec et al studied 83 social media users and found that social media users have increased cognitive activity when flagging fake news on social media such flagging was found not to affect the judgment of truth regarding believing in a particular post the news headlines contradicting ones political opinion often get ignored and social media users continue believing in what aligns with their political ideologies while arguing for the need for behavioral research to inform web governance for empowering netizens lorenzspreen et al view technological potential such as nudging and boosting to improve the online environment for netizens amidst misinformation online nilan examined the dominant communication technologies concerning human cognition and how human beings organize their societies electronic networks have great potential for improving the richness of human cognition and facilitating democratic organizing nilan argues for public money to be devoted to developing online social networks with universal access while ensuring diversity and open exchange of information urging netizens to think critically before engaging amidst conflict situations evaluating the credibility of information online is a complex challenge while studying the russianukrainian conflict pasitselska identified three practices of verifying the news or information reliance on ideologically close sources skepticism toward individual sources while trusting media as an institution or institutional distrust and cynical disillusionment the first practice of reliance on ideologically close sources is associated with the higher risks of being manipulated while not listening to the other side of the story amidst covid19 pennycook et al surveyed 1700 adults in the us and found that respondents did not think critically before sharing information online until asked about the accuracy people were not considering if the information was true or false before sharing that on social media hence nudging people for critical thinking before sharing information is a simple way to prevent the spread of fake news on social media platforms identifying online subversive activities such as manufacturedfake news is becoming increasingly important requiring thoroughness and a detailed understanding of the issue being discussed online netizens should try to assess the associated discourses with a lens of partiality or cognitive influence to get the correct sense of online activity or piece of information muhlmeyer et al proposed contextaware frameworks to capture specific scenarios and dynamics in the information spread through social media which can help counter truth manipulation crosssectoral and multidisciplinary efforts to understand fake news are required along with devising strategies to mitigate the risks of behavior modification through social media networks a contextually aware and multidisciplinary framework educating netizens through social media to counter falsehood though social media platforms allow the spread of misinformation they also provide a space to educate the masses with corrective messages one example is information sharing about covid19 by dr anthony fauci the corrective messages spread through social media can increase peoples knowledge and influence their cognition for the correct version of the information to fight misinformation online about key social issues such as vaccine hesitancy for covid19 johnson et al argue for multifacet messages through social media platforms amidst increased discussion on social media platforms about the higher risks of covid19 among people with dementia bascu et al found that unscientific discussions add misconceptions and false information about dementia bascu et al argue that though social media has been used to fuel stigma about dementia it can also be used to counter negative beliefs stereotypes and false information similarly allem et al found the need for health education to correct or counter the misinformation or misconceptions about unproven health claims on twitter improving the critical social media literacy of netizens media literacy is critical for young adults to utilize new media technologies such as social media responsibly xiao et al claim that a lack of studies empirically examining the relationships between new media literacy and perceptionsactions related to controversial issues increasing critical media literacy help reduce misperceptions induced by misinformation rampant in the new media environment kahne and bowyer studied how youth judges the accuracy of controversial public issues debated online and found the need for social media literacy to improve judgments for information accuracy assessment they conclude that political knowledge did not enhance judgment of accuracy but social media literacy did howell and brossard view literacy as critical to prevent misinformation when discussing science issues being discussed online while highlighting that digital divides are the key structural barrier howell and brossard argue for civic literacy digital media literacy and cognitive literacy to counter misinformation online conclusion this study concludes that social media is heavily being used intentionally and unintentionally to manipulate and manufacture the truth about the sociopolitical realities of the current world people having lesser trust in state institutions are more likely to believe false information and conspiracies frequently being spread through social media platforms through understanding community psychology disinformation agents use social media language and imagery to target potential audiences under cover of the sociopolitical wellbeing of media users disinformants manipulate and manufacture the truth to establish their narratives proxies and propaganda by spreading rumors and hoaxes about current events of public interest the results of this study highlight the need for social media users to develop critical social media literacies to strengthen their intellect and fend off the spread of disinformation by identifying and reporting the manipulatedmanufactured truth online though social media service providers have taken various steps to prevent and counter the manipulation of truth on their platforms their effectiveness is minimal this study has significant implications for being a resource synthesizing peerreviewed research published on truth manipulation on social media through disinformation misinformation fake news and propaganda it summarizes the reasons for manufacturing truth on social media and various ways for social media users to cognitively prevent and counter false information online during their online social experiences the bibliometric analysis conducted in this study highlights the countries focusing on studying cognition and truth manipulation on social media which also invites prioritized focus from other countries this study has certain limitations though the wos database is well respected for its credibility and the quality of the research index more studies can be published on manufactured truth fake news and misdisinformation indexed in other databases it may not be humanly possible to cover all the databases for a systematic review on a certain topic as we have to set boundaries to be specific in our studies since wos is a database that indexes and manages research publications there are chances that future technology and design updates in the database may shift the results of the same search criteria we used for this study at the first step in the selection process as outlined in fig 1 there are chances that a few relevant studies may have been skipped while screening titles and abstracts furthermore in the content analysis section of this study we have placed more emphasis on the preventing and countering measures suggested in various studies so that this study can better inform the remedial actions in terms of future research this study draws attention to a knowledge gap in empirical research on the direct influence of truth manipulation through social media on societal psychology this study points out areas requiring further investigation such as the contribution of cognition to the facilitation or obstruction of truth manipulation on social media platforms the article also highlights the need to study the factors leading to the ineffectiveness of remedial actions in countering truth manipulation on social media additionally it is vital to research the types of cognitive reactions to truth manipulation so that targeted recommendations can be made for the pleasant experience of social media users since disinformation and misinformation on social media impact users cognition and behavior significantly it is vital to investigate the monitoring and control indicators further there is a need for pilot intervention studies to assess ways to combat truth manipulation on social media in the context of restricted worldviews and limited social media literacies it would be crucial to consider societal and psychological factors in future research the service providers should provide extended access to their platform databases for social and psychological researchers it will help study the truth manipulation patterns through social media which will help improve the social media literacies of netizens with skills to prevent and counter disinformation manufacturedfake news misinformation and propaganda politically biased news sources are popular in the media but reap unwanted consequences kelly developed a framework for choosing news based on the perceptions of objectivity and credibility and found that information from unfamiliar sources is perceived to be more credible and less biased if that aligns with existing beliefs since the internet and social media have connected the media world there are higher chances that people will get exposed to unknown media sources potentially containing fake news kelly further found that politically selective exposure to information sources may arise from an individuals wish for unbiased news which may not be the case swire et al studied the cognitive processing of true and false political information amidst the 2016 presential election in the usa they found that knowing the information source had a lesser impact than perceived credibility their study found that people believe in their political heroes to evaluate if the information is true or false author statement the authors declare that there is no conflict of interest

the manipulated or manufactured truth on social media platforms spreads false information to influence netizens cognition often resulting in fabricated social and political narratives this study systematically reviews the literature on truth manipulation and its impact on the cognition of social media users the primary focus is on disinformation misinformation fake news and propaganda the study appraises 162 peerreviewed publications indexed in the web of science core collection database using the systematic review method the data was put through a bibliometric analysis to unpack the evolutionary nuances of netizens cognitive response to manufactured truth informativity and manipulation on social media the study highlights emerging trends and issues from truth manipulation on social media the bibliometric analysis reveals since 2017 there has been an increase in the trend of scholarly work about truth manipulation on social media and its effects on the cognition of netizens the usa seems to be the most prominent node to contribute to the study of truth manipulation the content analysis shows multiple aspects causing truth manipulation this study also seeks ways and methods to prevent and counter truth manipulation on social media it looks at the possibilities of altering netizens cognitive abilities by improving their critical social media literacies through factchecking the study results show that knowledge gaps persist in truth manipulation on social media and the cognitional aspects in response to fabricated narratives we emphasize the importance of further investigations in this domain

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introduction since the emergence of the internet in the 1990s rural areas in advanced economies have been disadvantaged with respect to the development of their digital connections the telecom market does not consider these areas to be sufficiently lucrative as the number of potential users is low and the costs are high in most western countries national and regional governments are unable due to for example eu regulation or unwilling because of political and thus financial priorities to provide rural citizens with highspeed internet this is also the case in the netherlands and has impacted a number of rural sectors and stakeholders recently many local initiative groups came into being to create local solutions for this disadvantageous situation in our case in the netherlands but for example the uk also has seen a rise in the number of initiatives in these initiatives citizens farmers entrepreneurs in collaboration with other local stakeholders try to install fixed broadband networks or wireless solutions against the laws of the market these initiatives try to realize a fast and reliable broadband connection or next generation access for their community there is some variation when it comes to speed and capacity but a previous study has shown that most of them aim for an easily upscalable network regarding both speed and number of users of at least 30 mbps and up to 100 mbps the emergence of these broadband initiatives has resulted in a complex interplay between market players governments on various levels and local communities this article discusses the emergence of these initiatives and their importance for the dutch countryside and rural development it consists of an analysis of 75 initiatives 1 spread across the netherlands and a detailed multiannual analysis of two specific cases in the east groningen region and the northeast drenthe region on the basis of these data the article shows which factors play a role in the success or failure of this type of initiative describing eight stages of rural broadband initiatives allows us to clearly demonstrate that established market players and governments find it difficult to respond appropriately to this new approach to realizing broadband connections the article concludes with a reflection on the role of the market and the various governments these kinds of citizen initiatives are not exclusive to the issue of broadband other examples include initiatives for community care community transport community shops and renewable energy this paper shows however that broadband turns out to be a striking example of community action for rural development and the community learning that comes with it from digital divide to rural penalty rural communities have experienced great difficulties in keeping up with digital developments to this day they find themselves on the wrong side of what is known as the digital divide these difficulties are comparable to earlier developments in the twentieth century when it proved to be difficult to equip the most isolated households with utilities such as water electricity and telephone the upgrading or substitution of the telephone network to internet technology has remained costly if not altogether unprofitable in rural areas the telecommunication market was liberalized in the 1990s at which time the market players became responsible for ensuring a suitable connection there are a number of technologies on the market for providing internet connections such as the telephone but also nga using coaxial cable fibreoptic or mobile internet the dutch countryside generally does not have access to these nga networks most rural addresses do have access to a basic form of internet through a telephone line even in the most remote places but the available minimum speed then is approximately 2 mbs this means that many digital services cannot be used such as cloud services videoconferencing distant learning applications and egovernment services due to low address density and thus insufficient numbers of customers and long digging distances rural areas are not an attractive area of investment for telecommunications companies they prefer to invest in urban areas with a high address density and a high market potential as many other governments in europe the dutch government does not regard highspeed internet access as a utility however it is convinced of the necessity of proper internet access in rural areas the dutch government has not yet found an instrument to resolve the market deficit furthermore european regulations on the distribution of state funds have in the past prevented financial support from being directed towards establishing new networks the european commission recently adjusted its regulations in this respect in the white areasareas with no more than one provider of basic broadband and no providers of nga authorities are allowed to offer financial support to improve internet connections in the netherlands these white areas mainly comprise rural areas ie countryside areas outside the curtilage of villages and business parks on the edge of towns the exact number of affected addresses is unknown but two recent estimations indicate that between 200000 and 220000 addresses that is to say half a million inhabitants and 60000 companies have no access to futureproof internet ie easily upscalable highspeed networks all of which are located in rural areas malecki places this lacuna in the broader context of poor access to key services in rural areas as compared to urban areas both online and offline also known as the rural penalty market failure as a driver for local initiatives various actors in rural areas suffer daily from limitations on their internet capacity companies have trouble conducting their business farmers are unable to operate their digitally controlled machines those in need are unable to receive the newest digital forms of care and young family members experience problems in digital learning environments as a result the quality of internet connections is increasingly becoming a decisive location factor particularly in those rural areas that are under pressure from ageing and a shrinking population larose et al state that in fact the problem of service decline and remoteness in general could for a large part be solved by improved digital connectivity yet so far the quality of digital connectivity only highlights the remoteness of rural areas irritation but also hope for a better future with a quick and reliable internet connection has driven active citizens and entrepreneurs to create their own initiatives and establish a nga network they no longer trust that the market will provide an affordable solution in due course often their ideal is a fully open network accessible to all service providers and owned by a local cooperative they wish to manage the network themselves and no longer be dependent on external telecom companies for potential solutions ensuring a futureproof network which can promote community resilience such local actions in response to the market deficit are reshaping the relationship between external and local stakeholders in rural areas this is also known as neoendogenous rural development for decades regional and rural development was primarily driven by external parties such as national governments that decentralized national services to peripheral areas since the emergence of more neoliberal policy agendas in the 1990s exogenous actors have been less active in stimulating this process as a result rural areas and communities have had to increasingly rely on their endogenous resources however in the case of broadband rural communities cannot manage with endogenous resources alone social intellectual and financial capital are required to create a broadband network for instance to establish and maintain contacts with external parties such as governments market parties it consultants financial institutions property owners furthermore every separate negotiation with one of these contacts requires sectorspecific knowledge and competencies highlighting the multifaceted and complex nature of rural broadband crucial in this is that these forms of capital are not available in equal measure in all rural areas other essential factors for starting and running initiatives such as social entrepreneurship and most importantly perseverance are also unequally divided over space this begs the question as to what will be the spatial impact of the current approach of the dutch government methodology as from 2011 the authors have engaged in two projects regarding rural broadband provision both projects have been carried out for the province of groningen in the northern netherlands the first project breedband op het platteland broadband in rural areas involved an explorative study of the institutional and technological landscape of rural broadband the second project next generation access voor heel groningen next generation access for the entire province of groningen was a study of the progress of rural broadband initiatives both studies included international and national examples but the implications of the findings were focused on the province of groningen during these research projects the authors got in contact with many rural broadband stakeholders such as policy makers and rural broadband initiatives these contacts resulted in a first version of our database of initiatives and gave a first impression that rural broadband initiatives were a phenomenon of growing importance building on these first results and using an online inventory and online call 2 we provisionally traced 75 broadband initiatives that were active in dutch rural areas these 75 initiatives are spread across all 12 provinces and cover 116 municipalities primarily outside the randstad area the amount of information varies per initiative but because we gathered information on every characteristic in table 1 for all 75 initiatives it is sufficient to provide a general picture of the dutch broadband landscape we documented and described broadband initiative groups on the basis of the following points in addition to the abovementioned database we also followed the development of the stichting oldambt verbindt in the province of groningen in the period from january 2012 until april 2015 3 and eco oostermoer in the province of drenthe from february 2013 until april 2015 during this period we interviewed the people involved and observed during meetings on the basis of these interviews and observations we were able to describe in more detail the stages a broadband initiative follows and what exogenous and endogenous powers play a role in this context rural broadband initiatives in the netherlands a diverse landscape we were able to extract a general process for rural broadband this process is discussed in the next section but first we discuss the elements of variety we found in the database the first important point of variation between the initiatives is the scope of their area of operation some initiatives encompass a number of municipalities while others only cover a few dozen addresses the origin of the initiatives and the key persons involved also vary greatly from rural entrepreneurs to active highly educated newcomers the key persons form the basis of the further network created by a given group the group often seeks support from local governments but also from major market players or farmers organizations an important difference we found in our database is the blend of bottomup and topdown initiatives some cases clearly have come from a bottomup or a grassroot movement whereas other cases are initiated by topdown forces such as local governments or regional cable companies the two indepth cases in this paper are exemplary eco oostermoer is a local action group run by citizens aiming for locally sourced renewable energy and fibreoptic broadband stichting oldambt verbindt on the other hand originates from topdown forces such as municipally initiated meetings and their board consists of mainly representatives of local and regional institutions key persons generally determine the flavour of the initiative the broader the representation of various stakeholders in the group the broader the campaigns argument that broadband will benefit the social and economic development of the entire area initiative groups that are led by farmers and other entrepreneurs focus primarily on economic arguments there are also differences in the choice of technology and the nature of the network technically speaking fibreoptic connections are superior to other technologies such as cable or 4g connections however some initiatives seem to be satisfied with any level of improvement even if it does not involve optical fibres this results in a patchwork of different approaches furthermore even when initiatives chose the same technology network designs can vary considerably this could prevent network integration in the future at the regional level some provinces try to structure this patchwork but in doing that they run the risk of disregarding local differences the provinces of friesland drenthe overijssel and north brabant currently have policies to support the initiatives in order to structure and make the developments of the initiatives manageable provinces come up with standardized or generic policies the fear of local initiatives in particular those in an advanced stage is that the generic character of the policies and centralized management will slow down the process forcing the more advanced initiatives to adapt to these new policy conditions the initiative groups are also afraid of losing their selfdetermination and becoming an instrument of government policy furthermore political parties can integrate broadband in rural areas into political campaigns which the major market players can use to their own advantage the market and policy context vary greatly per initiative any similarities are primarily to be found in the impact of nationwide market players or provincewide policy the complex and reciprocal relation between government market and citizen is specific to each area external parties such as established market players in the case of the coaxial provider with global shareholders try to protect their financial interests by preventing citizens initiatives from extending to their own area of operation the liberty global owned coaxial provider ziggo for example uses media campaigns to stress the quality of their network in a certain municipality in these media campaigns however they are not clear about the fact that they do not serve all households and business in that municipality the absence or lack of clarity regarding government policy and regulation on the national regional and local level leads to great uncertainties for the initiative groups this fact notwithstanding the minister of economic affairs recently indicated in a letter to the dutch parliament that the local initiatives are essential in realizing a broadband network in remote areas cooperative process for broadband in rural areas on the basis of the database and detailed insights from stichting oldambt verbindt and eco oostermoer we distinguish eight stages in the process of establishing a cooperative broadband network in rural areas this is not a blueprint it may be that initiatives combine a number of stages or that they have to take some stages more than once if complications arise in a subsequent stage 4 for each stage we describe the role of the established nationally operating market players and the various levels of government we also describe the implications these roles have this shows clearly how innovative interplay comes about but also how innovative opposition arises for each stage we indicate how many initiatives have completed it the other initiatives have not yet completed this specific stage or a previous one this makes it clear which stages we can consider to be decisive in the overall process stage 1 incentive initiatives usually start with the observation that the market for nga does not serve their area in response initiative will try to provide the underserved area with futureproof broadband access because all kinds of stakeholders in the area need a fast and reliable internet connection if the initiative originates from bottomup forces it usually involves a small number of key persons in areas with existing networks or action groups for example leader areas initiative groups often either originate in or join these existing networks in order for an initiative to materialize social capital and organizational skills must be available in the area in addition we noticed that many pioneers in this field can be found in the vicinity of eindhoven and enschede two cities with technical universities whose staff possess the relevant intellectual capital and live at least in some cases in the surrounding accessible rural municipalities in the case of topdown initiatives the process is at first facilitated by the local or regional government or a local or regional cable company in sparsely populated areas with little social intellectual or financial capital these governments are more likely to act as the driving force because it is less likely that citizens initiatives will originate in these areas stage 2 familiarization rural broadband is technically and financially complex and this can be discouraging to some initiatives familiarization is the first clear distinguishing step between the potentially successful groups and those that are less likely to succeed it is also at this stage that the decision is usually made to aim for an open network owned by the community bottomup initiatives tend to prefer an open network managed by the community as a reaction to the deficit created by the market at first some groups turn to established market players who as a rule reassure the key persons and tell them that everything will turn out all right in the long term without presenting them with concrete alternatives this tactic may have the effect of curbing the initiative some initiatives choose to rely on or collaborate with the market player in question this leads to the original ideal of an open network being abandoned and the initiative relinquishing its selfdetermination as established market players will not accommodate communitymanaged networks knowledge of the telecom sector can help accelerate this phase but our observations at stichting oldambt verbindt and eco oostermoer show that the progress of an initiative group is as fast as that of its slowest key persons quicker members run the risk of running ahead which undermines the cooperative spirit of the initiative such internal frictions can even lead to the formation of new competing initiatives within the same area initiatives that are led by small regional cable companies for example in the province of friesland twente region and the municipalities of veendam and harderwijk are at an advantage in this step they have the required technical expertise and they know how the broadband market works stage 3 inventory of demand in many cases this stage marks the official establishment of a cooperative or association the previous stages are mostly characterized by informal selforganization an inventory of demand requires an indicative business case for a preliminary area of operation with estimated total costs and recommended prices this requires intellectual capital a thorough understanding of the matter and financial capital which are decisive factors that determine the likelihood of success at this stage if there is enough demand the groups usually decide to proceed if demand is limited some groups decide to stop while others start campaigning optimaas in aalburg and landerdnet in landerd both located in the province of north brabant are examples of initiatives that were discontinued as a result of lack of demand the subsequent decision of the respective municipalities to no longer support the initiative since there was no demand to justify this support led to a definitive end in both cases stage 4 campaigning campaigns are usually launched to convince inhabitants and businesses located within the area of operation to sign up for broadband the more participants the greater the chances of success bottomup initiatives make use of their local knowledge and network but they need financial support in order to professionalize their approach this is the point at which many bottomup initiatives ask for support from the government endogenous resources are often not enough to run a campaign the initiatives can be delayed by a failure or contretemps in securing funding but also by a lack of concrete policy initiatives in the province of drenthe such as eco oostermoer and in the province of gelderland where policy has by now been formulated indicate that their projects were delayed as a result of the slow progress of the provincial government topdown initiatives on the other hand can launch professional campaigns because they have the required resources and expertise however they run the risk of applying a one size fits all strategy which does not do justice to the local situation topdown initiatives more frequently experience problems in organizing a network for accessing local expertise and conducting the campaign this is where external parties really need local stakeholders local social capital is essential at this stage especially for building trust in the campaigning stage the established market players sometimes launch countercampaigns of their own competition from the initiatives in some cases with competing technologies reflects on their product even if they do not serve the initiatives area of operation in order to protect their market position and shareholder value they slash prices in surrounding areas of operation such as the larger villages to create the impression that they are solving the problem and ultimately hinder the bundling of demand stage 5 bundling demand once the campaign has been conducted the demand in the area should be bundled the objective of this step is to have as many inhabitants as possible commit to subscribe to and pay for services subject to sufficient demand the analyses of the database show that this requires a commitment from over 50 of the addresses areas with long digging distances and therefore higher costs per user often require a higher percentage in order to create a profitable business case the bundling of demand may also reveal how much money the initiative still needs in order to create a feasible business case some provinces such as friesland overijssel drenthe and gelderland are prepared to make the initiatives business case profitable by granting a soft loan but only once the maximum amount of money has been obtained from the market due to european legislation on state funding only activities in the white areas can be granted financial support the initiatives that have reached this stage are not always successful in bundling demand bergen breedband breedband alkmaarbuiten and sallandglas for example have had to prolong their deadline for subscription the initiatives that experience this state in the media that this is a delay and it does not mean the initiative will be cancelled the 75 cases in the database show that substantial social capital is required at this stage to start bundling demand trust proves to be very important at this stage of rural broadband initiatives observations at stichting oldambt verbindt and eco oostermoer also show that intellectual capital understanding why broadband is important and financial capital being able to afford the high fees are important in the decision making stage 6 tender and contracting we have less information on this stage and stage 7 and 8 because only 15 of the 75 initiatives have completed the bundling of demand step while 16 others are still trying to complete stage 5 furthermore information on this stage is often confidential since contractors and providers do not want to reveal their competitive edge during the tender and contracting it is important that the initiative is able to impose requirements on the network for example an open network if that is still an aim and full coverage of the area of operation a full coverage network does require solidarity from the households and companies that are less remote potentially they would be able to gain access to broadband for a lower price if the more remote addresses did not take part most broadband initiatives want to connect all addresses which require them to appeal to community solidarity the contracting process can also be time consuming and therefore initiatives do not advance to stage 7 quickly and without problems legal and financial issues are usually the cause of the struggles at this stage often these issues prove to be too complex for the initiatives showing the need for professional support stage 7 construction and commissioning local involvement knowledge and support are important in the construction stage some groups of inhabitants or companies opt to do some of the digging work themselves in order to keep the costs down in addition it may be necessary for these routes to be dug through privately owned plots in this phase the role of being a commissioning party and managing the everyday issues of construction require the initiative to possess another set of relevant skills knowledge and experience stage 7 therefore shows that with the development of the initiative the capacities of the key persons also have to develop in the case of eco oostermoer the key persons try to anticipate this by recruiting volunteers that have these capacities stage 8 management and maintenance at this stage the initiatives require technical support to manage the network outsourcing of the management and maintenance is usually considered at this stage in their role as commissioning party the initiatives set requirements on network management once this stage is reached the process is completed there are examples of initiatives that decide after all to turn to established market players the province of drenthe even states in its funding and implementation policy that initiatives should at the start determine an exit strategy to sell the network to market players this once again requires technical expertise in the negotiations regarding outsourcing two of the four operational networks that are included in our database are fibreoptic networks while the other two are wireless boekelnet was the first bottomup operational fibreoptic network of the netherlands to be owned by a cooperative the municipalitys role as facilitator and source of financial support played a key role in the realization of this project the diverse landscape of rural broadband in the netherlands is presented in map 1 this map shows the 75 initiatives that were analysed and the stage they were in at the moment of analysis the initiatives are predominantly based in areas outside the randstad area in the north east and southeast of the country discussion and conclusion opportunities and challenges for cooperative interplay the emergence of a large number of initiatives shows the necessity of broadband connections in rural areas but it does not in any way guarantee that these areas will eventually be successfully connected to a futureproof network the outcomes of the process for rural broadband seem uncertain we discovered that the inventory and bundling of demand in particular are decisive stages in which many initiatives struggle to move forward during these stages the bottomup initiatives especially are dependent on the support or nonopposition at the least of governments and market players the case of eco oostermoer for example shows that negotiations with the province about the terms and conditions for funding require a lot of time and effort of the initiative the market players on the other hand are usually only willing to cooperate on the condition that they will later own the network while many initiatives are committed to creating an open network that they own and manage themselves these opposing interests of the initiative and the telco often results in an internal conflict within the initiative about what should be prioritized selfdetermination and following the original plan or settling for an altered plan with the telco in which selfdetermination is lost but the network will be realized managing the expectations of potential users proves to be both crucial and difficult at this stage as long as there is conflict within the initiative and there is no prospect of a cooperating market player the initiative will not succeed in addition wavering policy on the part of local and regional governments uncertainty about eu requirements related to state support as well as an absence of national policy result in insecurity and require much time and energy an investment that not every initiative or group is able to sustain although this is not a unique finding for rural broadband bosworth et al made similar observations regarding leader programmes in the uk the struggle to keep up with policy changes resonated throughout the dutch rural broadband landscape insights from stichting oldambt verbindt and eco oostermoer show that the capacity of an initiative can come under pressure and the key persons can get tired of policy the overall picture of rural broadband initiatives in the netherlands begs a question about the degree of skills capabilities and perseverance that are required not every rural area in the netherlands possesses that degree hence the absence of rural broadband initiatives in some of the dutch white areas furthermore and more critically our analysis indicates that the key persons in rural broadband initiatives run the risk of volunteer burnout once that occurs initiatives are at a considerable risk of failing in both bottomup and in topdown initiatives governments and citizens need each other in order to bring the initiative to completion an initiative typically begins on a small scale with a small group of key persons but often it soon becomes apparent that cooperation is required with various stakeholders both exogenous and endogenous in order to actually realize the broadband network local political conflicts and largescale market interests can hinder progress in some more advanced initiatives a cooperative as an organizational form and thus the formalization of collaboration between citizens government and institutions has ensured that the cooperative activities were in line with political decisionmaking thus greatly accelerating the overall process in any case up to the stage of bundling demand this paper also shows that efforts to create a broadband network represent a modern form of rural development a single player is no longer sufficient rather the process requires a cooperative interplay between highly educated and highly skilled citizens governments and market players confirming the theory of neoendogenous rural development this interplay requires various forms of capital and above all sectorspecific skills which do not come natural to every citizen endogenous and exogenous actors and capital have to contribute in order to create a rural broadband network this interplay is not unique to rural areas as a location or broadband connections as a theme but the example does show to what extent actors are able and willing to cooperate furthermore local and regional governments are forced by market players and initiatives to reconsider the current situation in which the free market acts as an instrument for providing every dutch citizen with telecom services rural broadband as a vehicle for neoendogenous development the reclaiming of rural futures many initiatives arise in response to a failing market or a reticent government once the first steps in the process have been completed it often appears that initiatives actually need the cooperation or nonopposition of market players and governments in order to achieve their objective in the case of rural broadband initiatives it is important for the local actors citizens and entrepreneurs in particular to be able to take part on their own terms and ultimately to be able to achieve their own objectives the analysis in this paper shows that power inequalities and a dependence on external parties or exogenous forces may hinder and delay this process in addition reclaiming and maintaining selfdetermination appears to be important to local stakeholders many campaigns for broadband in rural areas emphasize this reclaiming of selfdetermination as a triumph that citizens can jointly achieve themselves a triumph that proves that the rural penalty can be overcome behind this pursuit of broadband lies a deeper desire for a liveable countryside in which the citizen takes on an increasingly active role in this light the initiatives for rural broadband can be seen as a vehicle for rural emancipation and neoendogenous development nevertheless citizens organizing everything themselves seem to be a utopia as far as broadband networks in rural areas are concerned the free market rationale forces one to do things well but it does not necessarily force one to do the right thing local groups increasingly define what is right for them and work towards making it happen in order to do that they have to be able to organize themselves and bundle demand they then have to be able to safeguard their own objectives and interests it is up to the government to support or at least not hinder this selforganization and to initiate it where it does not come about naturally in doing that governments should not hinder the objectives of an initiative doing so would alienate the local citizens and entrepreneurs this could prove to be fatal since under the current conditions broadband in remote rural areas does not seem to be feasible without the commitment of local citizens and entrepreneurs the journey towards nga is accompanied by next generation rural development with a neoendogenous character the broadband initiatives act as a suitable training ground and learning experience for broader rural issues from an endogenous perspective delivering rural broadband requires a great variety of knowledge skills and capacities throughout the process every stage has its specific requirements and as the initiative develops the key persons have to deal with this variety of changing requirements the question remains however if every rural area and community holds these key persons and the much needed social intellectual and financial capital from an exogenous perspective a similar learning experience applies to governments and market players some of them are able to respond effectively to the local initiatives by facilitating and enabling the local action others however find it difficult to relinquish their usual approaches resulting in more conservative responses the current policy conditions endanger the universal realization of broadband in rural areas in the netherlands by local initiatives the key to successful rural broadband initiatives lies in the cooperative interplay between the various stakeholders to contribute to the knowledge about this interplay we therefore suggest that research on rural broadband and rural development more generally focuses on the mutual learning between endogenous and exogenous actors declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

rural broadband is assumed to be a solution to a variety of rural issues yet the delivery of broadband to rural areas remains problematic on the basis of a database of 75 rural broadband initiatives in the netherlands and the information gathered by studying two initiatives indepth for a number of years the authors discuss how citizens instigate and run initiatives to improve internet connectivity the authors present an eightstage model that demonstrates that citizens governments and market players have impact on the completion of each of these stages highlighting the neoendogenous character of rural broadband in this neoendogenous context both established market players and governments find it difficult to relinquish their usual approaches market players attempt to frustrate initiatives with rigid policies in order to prevent their share of the market being threatened on paper governments stress the importance of local action but in practice they come up with wavering or generic policies neglecting local organizational differences and frustrating the progress the broadband initiatives are in a constant learning curve and require perseverance as well as social intellectual and financial capital the current conditions under which the local initiatives operate endanger the realization of broadband in rural areas in the netherlands

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background diabetes is one of the worlds fastgrowing epidemics and the ninth leading cause of death around the world 1 according to the international diabetes federation 105 of the worlds adult population had diabetes in 2021 and this is expected to reach 122 in 2045 moreover diabetes also contributed to 67 million deaths among adult people around the world in 2021 2 population aging and changes in lifestyle due to increased urbanization are the main attributing factors to the rise in diabetes prevalence population aging is responsible for about 16 of predicted increase in diabetes prevalence worldwide 2 living in urban areas is usually associated with a more sedentary lifestyle and higher consumption of unhealthy food and hence high diabetes prevalence 3 although the rise in diabetes prevalence is occurring around the world africa has yet the lowest prevalence compared to other regions 2 however due to growing shift towards more urbanization associated with unhealthy diet and low physical activity the number of people with diabetes is expected to increase in this region from 24 million in 2021 to 55 million people in 2045 with a 129 increase 2 south africa is considered one of the major transitioning economies and ranked one of the uppermiddleincome countries according to the world bank 4 furthermore it is one of the countries experiencing the epidemiological shift from communicable to noncommunicable diseases 5 according to the who 51 of deaths in south africa are due to ncds 6 it also suffers from the double burden of infectious and noninfectious conditions like tuberculosis diabetes cerebrovascular diseases hiv hypertension influenza and pneumonia while there is a decline in tuberculosis the leading cause of death in south africa there is an increase in diabetes prevalence the second leading cause of death 5 south africa also had the highest number of people with diabetes in the african region with an increase from 19 million in 2011 to 42 million people in 2021 2 risk factors related to developing diabetes such as economic development and increased urbanization associated with unhealthy diet and physical inactivity are present in south africa 7 dietary consumption of foods with excessive sugar fat and salt contributed to remarkably high level of obesity in south africa apart from the fact that 388 of men and 693 of women in south africa are overweight or obese 8 south african women had the highest documented prevalence of obesity in subsaharan africa 9 according to the demographic and health surveys report in 2003 76 of men and 86 of women participating in the survey in south africa were physically inactive 10 furthermore it is estimated that 38 of people with diabetes in south africa are undiagnosed 11 in addition to previously mentioned risk factors the effect of socioeconomic status on developing diabetes is very evident in 1981 mueller and parcel defined ses as the relative position of a family or individual on a hierarchical social structure based on their access to or control over wealth prestige and power 12 health inequalities have been explained in relation to unequal burden of disease or behavioral risk factors that affect certain subgroups of the population 13 recently healthy people 2010 defined health disparities as differences that occur by gender race or ethnicity education or income disability geographic location or sexual orientation 14 an association between diabetes prevalence and socioeconomic inequalities has often been presented in the literature with varying results reported from different countries around the world 11 15 16 17 18 studies from highincome countries usually associate diabetes prevalence with low socioeconomic groups 15 16 17 18 however research done in lowand middleincome countries implies a higher prevalence among people with high socioeconomic status 111920 generally there are three indicators used in studying health inequalities related to ses which are education occupation and income 21 these variables are usually used together or separately choosing which variable to evaluate ses inequality depends on the study population and outcome in addition to data availability 22 23 24 objectives although south africa has the highest number of people with diabetes in the african region 2 there is scarcity in literature investigating socioeconomic inequalities in relation to diabetes prevalence ataguba akazili and mcintyre studied socioeconomic related health inequality in south africa between 2002 and 2008 using a set of common assets and household characteristics to create composite indices of socioeconomic status they found that diabetes is more common among the rich yet it is increasingly reported among poor people 25 mutyambizi et al investigated lifestyle factors influence on diabetes inequalities in south africa in 2012 and stated that selfreported diabetes is higher among rich people 11 using the demographic and health surveys program database this study aims to compare between diabetes prevalence and the existence of related socioeconomic inequalities at two time points furthermore it will explore risk factors related to diabetes development at each time point and identify vulnerable groups in 2016 vulnerable groups are people who have higher risk of developing diabetes in south africa in 2016 the present study will provide evidencebased literature for upcoming research by identifying risk factors and the characteristics of people or groups with diabetes in south africa this will help in health care planning preparing grouporiented prevention programs and raising awareness in the society and hence eliminating social inequalities research questions methods data this study was done using the demographic and health surveys data dhs program started in 1984 by giving technical assistance to more than 400 surveys in over 90 countries and helped improve global understanding of health and population trends in developing countries it collects and distributes nationally representative data on fertility family planning maternal and child health gender hivaids malaria and nutrition 26 south africa dhs sadhs 2003 the sadhs 2003 sample was designed to be a nationally representative probability sample hence the country was stratified into nine provinces and each province was further stratified into urban and nonurban areas statistics south africa provided the sampling frame for the sadhs based on the enumeration areas list of approximately 86 000 eas created during the 2001 census then the systematic sampling of householdsstands from the selected eas was done in 2003 7041 women aged 1549 years were interviewed using the womens questionnaire and 3118 men aged 1549 years were interviewed using the mens questionnaire in addition 8 115 adults aged 15 years and above were interviewed using the adult health questionnaire 10 the main objective of the sadhs 2003 was to deliver data on households and respondents characteristics contraception and fertility sexual behavior hiv and aids infant and child mortality maternal and child health infant and child feeding adolescent health mortality and morbidity in adults utilization of health services adult health risk factors for chronic diseases oral health and health of older persons 10 sadhs 2016 the statistics south africa master sample frame was used for the sadhs 2016 which was created using census 2011 enumeration areas in this frame eas of manageable size were treated as primary sampling units while small neighboring eas were joint together to form new psus and large eas were split into conceptual psus there was also information about the geographic type and the probable number of residential dwelling units in each psu a stratified twostage sample design was used in the sadhs 2016 the first stage included a probability proportional to size sampling of psus and the second stage involved systematic sampling of dus in 2016 8514 women 3618 men and 10336 adults were interviewed 27 in addition to previously mentioned objectives of the 2003 sadhs the 2016 sadhs collected information on breastfeeding practices nutrition and physical and sexual violence against women a key objective of the sadhs 2016 was to collect data about use of tobacco alcohol and codeinecontaining medications it also provided information on the prevalence of anemia among children aged 659 months and the prevalence of hypertension anemia high hba1c levels and hiv among adults aged 15 years and older 27 definition of diabetes cases sadhs was an interview survey hence case definition was based on selfreported information to identify people with diabetes participants were asked has a doctor or nurse or health worker told you that you have or have had diabetes or blood sugar if the response was yes the person was classified as having diabetes persons responding no were classified not to have diabetes participants who responded dont know and missing cases were excluded from the statistical analysis there were no missing cases in 2016 the question did not imply whether it is type 1 or type 2 diabetes independent variables participants were in the age between 15 and 95 years at the time of interview they were classified into three age groups 1539 years 4059 years and 60 years and older based on the highest achieved level of education there were four categories no education complete primary education complete secondary education and higher education place of residence was classified into rural and urban areas for identifying vulnerable groups in 2016 two additional variables were used wealth index and weight perception wealth index is a score given according to households belongings such as television bicycle or car materials used for housing and source and access to water and toilet facilities using principal components analysis households are located on a continuous scale of relative wealth all interviewed households are divided into five wealth quintiles 2728 wealth index has five categories poorest poorer middle richer and richest for the weight perception variable participants were asked do you personally think you are underweight normal weight overweight or obese and accordingly there were five categories underweight normal weight overweight obese and do not know vulnerable groups were not explored in 2003 due to lack of additional variables wealth index and weight perception in the 2003 dataset statistical analysis to answer the research questions analyses were performed in five steps the first step included descriptive analyses for all independent variables and calculating diabetes prevalence in the second step diabetes prevalence was predicted using logistic regression and using age gender educational level and place of residence as predictors results were reported as odds ratios with 95 confidence intervals this was repeated separately for men and women the first two steps were done for the 2003 and 2016 datasets individually the third step was analyzing time period differences in diabetes prevalence hence the two datasets were combined using the sadhs 2003 as reference logistic regression and odds ratios with 95 confidence intervals were then calculated for diabetes by age gender education and place of residence in the fourth step effect of ses on the prevalence of diabetes was assessed using education by repeating logistic regression analysis for each category of educational level for men and women separately these four steps were done using stata finally to identify vulnerable groups with high risk of developing diabetes in 2016 the method of pvalue based regression tree analysis was applied using wealth index and weight perception as additional variables classification and regression tree is a prediction method that is usually used with dichotomous outcomes preventing the assumptions of linearity in this technique the sample is repeatedly divided into subgroups according to the value of one of the predictor variables the result is a group of branches creating a treelike structure with each final branch providing a yesno prediction of the outcome 2930 results characteristics of study population study population consisted of 8006 participants in 2003 and 10292 participants in 2016 more than half the participants were in the age group 1539 years two thirds of the participants completed secondary school there was a decrease in the percentage of participants without education from 1245 in 2003 to 842 in 2016 other than a small difference in the percentage of men and women without education women had a higher percentage no significant gender differences were found in level of education 5732 of participants in 2003 lived in urban areas compared to 5504 in 2016 no gender differences were found regarding place of residence frequencies for population characteristics are presented in diabetes prevalence there was an increase in diabetes prevalence from 386 in 2003 to 446 in 2016 diabetes was more prevalent in women at both time points in 2003 430 of women had diabetes compared to 321 of men percentage of women with diabetes was 505 in 2016 compared to 359 of men the highest percentage of diabetes was found in the age group 4059 years in 2003 however it was highest social inequalities in diabetes prevalence the highest percentage of participants with diabetes at both time points was seen in men after applying logistic regression significant effects were found in age and place of residence at both time points there was a consistent positive relationship between age and diabetes prevalence at both time points for both men and women however it was more prominent in 2016 where the risk of developing diabetes for participants aged 60 years and older was relatively high risk of developing diabetes was more in women compared to men at both time points living in urban areas was also associated with more risk of developing diabetes at both time points nevertheless it was more distinct in 2003 no gender differences were observed regarding place of residence higher education was associated with lower risk of developing diabetes in 2003 but was a risk factor for developing diabetes in 2016 results were statistically significant for participants who completed their secondary education or who had a higher diploma or above in 2016 there was no specific pattern regarding risk of developing diabetes and educational level in case of women on the other hand men who completed secondary school or had a higher diploma or above have shown a significant risk of developing diabetes in 2016 difference in the effect of ses on diabetes prevalence between 2003 and 2016 after merging the two datasets using 2003 dataset as reference there was almost no difference in risk of developing diabetes between 2003 and 2016 the same was noticed after repeating logistic regression for men and women separately age effect was observed for both men and women however men at the age of 60 years and older had a higher risk of having diabetes in 2016 compared to women from the same age group while the effect of educational level had no specific pattern regarding risk of developing diabetes in women it was a clear risk factor for men in 2016 men who completed secondary school or had a higher diploma or above had a greater risk of having diabetes in 2016 in comparison to 2003 participants living in urban areas had a higher risk of developing diabetes in 2016 this applies for both men and women vulnerable groups at risk of developing diabetes in 2016 the method of pvalue based regression tree analysis was used to identify vulnerable groups who have higher risk of developing diabetes in 2016 hence participants who were 60 years and older with a wealth index of rich or richer were the most vulnerable group identified followed by participants from the same age group with a wealth index of poor or poorer and participants who were 4059 years with a wealth index of rich or richer subsequently were participants from the age group 1539 years with a weight perception of overweight or obese and with educational level of no education or high education followed by participants who were 4059 years with a wealth index of poor or poorer subgroups with the lowest risk of developing diabetes were participants from the age group 1539 years with a weight perception of underweight normal weight or dont know and participants from the same age group with a weight perception of overweight or obese and with educational level of primary or secondary discussion diabetes prevalence and its association with ses in 2003 and 2016 this study investigated difference in diabetes prevalence and associated socioeconomic inequalities in south africa between 2003 and 2016 in accordance with the literature diabetes prevalence was higher in 2016 compared to 2003 with age gender and living in urban areas being the main risk factors at both time points yet the extent of the association of these risk factors with diabetes prevalence was different between 2003 and 2016 on the other hand the effect of educational level was not consistent at both time points there was however an indication of increased risk of diabetes with higher educational level in 2016 which was more prominent in men according to the idf report diabetes prevalence has indeed increased in south africa from 34 in 2003 to 54 in 2017 3132 although diabetes prevalence is increasing in africa the pattern of this increase is diverse among african countries while the increase was minimal in botswana from 36 in 2003 to 38 in 2017 it was very distinct in gabon from 29 in 2003 to 70 in 2017 3132 in brazil diabetes prevalence increased from 55 in 2006 to 89 in 2016 33 though south africa was the second african country after ethiopia with the highest number of people with diabetes in 2017 it became the first in 2021 232 increased urbanization associated with physical inactivity and unhealthy diet leading to obesity in addition to tobacco use and harmful a this is the reference group used in the logistic regression hence no odds ratio could be computed to this group since the other groups are compared to it fig 1 results from the regression tree analysis predicting vulnerable groups at risk of developing diabetes in 2016 consumption of alcohol are considered risk factors contributing to the increase in diabetes prevalence 34 global reports indicate the association between age and diabetes development 23132 whereas participants aged 4059 years followed by participants aged 60 years and older had the highest diabetes prevalence for both men and women in 2003 diabetes prevalence increased with age for both genders in 2016 lower prevalence of diabetes in participants aged 60 years and older in 2003 could be due to high levels of undiagnosed diabetes as previously mentioned 38 of diabetics in south africa are undiagnosed 11 in a study done in botswana on patients admitted with acute heart failure they found that almost half of them had undiagnosed diabetes 35 moreover the highest percentage of undiagnosed diabetes is in africa 2 gender variations in diabetes prevalence were frequently discussed in the literature although few studies reported that diabetes prevalence was higher in men 3637 most studies found women more at risk of developing diabetes 313839 consistent with majority of the studies results of this study revealed a higher diabetes prevalence among women at both time points possible reason for this could be the high level of obesity among south african women it was stated in the literature that 693 of women in south africa are overweight or obese compared to 388 of men 89 research done in nigeria 40 uganda 38 and some west african countries indicates that women reportedly had higher levels of obesity compared to men 41 obesity is directly linked to developing diabetes especially in women 244243 in a study done by mutyambizi et al they found that obesity contributed to 248 of selfreported diabetes in south africa 11 place of residence is one of the factors that contribute to inequalities in diabetes prevalence 2313239 living in urban areas was frequently related to higher risk of developing diabetes yet there are reported gender differences in studies done in some countries like ghana 44 and cameron 45 in the present study developing diabetes at both time points was more prominent in participants living in urban areas in comparison to participants living in rural areas this was more evident in 2003 compared to 2016 and in men more than women it is usually acknowledged that diabetes prevalence is higher in urban areas due to sedentary lifestyle and decreased physical activity though this is true in many cases some authors identify other reasons in studies done in india 46 and bangladesh 47 they indicated that living in urban areas was associated with more awareness about diabetes and hence higher prevalence 46 likewise in cameron mbanya et al found that undiagnosed diabetes was more in rural areas compared to urban areas 45 other explanations for this could be that rural areas are usually associated with inadequate resources difficulty in access to healthcare services and prioritization of other health issues 2 socioeconomic inequalities and its association with diabetes prevalence were discussed in the literature with diverse results while most of the studies done in usa 48 canada 22 and western europe 24 indicate that higher ses was associated with lower level of diabetes prevalence studies done in lowand middleincome countries did not always show similar results 1820 results of this study show that diabetes prevalence had witnessed a steady increase with increased educational level and reached the highest level in participants who had secondary education however it exhibited a noticeable decrease in participants with higher educational level especially in 2003 and in women gender differences regarding ses effect on diabetes prevalence were also registered in the literature women were usually more affected by their ses and the higher it was the lower was their risk of developing diabetes compared to men 49 50 51 addo et al did a study on ghanian adults residing in europe based on data derived from the multicenter research on obesity and diabetes among african migrants they found that diabetes prevalence decreased with increasing educational level in ghanaian men and women in europe and in men in urban ghana however it increased with increasing level of education in men and women in rural ghana 44 difference between 2003 and 2016 in the effect of ses on risk of developing diabetes when examining the overall risk of developing diabetes in 2016 compared to 2003 there was no substantial difference found the aforementioned risk factors of age gender and urbanization were still present however high educational level was a distinct risk factor in 2016 furthermore assessing the effect of these risk factors on men and women separately revealed evident gender differences men aged 60 years and older and the ones with high educational level were noticeably more at risk of developing diabetes in 2016 compared to women from the same categories similar results were found in a study done in west african countries where older men were more at risk of developing diabetes than women 52 in addition seiglie et al studied diabetes prevalence in 29 lowand middleincome countries and found that diabetes risk increased with increased educational level 20 an explanation for this could be low level of physical activity associated with easy access to unhealthy diets and general sedentary lifestyle wu et al did a study on adults aged 50 years and older from china ghana india mexico the russian federation and south africa the highest prevalence of low physical activity and obesity was in south africa 53 furthermore decline in physical activity with age is usually more prominent in men than women 5455 it is not uncommon for studies done in highincome countries such as canada 56 germany 24 and australia 42 to link diabetes prevalence with lower ses however studies from lowand middleincome countries usually present contrasting results link between high income and high educational level with greater diabetes risk was stated in the literature 20 although the relation between diabetes risk and educational level was not merely linked to higher bmi 57 obesity and physical inactivity are still major contributors vulnerable groups who are at risk of developing diabetes in 2016 results from the present study affirmed that participants aged 40 years and older have higher risk of developing diabetes and this risk increases at age 60 years and older participants aged 40 years and older have an additional risk factor namely wealth status subsequently being rich or richer increases the risk factor of developing diabetes mutyambizi et al indicate that selfreported diabetes in south africa is more common among rich people while undiagnosed diabetes is usually found among the poor 11 whereas some studies associate between higher diabetes prevalence and lower ses especially in women 224849 others link between higher diabetes prevalence and rich men with high ses 5859 additionally men with lower ses in south africa usually work in jobs that necessitate physical activity 58 being rich is associated with high diabetes prevalence not only because it is usually associated with sedentary lifestyle and unhealthy diet but also because it is sometimes associated with higher level of awareness about diabetes 47 and easier access to healthcare facilities 2 on the other hand younger participants aged 1539 years who have a weight perception of overweight or obese have higher risk of developing diabetes compared to participants from the same age group who are underor normal weight particularly when they received no education or had higher educational level as previously mentioned obesity and physical inactivity are consistently linked to diabetes risk 39 younger people are thought to have high level of physical activity yet the who in its global report on diabetes indicated that high level of physical inactivity was observed among adolescents 39 young adults also consume a lot of alcohol and tobacco which are linked to increased diabetes prevalence 5052 the reason why this was more common in participants with no education together with the ones having higher educational level particularly is not clear south africa is one of the fastest growing economies around the world and ranked as an uppermiddleincome country by the world bank 4 in order to understand the reason for the increasing diabetes prevalence and the difference in the effect of risk factors compared to highincome countries there are certain sociocultural and lifestyle factors that need to be considered though obesity is often linked to low ses in highincome country in many african countries it is a sign of high ses and wealth it is even seen as an indication for good health and beauty among females physical activity is also not preferable for females and seen as a masculine action in many cultures it is also associated with performing sports not as a healthy lifestyle 52 effect of urbanization and population aging is anticipated to cause the steady increase in diabetes prevalence and is expected to be doubled by 2030 60 omran described the epidemiological transition as the change from high prevalence of infectious diseases associated with malnutrition to high prevalence of chronic diseases associated with urbanindustrial lifestyles 61 nutritional and physical activity transition due to demographic and economic factors has been described by young et al in five patterns in the first pattern diet consisted of high carbohydrates and fiber and low in fat but high physical activity and minimal obesity this gradually changes through the different patterns until it reaches the fourth pattern where diet is high in total fat cholesterol sugar and other refined carbohydrates and low in polyunsaturated fatty acids and fiber associated with increase in sedentary life leading to obesity and chronic diseases such as diabetes 62 nutrition transition is south africa is due to urbanization and globalization which lead to the consumption of energydense foods and sugary beverages 59 socioeconomic inequalities in diabetes were also identified regarding fruit and vegetable consumption people with low ses reportedly eat less fruits and vegetables 1150 another factor that should be taken into account is the high percentage of undiagnosed diabetes as previously mentioned 38 of people with diabetes in south africa are undiagnosed 11 this study confirmed that there is morbidity expansion in diabetes in south africa obesity and physical inactivity are the main contributing factors however understanding the predisposing circumstances for this is very important taking into consideration the aforementioned sociocultural and lifestyle factors grouporiented prevention programs should take place with the right and convenient message that leads to better response and more compliance from each group it is indicated in the literature that moderate levels of physical activity could provide protection from certain chronic diseases including diabetes 55 providing suitable ways to increase physical activity and raising the awareness about the importance of eating a nutritional and healthy diet particularly in vulnerable groups is very essential furthermore facilitating access examination and treatment in health care centers to all groups of the society and especially people living in rural areas should be a priority limitations there are some limitations that need to be considered while interpreting these data the sadhs 2003 sample had an overrepresentation of urban areas and the african population group along with an underrepresentation of whites and indian females also there seem to be data problems related to poor fieldwork and inadequate training and supervision 31 over and under representation of some ethnicities might affect generalizability of such data within south africa at that time point furthermore the sadhs 2016 had some sampling and nonsampling errors which are common in most surveys 32 nonsampling errors such as failure to locate and interview the correct household misunderstanding of the questions on the part of either the interviewer or the respondent and data entry errors can only be minimized but are inevitable in any survey sampling errors however can be evaluated statistically another consideration is participants age range which was between 15 and 95 years this age range is different from some studies that were done in the same field and were used for comparison then again dividing the participants in three different age groups makes certain agegroup targeted comparison easier additionally certain variables were not available in both datasets such as wealth index and weight perception which limited the comparison between the two time points occupation was also not included in the analysis because it was not clearly defined in both datasets furthermore it was not specified whether participants had diabetes type 1 or type 2 given that people with type 1 diabetes are estimated to be 7 to 12 of total diabetes population 32 participants with diabetes in this study were considered to be having type 2 diabetes another possible limitation is that data were based on selfreported diabetes not based on examination which could be subjected to recall bias nonetheless it is a widely used method in surveys and proved its reliability conclusion there was an increase in diabetes prevalence in south africa between 2003 and 2016 socioeconomic inequalities were recognized at both time points main risk factors for developing diabetes were age gender and living in urban areas educational level effect was not consistent in 2003 and for women however men with high educational level were more at risk of developing diabetes in 2016 vulnerable groups in 2016 were participants 40 years and older where risk of developing diabetes increased with increasing age and ses participants younger than 40 years who were obese or overweight were more at risk of developing diabetes compared to their counterparts from the same age list of abbreviations data availability the 2016 dataset was available without restriction researchers can gain access to datasets used for the analyses of this study through registration as dhs data user in this webpage dhsprogramcomdatadatasetadminloginmaincfm the 2003 dhs was not published dhs team were contacted and dr tshilidzi muthivhi sent an email with an attachment containing the 2003 dataset author contribution sahar sidahmed conceptualization methodology formal analysis writing original draft prof dr siegfried geyer conceptualization methodology supervisiondr johannes beller conceptualization methodology supervision writing review editing declarations competing interests the authors declare no competing interests competing interests the authors have declared that no competing interests exist

background diabetes is a growing epidemic worldwide and the effect of socioeconomic status ses is frequently acknowledged in the literature this study aims to compare the effect of ses on diabetes prevalence in south africa between 2003 and 2016 in addition vulnerable groups regarding diabetes development in 2016 will be identifiedusing dhs data there were 8006 participants 5919 women in 2003 and 10292 participants 5942 women in 2016 logistic regression and odds ratios ors with 95 confidence intervals cis were calculated for diabetes by age gender educational level and place of residence to identify vulnerable groups with high risk of developing diabetes in 2016 the method of pvalue based regression tree analysis was applied using wealth index and weight perception as additional variablesthere was an increase in diabetes prevalence from 386 in 2003 to 446 in 2016 women had more risk of developing diabetes at both time points 27 in 2003 and 24 in 2016 more risk increase in age and living in urban areas were associated with more risk of developing diabetes at both time points there was no specific pattern regarding risk of developing diabetes and educational level in case of women however men who completed secondary school or had a higher diploma or above had more risk of developing diabetes in 2016 or 224 and 467 respectively vulnerable groups who have higher risk of developing diabetes in 2016 were participants aged 60 years or older with a wealth index of rich or richer followed by participants from the same age group who were poor or poorer and participants aged 4059 years with a wealth index of rich or richer subsequently were participants from the age group 1539 years with a weight perception of overweight or obesediabetes prevalence increased in south africa between 2003 and 2016 main risk factors were age gender and living in urban areas men with high educational level were more at risk of developing diabetes in 2016 vulnerable groups in 2016 were participants 40 years and older particularly with high ses this was followed by younger participants who were obese or overweight

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social network type is an important indicator of social capitalthe array of social contacts that give access to social emotional and practical support network type is a composite characterization of the interpersonal milieu in which people are embedded the measurement of network type and the analysis of its role in promoting wellbeing among older adults should be of concern to gerontologists and particularly to practitioners who serve the older population however there is still only limited attention paid to the notion of social network type in the gerontological literature studies of social network type groundbreaking social network studies in england and wales initially derived five social network types that effectively identified communitydwelling older people at risk and later served as diagnostic criteria for gerontological social work practice subsequent analysis of survey data on older adults residing in the community in israel derived five slightly different social network groupings termed diverse friend focused neighbor focused family focused and restricted the respective network types mainly reflected variations in social network composition it was found moreover that the networks with a wider range of social ties such as the diverse and friendfocused network types had the best outcomes in comparison the social network grouping with the most limited tiesthe restricted networkrevealed the poorest mental health the least physical activity and the greatest sevenyear mortality efforts to replicate the israeli typology in an american sample have been recently reported analysis of data from the americans changing lives study derived diverse family friends and restricted social network types with some variationthat is two types of restricted networks were discerned as noted restricted network types are those with the most limited extent of social ties in the american study depressive symptomatology was highest for individuals embedded in nonfriends restricted networks and lowest for those who maintained diverse networks similar analyses of data from a study of older people in the united states and japan derived mostly similar network types however although the network types were associated with wellbeing in the american sample in the study they were not related in the japanese sample in a recent korean study of older adults a simpler social network typology was identified and an association between network type and wellbeing was discerned those in diverse networks reported the best health and those in isolated networks reported the worst analysis of data from the australian longitudinal study of aging found that social networks rich in friends were protective against 10year mortality among 70year olds however the alsa study considered characteristics of network composition rather than composite social network types per se an analysis of data from the berlin aging study derived six multidimensional network types taking into account network structure function and quality the investigators found a relationship between the resultant network types and depressive symptoms subjective wellbeing and morbidity wellbeing the construct of wellbeing reflects a rather large collection of states that range from objective functional health to subjective perceptions of life quality subjective wellbeing most often refers to a positive orientation toward life and is generally based upon such feelings as happiness morale positive affect and life satisfaction research has shown that these various measures are mostly interrelated and that they frequently constitute a single dimension negative affect is also addressed by investigators as an independent measure of wellbeing the indicators of subjective wellbeing in late life are associated with several background factors meta analyses show that age income and education are positively related to subjective wellbeing whereas female gender is negatively related blacks and hispanics score lower than whites on various subjective wellbeing measures health has emerged as the primary correlate but the principal health measureselfrated healthmay confound with the subjective wellbeing outcome the current analysis focuses upon three selected indicators of subjective wellbeing loneliness anxiety and happiness loneliness is a discrete subjective construct that reflects the perceived discrepancy between desired and achieved social relationships in the united states some 17 of people aged 50 years and above report loneliness studies of older people show that loneliness is negatively associated with emotional wellbeing a predictor of cognitive decline and a risk factor for depressive symptoms furthermore loneliness poses substantial mortality risk even after controlling for demographic and clinical characteristics although anxiety is highly comorbid with depression it constitutes a distinct indicator of poor mental health moreover anxiety is associated with medical illness cognitive decline disability sleep disturbance and hospitalization all matters of concern to older people happiness is a common outcome measure employed in studies of subjective wellbeing surveys indicate that the vast majority of american adults are happy moreover older adults particularly men tend to report higher levels of happiness whereas health impairment is an inverse predictor of happiness among centenarians social network loneliness anxiety and happiness there is little reported research on the association between social network types among older adults and loneliness anxiety or happiness however analyses based upon data from the framingham heart study seem to suggest that loneliness and happiness may both be products of ones social network it was found that people tended to cluster by the traits and states of members within three degrees of their network moreover happy networks seemed to make their members happier and lonely networks further isolated lonely people a study in dublin examined the wenger social network typology in relation to anxiety and depression among very old persons the analysis considered the effects of loneliness and network type separately it found that loneliness accounted for most of the depressed mood but that network type was an independent predictor as well albeit to a lesser degree a longitudinal study of very old people in the kungsholmen district of stockholm in sweden found that anxiety among those with no previous psychiatric disorder was associated with having an insufficient network that is no children and no regular visitors research questions based upon the preceding review the study reported here addresses three major questions firstly can a robust typology of social network types indeed be discerned among older americans secondly are social network types among older americans unique to this population or do they reflect the kinds of social networks that are found in other settings thirdly does the social network type in which one is embedded really matter that is to say is there a significant association between network type and wellbeing among older americans design and methods the analysis is based upon data from the first wave of the national social life health and aging project a survey that examines health and interpersonal connections among older americans generated using the field operation employed for the 2004 wave of the health and retirement study the nshap sample is representative of the population of noninstitutionalized americans aged 5785 years data collection was executed in 200506 yielding 3005 respondents african americans latinos men and the older age group were oversampled in order to provide adequate representation of these subgroups the main nshap instrument was a 2hr inhome computerassisted personal interview conducted in english or spanish with a weighted response rate of 755 data collection included a brief selfadministrated postinterview questionnaire the response rate for which was about 84 the current analysis focused on respondents aged 65 years and older within the nshap sample and included only those who completed both the capi interview and the selfadministrated questionnaire the resultant analytic sample was n 1462 given that we addressed a selected part of the sample only and sought primarily to derive social network types and to clarify the relationships between selected variables we did not employ the weights that are available for the entire nshap sample study variables as in previous analyses network type was derived through the application of kmeans cluster analysis to the following social capital variables relevant to older adults current marital status number of children number of close relatives number of friends frequency of getting together with neighbors frequency of attendance at religious services and frequency of attendance at organized group meetings these particular variables reflect the main components of the social networks of older people as they are reported in the social support literature current marital status was measured as a dichotomy 1 married or living with a partner and 0 other number of children was a simple count in which the final category reflected six or more children number of close relatives and number of friends were both measured on a 6point scale as it was solicited in the original nshap questionnaire frequency of getting together with neighbors was tapped on a 5point scale ranging from hardly ever to daily or almost daily frequency of attendance at religious services and at organized group meetings were also measured on 5point scales ranging from never to weekly or more the frequency ratings for attendance at religious services and organized group meetings were asked in relation to the previous 12 months whereas the frequency of neighbor contact was queried in general the dependent variable in the analysis was wellbeing as measured on three separate constructs loneliness anxiety and happiness the loneliness measure was the specific item in the center for epidemiological studiesdepression scale that asks how often the respondent felt lonely in the previous week we collapsed the 4point answer scale into a dichotomous response anxiety was tapped by a modified version of the sevenitem anxiety subscale of the hospital anxiety and depression scale respondents report on feelings of anxious mood thoughts and restlessness over the past week with higher values indicating higher anxiety levels the modified anxiety measure achieved satisfactory concurrent validity and significant correlations with other quality of life indicators in nshap the total score for the anxiety subscale ranges from 0 to 21 the suggested cutoff point for the presence of possible anxiety is between 7 and 8 we employed this cutoff to create a dichotomous anxiety measure happiness was measured by a single probe if you were to consider your life in general these days how happy or unhappy would you say you are on the whole extremely happy very happy pretty happy unhappy sometimes or unhappy usually this question was adopted by nshap in light of its equivalence to an item from the general social survey which established concurrent validity and its use in several different studies it was dichotomized here to distinguish between very happy or more and pretty happy or less correlates included sociodemographic background and health the background variablesage gender education ethnicity and subjective incomewere gathered through selfreport in the case of subjective income the subjects were asked compared with american families in general would you say that your household income is far below average below average average above average or far above average subjective income has been found elsewhere to constitute a robust reflection of economic status health was measured in terms of respondents functional capacity as reflected in the difficulty experienced with six basic activities of daily living walking across a room dressing bathing eating getting in or out of bed and using the toilet measured on a 4point ordinal scale ranging from no difficulty to unable to do so we dichotomized the functional health indicator to reflect no adl difficulty and one or more such difficulties analysis in order to test the association between social network type and wellbeing bivariate and multivariate analyses were executed crosstabulations were carried out between network type and the three dichotomous wellbeing outcomes bivariate associations were also examined between the correlates and the outcome measures and between the correlates and the network type construct the chisquare statistic was consulted in each case in the multivariate stage of the analysis the wellbeing outcomes were regressed on the collection of study variables by means of logistic regression odds ratios were computed to show the relative likelihood that people with a given characteristic felt lonely anxious or happy the reference categories for each variable in the analysis are indicated in the appropriate table results table 1 presents the characteristics of the social network types that were identified through the clustering process the results of post hoc group comparisons that were performed on each of the delineating characteristics using the tukey hsd test are also shown in the table the numbers that appear in bold italics constitute the subsets with the highest values whereas the numbers that are underlined constitute the subsets with the lowest values as may be seen in the table five network types were derived the diverse network in the nshap sample demonstrated the greatest degree of sociability on the whole its members had the greatest percentage of married members as well as the greatest number of children and close family members the highest degree of neighbor gettogethers and the most frequent attendance at religious services respondents in this network type also exhibited a considerable number of friends and fairly frequent attendance at organized group meetings respondents clustered in the grouping termed friend network reported the greatest number of friends and the most frequent attendance at organized group meetings as well as relatively frequent attendance at religious services the social strengths of the friend network therefore were in the extrafamilial ties maintained by its members in comparison those included in the congregant network type also had frequent attendance at religious services but were indistinguishable on most of the other clustering criteria they also showed the lowest rate of attendance at organized group meetings it can be assumed for these reasons that the people in the congregant network engaged in social exchange primarily with other congregants at their place of worship the next grouping labeled family network was characterized by its relatively high number of children on average and by the relative dearth of other kinds of ties in the entourage especially extrafamilial ties it seems that respondents in the family network type could count mainly on their children finally the members of the restricted network cluster in the nshap sample reported the lowest scores on four of the seven criterion variables moreover the remaining three criteria on which they showed only midrange rankings were all extrafamilial in nature respondents in the restricted network type had the least social capital and were most at risk in terms of sociability the frequency distributions of the social network types show that almost one fifth of the sample was embedded in a diverse network friend networks accounted for more than a quarter about a sixth was in congregant networks and a bit less in family networks more than a fifth of sample respondents belonged to restricted networks as for the wellbeing outcomes about a third of all respondents felt lonely in the previous week some 13 felt anxious and a bit more than half were very happy in general at the bivariate level social network type was found to be related to all three wellbeing outcome measures the vast majority of background and health variables were also related to loneliness anxiety and happiness for example lower education was related to greater loneliness greater anxiety and less happiness additional bivariate analyses revealed that the respondents background and health characteristics were also related to the network types age gender ethnic group education income and health thus for example more high income respondents belonged to friend networks than to other network types and those in the family network had worse functional health than respondents in the other networks the bivariate analyses substantiated the need to control for the background and health characteristics in examination of the association between social network type and wellbeing table 3 presents the multivariate regressions in which each of the dichotomous wellbeing outcomes was regressed on the network background and health variables looking first at the background and health characteristics the following associations were observed female respondents felt lonelier than men had greater anxiety and were less happy the same was true for respondents with one or more functional health disabilities when compared with those with no disability other findings showed that those with less education were lonelier than persons with college degrees and those with lower income were less happy than persons in the highincome reference category finally the youngold reported being happier than the oldold blacks and hispanics expressed a greater degree of anxiety when compared with whites after controlling for respondents background and health characteristics the construct of network type maintained an independent association with each of the outcome measures thus when compared with the reference category respondents in the diverse network were less likely to have felt lonely and less likely to have felt anxious moreover a positive association with happiness had borderline significance respondents who belonged to the friend network were less likely to feel anxious and more likely to feel happy however their scores on the loneliness outcome measure were not different than those of respondents in the reference category members of the congregant network were also found to be happier and people in the family network were less anxious than those in the restricted network comparison group also worthy of note is that the associations between the network types and the happinessloneliness outcome variables were mostly the same when linear regressions were performed on the original ordinal scales discussion using a methodology that was applied in previous research on a nonamerican sample the current analysis identified five discernable network groupings among respondents in the nshap these groupings were appreciably different in terms of seven different aspects of social capital the resultant network constellations that were derived in this procedure were termed diverse friend congregant family and restricted network types although the groupings varied somewhat in their relative distribution within the sample each social network type was nevertheless representative of a meaningful proportion of the study population reflecting the different interpersonal milieus in which older americans are embedded the analysis also revealed that four of the five network types derived from the nshap data reflect the main social network types that have been identified in previous studies these include the diverse friend family and restricted networks however a fifth network grouping also emerged one that is unique to the current study sample its exceptional characteristic was its high relative frequency of attendance at religious services as well as its minimal attendance at organized group meetings of other kinds we termed this grouping the congregant network insofar as its outstanding feature was its social exchange with other people at a place of worship it seems that the social networks of older americans in the nshap sample are mostly similar to the main types that have been identified earlier this suggests that the network type construct can indeed be used as an assessment measure for characterizing the nature of the social worlds in which older adults live and function at the same time the study also points to a new social aggregate that seems to draw support from its religious social connections this network grouping accounts for about a sixth of the sample respondents suggesting that faithbased social networks may have particular importance for certain segments of the current older american population future inquiry on the antecedents and the concomitants of belonging to a congregant network type is indeed warranted the present study also considered whether there is an association between social network type and subjective wellbeing among older americans the findings confirm that networks with a wider range of social ties are indeed related to better wellbeing independent of the effects of demographic and health confounders respondents embedded in diverse friend and congregant network types expressed a superior sense of subjective wellbeing as reflected to varying degrees in their levels of loneliness anxiety andor happiness it is important therefore to recognize the potential effect of different social network types on the subjective wellbeing of their members a few limitations of the current analysis should be cited the distributions of the network types as reported here reflect their relative proportion in the unweighted sample as specific weights for the 65 cohort were not available for more precise specification of network type distribution in the older american population therefore additional analysis would be required nevertheless the current distribution still provides useful initial parameters for consideration of social network types and their concomitants a second limitation is that the analysis was based upon available measures in the database this is a constraint that is inherent in all secondary analysis however this obstacle was only a minor limitation insofar as the nshap data provided a wealth of relevant indicators finally we note that the current analysis is based upon a single wave of crosssectional data thus we cannot yet determine whether it is the social network type that affects older persons subjective wellbeing or whether it is the nature of lonely anxious andor happy people that tends to lead them to cluster a priori in different social network types further research on this question is certainly warranted given the instructive findings from this research a supplementary question to be considered concerns how the notion of social network type can aid in the work of gerontological practitioners there are four practical implications in this regard first the awareness of existing network types may help sensitize gerontological practitioners to the varied interpersonal environments in which older adults are embedded this may result in improved critical consideration of how social networks function to enhance or restrain the wellbeing of their members second efforts should be made to create practitionerfriendly instruments that can type clients social networks in a costeffective and an efficient manner additional empirical work that tests the parameters of network type criterion variables and formulates appropriate algorithms for network typing is recommended attention should also be given as to how to involve older clients in the assessment of their social networks third the social network type construct can serve as a basis for risk assessment as well as a means for determining the efficacy of interventions for example the documented movement of a person from a diverse network to a restricted network could be a warning signal that he or she is at increased risk conversely ones transition from a family network to a congregant network could indicate that networking interventions carried out on his or her behalf were indeed successful these applications imply that periodic assessments of older adults social network types are warranted fourth service agency practitioners should think further about how the notion of social network type might enhance their own professional practice leading to the development of additional fielddriven applications of this construct in sum the construct of social network type has much potential for gerontological research and practice future inquiry should address additional aspects of the interpersonal milieu that can be included in the derivation and identification of different network types research can clarify for example whether social network types derived by the present methodology are as effective in terms of assessment as more structurally driven social network inventories such as those that employ name generating mechanisms further inquiry in this respect is likely to provide additional useful benefit and should be encouraged

the study considers the social networks of older americans a population for whom there have been few studies of social network type it also examines associations between network types and wellbeing indicators loneliness anxiety and happiness design and methods a subsample of persons aged 65 years and older from the first wave of the national social life health and aging project was employed n 1462 we applied kmeans cluster analysis to derive social network types using 7 criterion variables in the multivariate stage the wellbeing outcomes were regressed on the network type construct and on background and health characteristics by means of logistic regression results five social network types were derived diverse friend congregant family and restricted social network type was found to be associated with each of the wellbeing indicators after adjusting for demographic and health confounders respondents embedded in network types characterized by greater social capital tended to exhibit better wellbeing in terms of less loneliness less anxiety and greater happiness implications knowledge about differing network types should make gerontological practitioners more aware of the varying interpersonal milieus in which older people function adopting network type assessment as an integral part of intake procedures and tracing network shifts over time can serve as a basis for risk assessment as well as a means for determining the efficacy of interventions

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introduction twothirds of all people infected with hiv live in subsaharan africa although this region contains little more than 12 percent of the worlds population 1 in particular 31 of new hiv infections in the same year occurred in the 10 countries in southern africa 2 the devastating impact of hivaids spans lifeexpectancy public health and the economy through its effects on labor productivity 3 under resourcepoor conditions using the media to increase hivaidsrelated knowledge and promoting condom use may be important for stopping the spread of hivaids 2 in fact the level of hivaidsrelated knowledge and the degree of condom use vary according to socioeconomic status 45 little is known about their associations in subsaharan africa our hypothesis is that the degree of media use mediates the relationship between ses and hivaidsrelated knowledge and condom use 67 the importance of mass media in health promotion and disease prevention is well documented since both routine exposure to and strategic use of mass media play a significant role in promoting awareness increasing knowledge and changing health behaviors 7 8 9 accordingly mass media campaigns have been reliably linked to an increase in hivaids knowledge among individuals in lowincome countries 8 including an awareness of hiv aids the ways in which the virus is transmitted and preventive behaviors 10 knowledge is an important determinant in the pathways to changing health behaviors 11 in the case of hiv aids a high level of awareness is likely to promote safe sex practices such as the regular use of condoms which may reduce the prevalence rate of hiv infection 412 those paths however are embedded in an individuals socioeconomic status as well as in their social and political context 11 while the contribution of media use to disease prevention and to the promotion of healthy behavior is widely acknowledged 7 8 9 there is mounting evidence of disparities in health communication characterized as communication inequalities among different social groups 13 although mass media channels such as radio television and newspapers are important sources of information about hivaids 11 mediapoor groups do not have easy access to these channels 14 in fact individuals of lower socioeconomic status tend to gain less benefit from information flows than their counterparts of higher ses 13 therefore an understanding of inequalities in health communication may contribute to a mass media campaign for populationbased approaches that could address the spread of hivaids worldwide particularly in lowincome countries also media use may blunt the impact of social inequalities in subsaharan african countries we thus focused on this thread linking ses the media and hivaidsrelated knowledge and behavior subsaharan africa has lagged behind in mass media use and telecommunications during the last 50 years since gaining independence from western colonial rule however the use of media has spread rapidly since the start of the twentyfirst century 15 radio is the major source of information in subsaharan africa and television is the second major source of information 16 the region saw impressive growth in the number of tv sets owned as well as in the number of television channels available drawing the attention of international media players as a top emerging territory 17 in subsaharan africa 52 of all households now have a television set with over 50 major paytv service platforms and 369 of the population subscribes to mobile services 18 the expansion of media provides an important opportunity to address hivaidsrelated knowledge and preventive behaviors as limited research on health communication inequalities has been conducted in subsaharan africa the purpose of this study is to use nationally representative surveys of men and women from thirteen african countries to investigate the effect of media use on hivaidsrelated knowledge and behavior our hypothesis is that communication inequalities differential media use among social classes may be one plausible mechanism through which social inequalities in wealth and education lead to knowledge disparities of hivaids in subsaharan africa methods ethics statement approval for the study was granted by the harvard school of public health institutional review board all participants gave written informed consent to participate the ethics committees of the demographic health survey approved this consent procedure during the data collection process any information that could distinguish individual respondents was not collected dataset all of the data used in this study were collected by demographic and health surveys conducted in various subsaharan african countries from 2004 to 2010 the dhs are nationally representative crosssectional household surveys that use a standardized questionnaire to facilitate comparisons among countries particularly for lowincome settings 1920 respondents were recruited using a multistage sampling procedure that stratified all the states of each country into urban and rural areas with each states sample size determined in proportion to the size of the states urban and rural populations and in consideration of each states gender ratio primary sampling units conceptualized as neighborhoods for the purposes of this research were defined as census enumeration blocks in urban areas and as villages or village clusters in rural areas these neighborhoods were selected within each state according to the probability proportional to the population size from the sampling units the 220099 respondents men and women 15 years of age and older were proportionally selected by gender and age based on the census data facetoface interviews were conducted on the topics of mass media use hivaids knowledge and condom use the response rates of all the countries were more than 90 to generate a large dataset with sufficient statistical power to investigate the effect of media use on hivaidsrelated knowledge and condom use we pooled data from the most recent survey in thirteen countries in subsaharan africa since 2004 all of the surveys were carried out under the direction of the government of each country measures the measurement indicators of the dhs were developed by the united states agency for international development 19 dependent variables four binary variables were created using a methodology developed by the joint united nations program on hivaids to measure knowledge and behavior about hivaids awareness prevention knowledge transmission knowledge and condom use 21 the hivaids awareness variable was created using the question have you ever heard of an illness called aids and allowed for a binary yesno response individuals were considered to be knowledgeable about hiv aids transmission if they responded to three distinct questions by indicating that mosquito bites and sharing food could not spread hivaids and that it was possible for a healthylooking person to have hivaids individuals were considered to be knowledgeable about hivaids prevention if they responded affirmatively to each of three questions indicating that an individual could reduce their risk of contracting hivaids if they abstained from sexual intercourse had only one uninfected sexual partner and used a condom every time they had sex condom use was assessed with a singleitem question the last time you had sexual intercourse was a condom used with response options of yes or no independent variables media use individuals reported how often they used three mass media sourcesradio television and newspaperwith possible answers being almost every day at least once a week less than once a week and not at all socioeconomic status wealth was defined using an established methodology developed for the subsaharan africa context in which each individual was assigned a wealth score created by weighting responses to 33 questions regarding household possessions and characteristics such as quality of housing ownership of land and possession of an automobile with a factor analysis procedure and dividing the results into quintiles 22 educational attainment was assessed on the basis of have you ever attended school and what is the highest level of school you attended with responses categorized as no education incomplete primary complete primary incomplete secondary complete secondary and higher potential confounders sociodemographic confounders were selected based on a theoretically 23 and empirically 24 defined relationship with hivaids knowledge and behavior the type of place of residence categorized as belonging to large cities small cities towns and villages the literacy level was measured by asking the respondent can you read whole or any part of this sentence to me which was collapsed into categories of cannot read at all able to read only parts of sentence and able to read whole sentence occupation was created from selfreported jobs and was categorized as not working performing manual work performing agricultural work or performing nonagricultural manual work we considered occupation as a confounder not an independent variable due to the characteristics of the industrial structure of subsaharan africa countries two marital status classifications were single or married couple including cohabitation age was divided into the groups of 1519 2024 2529 3034 3539 4044 4549 5054 and 55 or older statistical analysis each binary hivaidsrelated outcome was modeled with a modified poisson regression by gender using stata version 100 for providing an accurate relative risk and 95 confidence interval while simultaneously accounting for clustering within neighborhoods 25 this is because a poisson regression is necessary when the dependent variable y has a poisson distribution and it assumes the logarithm of its expected value can be modeled by a linear combination of unknown parameters survey weights were applied to each model to account for multiple adjustments in the sampling procedure to ensure that sample was representative of each subsaharan african country features of complex sampling design were taken into account using statas svy suite of commands results as detailed in table 1 a total of 220099 subsaharan africans were recruited for the study the largest sample was from nigeria and the smallest was from swaziland on average over 90 of the respondents were aware of what hiv aids is but a smaller proportion had knowledge about hivaids transmission and prevention practice of condom use was much lower than the level of hivaids knowledge only 12 people out of ten had used a condom during their last sexual intercourse regarding the practice of condom use the scores for men were two times higher than those of women which is in line with the literature 26 the variation in knowledge levels among countries was highest regarding prevention knowledge the descriptive characteristics of the sample from table 2 indicate that the most frequently used media type was radio to which 367 listened daily whereas only 176 and 64 watched television and read newspapers daily notably only about 217 of the respondents did not use a radio at all compared to 544 for television and 650 for newspapers both socioeconomic status and media use indicators were positively associated with each other and they were consistently associated with hivaids knowledge and condom use based on these associations we modeled the multivariate poisson regression hivaids awareness women in the wealthiest quintile and having 13 or more years of education were most likely to have heard of hivaids compared to those in the lowest wealth quintile and those with no education respectively these relationships were attenuated after adjusting for mass media use daily radio listening was the medium most strongly associated with hivaids awareness similar results were found for men as well hivaids transmission knowledge hivaids transmission knowledge was also strongly associated with wealth and education among women as shown in model 1 of table 3 however these relationships were attenuated when media use was added to the model for example after adjusting for mass media use the associations for those in the most educated quintile with knowledge of hivaids transmission was attenuated in model 2 hivaids transmission knowledge was associated with daily newspapers television and radio use the analysis of men was not significant in either direction as the confidence interval crosses 1 in most cases except for less than once a week radio and daily radio hivaids prevention knowledge as shown in table 3 we found a similar trend of the wealth gradient and attenuation with the addition of media variables for prevention knowledge among women hivaids prevention knowledge was associated with wealth and education after adjusting for mass media use the associations for those in the wealthiest quintile with knowledge of hivaids prevention was attenuated in model 2 only the daily use of radio was strongly associated with increased knowledge of hivaids prevention this association among men was more apparent than it was among women condom use the pattern of the influence of ses and the attenuation of its role with media exposure continued for condom use we found wealthand educationbased gradients on condom use and these gradients were attenuated once we accounted for mass media use among women the wealthiest group and those with 13 years or more of schooling were the most likely to use a condom during her last instance of sexual intercourse but the relationships were attenuated among all classes when accounting for mass media use in the models those who use newspapers radio and television daily were more likely to use a condom at the last sexual intercourse we found similar associations between media use and hiv prevention behavior such as condom use among men after standardizing the average characteristics of the pooled population of all countries as the reference the associations between media use and hivaidsrelated knowledge and condom use which were shown in table 3 and4 were more significant in southern regions such as swaziland and namibia than in others this probably means that profound inequalities in health communication still exist not only among individuals but also within the country and region despite mass media campaigns for hivaids control in those countries 2728 discussion communication behaviors are often linked to an individuals socioeconomic background and his or her knowledge and behavior relating to a specific issue our results indicated that the relationship between ses and hivaidsrelated knowledge and safesex behavior are moderated by the effect of media use we found that social inequalities are associated with communication inequalities in subsaharan africa first while there is substantial hivaids awareness among individuals at every socioeconomic level increasing wealth and education are consistently associated with hivaids awareness prevention and transmission knowledge and condom use among both men and women education is particularly strongly associated with both forms of knowledge and behavior this result is consistent with the results of other hivaids studies in subsaharan africa which have found a social gradient in the relationship between ses and hivaids 45 second these associations are attenuated when media use is added to the models there may be profound inequalities in communication among different social groups in subsaharan africa media use is positively associated with wealth and education in a gradient that is clear and convincing indeed newspaper and radio use are significantly associated with ses this observation is consistent with the notion that individuals of higher ses tend to gain more benefits from information resources than their counterparts of lower ses in lics 28 however little is known about how media use may blunt the impact of ses in subsaharan african countries our observation is also consistent with the notion that individuals of any socioeconomic status can work to protect their own health if they can access the resources and information required to do so 14 lastly the effects of mass media in this study vary by country and region southern countries where hiv prevalence is high also show stronger effects of media use compared to the other regions this indicates that the effects of mass media campaigns and outreach programs in these high prevalence countries have been effective thus we need to further reduce communication inequalities in order to improve the average level of hivaids knowledge and to promote condom use knowledge is a key variable influencing condom use according to the previous metaanalysis 29 several limitations of this study should be noted the observational nature of the crosssectional data prevents us from making causal inferences regarding the associations among socioeconomic variables media use and hivaidsrelated knowledge however the outcomes of interest in this studythe aspects of media useare unlikely to precede the exposures under investigation education and income thereby reducing the possibility that the results would reflect reverse causation in addition previous studies demonstrating that media use leads to increased knowledge and healthy behavior support our assumptions regarding the ordering of the constructs 1330 concerning the generalizability of the study more robust longitudinal studies are needed to establish a causal relation between media use and hivaidsrelated knowledge and behavior lastly this study did not conduct media content analysis so it is not possible to determine which messages the study subjects received from their media use also future research should explore the potential of mobile phones and how they can be harnessed for health promotion given their increasing penetration despite these limitations the study is a novel use of thirteen nationally representative datasets created to study communication inequality as a driver of social inequalities in hivaidsrelated knowledge and behavior with sensitivity to differences in country and region the findings of this study clearly point to an opportunity for mass media to promote hivaids knowledge and condom use to reduce the invidious impact of socioeconomic status on health the caveat however is that inequalities in communication specifically unequal use and exposure to different communication channels between higher and lower ses groups has the potential to obstruct the promise of mass media this calls for public health communication strategies that take into account these inequalities in order to overcome barriers across social classes thus we need to apply mediabased approaches to improve hivaidsrelated knowledge and condom use in subsaharan africa while considering the differences in media use and exposure according to wealth and education at the same time we should pay attention to reducing communication inequalities among social groups and countries so as to achieve health equity on hivaids supporting information

it is known that the level of hivaidsrelated knowledge and the degree of condom use varies by socioeconomic status ses however there is limited research on the effect of mass media use on hivaidsrelated cognitive and behavioral outcomes in lowincome countries and how it might influence the association between ses and hivrelated outcomes we investigated the moderating effect of media use on the relationship between ses and hivaidsrelated knowledge and condom use in subsaharan africa in terms of communication inequalities crosssectional data from the demographic health surveys from 13 subsaharan countries 200410 were pooled genderstratified multivariable poisson regression of 151209 women and 68890 men were used to calculate adjusted relative ratios and 95 confidence intervals for the associations between ses media use hivrelated outcomes and condom use we found significant disparities in mass media use among people from different ses groups as well as among countries education and wealth are strongly and positively associated with awareness of hivaids and knowledge about transmission and prevention of hivaids and are significantly associated with condom use these associations are attenuated when the use of various types of mass media is added to the models with newspapers showing the strongest effect the findings of this study suggest that media use has the potential to blunt the impact of socioeconomic status though not completely eliminate it thus we need to pay attention to reducing communication inequalities among social groups and countries to moderate the effect of wealth and ses on hivaids

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introduction the pandemic that has marked and continues to mark humanity since 2020 has had a strong impact on the health of the population on health systems around the world and on economic and social life at the same time the architecture of social relations has changed both as a result of restrictions imposed by the authorities and as a result of personal decisions about the need to protect against an enemy that is still little known under these conditions values such as solidarity with the most vulnerable to the disease concrete involvement in helping them and responsibility towards others and towards the community to which you belong have acquired new forms of manifestation and meanings the covid19 crisis is proving to be one of the most significant paradigm shifts in the contemporary world along with studies analyzing the impact of the pandemic on health education and economic systems both globally and locally concerns have been raised about how society has reacted to this major crisis 1 2 3 4 5 this shapes the idea that the current context has led to an increase in creativity in the manifestation of solidarity 67 and this boost in creativity was all the greater as the experience in showing solidarity was less are those concerned with correcting the shortcomings in the romanian health system and the campaigns carried out for this purpose enjoy the greatest support and visibility magicamp and dăruies te viat a are only two such examples 38 at the local level however social activism is almost nonexistent in fact most of the manifestations of the civil society both at national and local level took place within campaigns initiated by the media the church or various personalities with visibility in the public space either they were determined by the desire to help in case of natural disasters tragic events or they started from the supportcontestation of some ideas or projects in which case they were quickly confiscated politically these expressions of solidarity rarely had a spontaneous character being in fact impelled by somethingsomeone another characteristic of the involvement of the civil society formal and informal in the romanian space is the more active involvement against somethingsomeone than for somethingsomeone with very few exceptions the voice of civil society in the romanian public space was heard to challenge not to support in this context it was considered that suceava county is an adequate space for the analysis of how the difficult situation faced by the population at the beginning of the pandemic influenced the collective involvement andor its individuality in solving community problems the present study aims to answer a few research questions to finally outline a picture of resilience at the collective and individual level an experiment or test of civic solidarity what were the ways of involving the population and what is the profile of those involved how did the population perceive the reaction of civil society in a time of major crisis to what extent has the involvement of the population been influenced by the way in which the media has reflected this crisis in order to decipher the mechanisms of civic involvementnoninvolvement the following hypotheses were taken into consideration h1 the population has seen the crisis resolved through the involvement of the authorities and passive personal involvement rather than their own or active group involvement h2 the reaction at individual andor collective level was conditioned by the distance from the disease and by sociodemographic factors h3 the media acted as a catalyst for individual andor collective involvement materials and methods the present sociological diagnosis used data that were collected through an online survey at the beginning of may 2020 among the population of suceava county the pandemic period meant a limitation of social interactions the situation in which the most appropriate way to collect research data was online collection through google forms in order to increase the level of heterogeneity of the sample and to include in the sample as high a diversity of respondents as possible we resorted to the construction of the sample by snowball method in this case all participants being asked in turn to send the link of the questionnaire to other people in order to increase the number of participants the data collection tool was designed as a sociological questionnaire that brought together a total of 33 questions most of which were predefined questions in the beginning the main limitation was that females were prevalent in the sample which is why we used a weighting of the sample by gender variable in this way we balanced the structure of the sample so that its sample can reflect the characteristics of the reference population another limitation of the study was the unequal access to digital technology which explains the lower share of respondents in rural areas and those with lower education the data collected focused on several aspects including the perception of the population on the causes underlying the outbreak of covid19 but this article focused only on how the intervention of civil society was perceived the influence which was expressed by the media and last but not least the way in which the participants in the study were involved in resolving the crisis the aim was also to identify how the reaction of civil society was perceived and how it was mobilized as well as how the mass media contributed to reducing the effects of the pandemic a distinct objective was to measure the level of involvement of study participants and the forms in which they were involved after the elimination phase of noncompliant responses the volume of the sample included a total of 1231 people of which 673 were female and 327 were male the mean age of the study participants was 3805 years results civil society involvement at the end of march 2020 in the conditions of the sustained increase in the number of cases of infection with the new coronavirus at the national level the situation seemed out of control at suceava county hospital a very large number of infected medical staff dysfunctional drug and food supply circuits for patients a climate of panic and insecurity that determined even the unjustified absence of staff completely outdated management and a lack of minimum measures to protect both staff and uninfected patients all featured amid the explosive increase in numbers of requests from the beneficiaries of medical services the local authorities under which the sch was subordinated reacted late without firmness and without proving that they had a coherent crisis management plan the sch leadership was fired but the new interim leadership resigned after only a few days declaring its inability to manage the situation under these conditions the local and national media presented an apocalyptic situation an image with a strong emotional impact that accentuated the panic and the feeling of abandonment that had already settled especially among the population of the county seat suceava in the face of the almost total lack of reaction of the authorities more or less known actors of the local civil society started to get involved the most effective and visible involvement was that of the entrepreneur s tefan mandachi who using the notoriety he already enjoyed locally as a result of a previous action launched the campaign 1 cm of good deedsall in the front line in partnership with the red cross suceava branch and the society of medical students from ias i this campaign managed to raise over 15 million euros in a short time which was the largest amount ever obtained in romania through a campaign initiated by an individual the money obtained both from substantial donations from companies or personalities from various fields and from symbolic donations from community members was used to equip hospitals in the cities of suceava county and to provide support to nursing homes in addition the initiator of the campaign supported sch by offering free accommodation in one of its hotels for medical staff and by distributing free food to medical staff and sch patients when the operation of the hotel could no longer be managed with its own resources this campaign was the largest and most visible but it was not the only one other associations and organizations as well as many local entrepreneurs helped both the medical units in the county and institutions for vulnerable people or simply individuals affected by the pandemic among the campaigns and actors noted by the respondents mention should be made of rotary club suceava cetateend covid now rădăut iul civicemergency fund for rădăut i support group for vatra dornei salvamont vatra dorneitogether we help vatra dornei and the humanitarian foundation 2001 for romania another very visible and present actor in the critical period that the city of suceava went through in marchapril 2020 was the stefan cel mare university of suceava usvs involvement had several components and continued even after the critical period was over among the most important actions of usv one can mention the implementation of a complete line of semiautomatic covid19 tests which were transferred to sch the creation and implementation of the counseling center for both medical staff and students and people emotionally affected by the pandemic through launching a telephone line for psychological medical and logistical counseling and the digitization of the activity of the public health directorate suceava in addition usv teachers researchers and students volunteered to train and assist both medical staff and those in need the romanian orthodox church is another essential component of romanian civil society that enjoys great trust among the population together with the national army bor ranks first in opinion polls in terms of public confidence in state and nongovernmental institutions 39 the church also acted in support of the suceava community getting involved through the direct purchase and donation of medical equipment by initiating platforms for donations and humanitarian campaigns the funds thus obtained being intended for the purchase of medical equipment and hospital supplies and by organizing teams of volunteers to provide assistance to vulnerable people the challenges of the pandemic and the tension existing at that time in suceava county contributed as previously shown to the involvement of civil society and to the mobilization of several actors in the public space in this regard study participants were invited to mention some of the initiatives in support of the fight against covid19 that they noted in the public space the inventory of the free answers offered by the respondents allowed us to make a graphic representation in the form of a cloud of words of the most common answers emergency fund for rădăuți support group for vatra dornei salvamont vatra dorneitogether we help vatra dornei and the humanitarian foundation 2001 for romania another very visible and present actor in the critical period that the city of suceava went through in marchapril 2020 was the stefan cel mare university of suceava usvs involvement had several components and continued even after the critical period was over among the most important actions of usv one can mention the implementation of a complete line of semiautomatic covid19 tests which were transferred to sch the creation and implementation of the counseling center for both medical staff and students and people emotionally affected by the pandemic through launching a telephone line for psychological medical and logistical counseling and the digitization of the activity of the public health directorate suceava in addition usv teachers researchers and students volunteered to train and assist both medical staff and those in need the romanian orthodox church is another essential component of romanian civil society that enjoys great trust among the population together with the national army bor ranks first in opinion polls in terms of public confidence in state and nongovernmental institutions 39 the church also acted in support of the suceava community getting involved through the direct purchase and donation of medical equipment by initiating platforms for donations and humanitarian campaigns the funds thus obtained being intended for the purchase of medical equipment and hospital supplies and by organizing teams of volunteers to provide assistance to vulnerable people the challenges of the pandemic and the tension existing at that time in suceava county contributed as previously shown to the involvement of civil society and to the mobilization of several actors in the public space in this regard study participants were invited to mention some of the initiatives in support of the fight against covid19 that they noted in the public space the inventory of the free answers offered by the respondents allowed us to make a graphic representation in the form of a cloud of words of the most common answers an analysis of the word cloud highlights the following aspects donations and compliance with the rules were the most visible manifestations of society in the face of the crisis most of the actions taken were aimed at supporting the medical system and vulnerable groups in public perception ștefan mandachi an analysis of the word cloud highlights the following aspects donations and compliance with the rules were the most visible manifestations of society in the face of the crisis most of the actions taken were aimed at supporting the medical system and vulnerable groups in public perception s tefan mandachi imposed himself as the initiator leader and catalyst of the actions undertaken by civil society and solidarity and involvement appear to be important elements in respondents perceptions of the fight against covid19 the heterogeneity of the inventoried answers required their grouping and the outlining of initiatives with a higher degree of generality however where the category of answers allowed the identification of distinct subcategories they were mentioned almost 1 4 of the participants in the study mentioned elements that can be attributed to the activities undertaken by civil society both in an organized form through the initiative of nongovernmental organizations and by the inclusion of initiatives that belonged to individuals the initiative taken by the entrepreneur s tefan mandachi who initiated the campaign 1 cm of good deedsall in the first line reaching a level of notoriety of 72 of the total of the mentioned initiatives definitely stood out from the category of nongovernmental organizations a distinct category of responses was represented by initiatives that directly aimed at supporting the activity of the medical sector this category of responses included a variety of mentions that respondents listed including support for physicians and medical staff with protective equipment with material and financial resources to enable the purchase of medical equipment emotional support and the provision of accommodation for medical staff so that they do not come into contact with family or other persons when they were at rest the third category of initiatives that remained in the collective mind concerned the campaigns that were carried out mainly in the media and aimed at respecting the rules of personal hygiene quarantine and maintaining social distance in public spaces while the first two categories of initiatives listed directly concerned the health system and the work of civil society this category of initiatives focused exclusively on how individuals directly contributed in the fight against covid19 through personal actions and behavior the epidemiological crisis that suceava county faced at the beginning of the pandemic period was a challenge that brought together the combined efforts of several actors from different levels of the community organization in this sense the inventory of initiatives to combat covid19 allowed us to group them according to the level of involvement of the actors thus two categories of initiatives were outlined institutional initiatives and respectively individual initiatives the category of institutional initiatives included the response of various institutions in reducing the spread and limiting the effects of the pandemic thus included in the category of institutional initiatives were the actions of nongovernmental organizations and the red cross but also of public institutions s tefan cel mare university of suceava and the church the relevance of institutional initiatives at the level of the collective mind proved to be more consistent compared to that of individual initiatives in relation to the environment of residence the institutional initiatives are mainly associated with the urban environment 1459 p 000 and the localities that were quarantined 18052 p 000 while the individual initiatives are mainly mentioned by the respondents from the rural area especially from the nonquarantined localities personal involvement in the fight against covid19 the analysis of how the involvement of civil society in the fight against covid19 was perceived requires the consideration of the way in which the participants in the study were involved the category of individual initiatives included those that came from individuals aimed at internalizing the rules of maintaining personal hygiene adopting behaviors that limit the transmission of the virus and supporting disadvantaged people and sick or destitute people at home the analysis of the answers showed that 81 of the total participants in the study were involved in the fight against covid19 through at least one of the following forms by volunteering by making donations or by helping vulnerable people alternatively 19 did not show solidarity with the challenges of the pandemic suceava county faced from a structural point of view the individual involvement was differentiated the analysis of the results shows a relatively low level of individual involvement through voluntary actions the considerable share being limited to supporting the activities of civil society either through donations or by supporting vulnerable people in extreme situations an important element that can contribute to shaping an overview of personal involvement in mitigating the effects of the pandemic may be personal experience in relation to the actual illness thus starting from the answers provided by the study participants two categories of respondents were outlined the category of respondents who were diagnosed with covid19 themselves or had family members who were infected and the category of respondents who had social proximity to people who were ill or even died the involvement of people who had contextual experiences in relation to the activities in which they were actually involved highlights the predominance of help to vulnerable people donations and last but not least involvement through volunteering on the other hand those who had subjective experiences in relation to the disease with covid19 were mainly involved in activities to support vulnerable people 517 p 002 in order to have a more complete picture of the profile of the people who were involved in the activities to reduce the effects of the pandemic we collected series of variables of a sociodemographic character as well as variables that will highlight the personal experience of the respondents in relation to covid19 thus it can be remarked that the average age of the people involved in the activities of mitigating the effects of the pandemic differs statistically significantly from the average age of those who did not make any effort in this regard 324 p 000 the average age of the people involved is 3 years older than that of those who did not join the fight to reduce the effects of the pandemic this difference highlights the fact that those involved understood the need to support this approach and the difficulties faced at that time by the community in suceava county last but not least there was the possibility of personal fears especially as in the public space at that time there circulated the information that the pandemic can generate negative effects among older people referring to the concrete way in which the study participants were involved for all three forms of involvement the average age of those involved was statistically differentiated from the age of those who did not make efforts having slightly higher values as follows involvement through volunteering 206 p 000 involvement by making donations 255 p 001 and the involvement through help offered to vulnerable people 260 p 000 regarding the involvement of the study participants in the fight against covid19 in relation to gender a predominantly female participation can be observed both in terms of overall involvement 1844 p 000 as well as involvement in donation support activities and support for vulnerable people all these manifestations of formal civil society have been visible in the local community the perception of the participants in the study on the way in which the civil society was involved in diminishing the effects of the pandemic during the beginning of the crisis has a predominantly positive connotation in the context in which approximately three quarters of the respondents appreciate the interventions of the civil society being very good and efficient alternatively 28 of the respondents considered the interventions of the civil society rather modest as expected assessments of civil society activity may be associated with or determined by a number of factors that have acted latently in the context of the pandemic with regard to informal civil society that is ordinary citizens most respondents stated that they were involved in helping vulnerable people fewer mentioned donations as a form of involvement and fewer still said they were involved through volunteer work a first element that marks the perception of civil society interventions is the age of the study participants thus we can observe the existence of statistically significant differences in terms of the age of the respondents who expressed themselves regarding the intervention of the nongovernmental environment in the fight against covid19 we find that the positive assessments come from people with a higher average age compared to the more reserved assessments of younger respondents the rather passive and impersonal involvement of respondents in resolving the suceava crisis as well as the perception of the same type of action as important in limiting the effects of the pandemic indicates a certain stage in the evolution of local civil society after 30 years of democracy people still expect solutions from the outside but there are still germs of a proactive attitude through which the individual and society can become relevant actors in crisis management analyzing the profile of those involved in the fight against covid19 in relation to the distance from the disease we can see the trend of higher involvement from people who were in social proximity with people who got sick or even died compared to people who did not have this unfortunate experience in other words when there were certainties regarding the results of contamination people mobilized and made an effort in this regard one can also notice a slight association between involvement in the fight against covid19 and subjective experience but this time the association is at the limit of statistical significance however one can appreciate that the relatively limited involvement of those who had subjective experiences can be explained either by the fear of relapse or by their limited ability to get directly involved in this struggle an important factor in empowering the population in the fight against covid19 was the way in which the reflection of the situation created in the local and national media was perceived as expected the participants in the study appreciated that the local media presented an image closer to the truth compared to the national media these beliefs could also be due to the fact that the local media reflected realities from the geographical proximity and could have known and understood the local context in more depth but also due to the fact that the participants in the study showed a high level of trust in the media thus it was found that the positive assessments related to the way in which the local media reflected the situation of the pandemic in the county are associated with the positive assessments of the national media χ 2 24225 p 000 an important element that contributed to the positive appreciation of the way in which the local media reflected the state of the pandemic can also be explained by the existence of contextual experiences arising from the illness of people in social proximity or even the death of acquaintances χ 2 10543 p 000 thus when there were such contextual experiences the appreciation of the activity of the local media was rather positive compared to the situations in which the respondents did not have victims of the pandemic in their social proximity this confirms that the level of credibility of how reality has been reflected through local communication channels is also strengthened as a result of personal experiences the involvement of study participants in the fight against covid19 materialized through various actions and was stimulated at the individual level by the way in which the local media reflected the reality of that period thus it has been considered that the association between offering donations and the appreciation of the local media as objective and close to the truth is not accidental 22858 p 000 the media directly contributing to the population mobilization in the process of collecting resources in the form of donations discussion according to the obtained results it is obvious that in the situation of the lockdown in suceava and the neighboring communes the civil society organizations took over tasks that the state should have managed the security of individuals and the community became in whole or in part the responsibility of some civil society organizations through their responsible involvement the involvement of civil society in solving the problems associated with the pandemic is a common fact all over the globe 16 which differs in the degree and manner of involvement the results of studies analyzing the role of social cohesion and civil society in managing the crisis caused by the covid19 pandemic in european countries 40 41 42 43 44 45 or outside the european space 354647 indicate that the success of managing a crisis situation depends on the reaction of civil society even if the authorities react very well the cited studies also show that the involvement of civil society can be very different depending on the moment the context and the cultural environment the existence of differences in the involvement and role of civil society between eastern and western european states has also been demonstrated 48 if in western societies with an active and present civil society in normal times the pandemic context only generated an adaptation of support actions to new needs 49 in postcommunist societies the current situation sometimes required awakening a civil society that many did not even know existed additionally the mobilization of the suceava civil society can be considered illustrative for the romanian society with a reduced seniority in democracy compared to the countries with a long democratic experience comparing the results of our study with those of the aforementioned studies on the role of civil society in managing the covid19 crisis we find that at least in suceava the health crisis has awakened civil society the effects of its actions being beneficial in the short term civil society actions have strengthened social cohesion and had only positive effects at the same time the actions of civil society in suceava have not been very diverse nor very creative being limited to classic support through donations and possibly volunteering through these characteristics the actions of the civil society in suceava are integrated in the model associated with the former communist states with a limited experience regarding the involvement of the civil society in solving the problems of the community the involvement of citizens in limiting the effects of the pandemic has been significant this aspect is very different from the results of a sociological survey conducted in 1998 at the request of the foundation for the development of civil society in romania which revealed that the reason why romanians joined a nongovernmental organization was to obtain aid the concern for defending group interests being secondary 50 prior to the pandemic in suceava there were sporadic demonstrations of solidarity in humanitarian campaigns organized by local institutions or individuals generally to help people in need from various points of view it can be stated however that in accordance with the situation at regional and national level the actions of civil society in normal conditions in suceava are still timid and the civic spirit is maturing the reaction of the suceava community in the face of a major crisis indicates a tendency to crystallize the role of civil society it can be deduced that in the context of the pandemic civil society presents as an essential trend the return to normal in the sense of consciously assuming its role and functions in a democratic society however the way in which the civil society of suceava reacted and mobilized in the face of the crisis indicates a change of attitude a step forward in terms of its transformation from a marginal insignificant actor to a participatory actor whose actions can generate change the media as a component of civil society managed to mobilize important segments of the population both in quarantined localities and in other localities in suceava county and moldova at the same time the civic actions of the media highlight the role assumed not only to inform its citizens but also its concrete commitment in the fight against covid19 and the promotion of a civic culture the local media made a radical contribution to reducing public apathy and shifting personal and public concerns social networks were used extensively and the easy and efficient communication of the people present on these platforms allowed an unprecedented mobilization from the emergence of new solidarity practices consisting of multiplication collection and distribution of food planning and organizing actions to crowdfunding age place of residence and distance from the disease are the variables that most influenced the perception of the population on the involvement of civil society in resolving the crisis the fact that a more favorable perception of how civil society reacted was more characteristic of people with a higher average age can also be explained by the informational context of that period when it was mentioned that older people are more at risk in this context older people were tempted to consider positive almost any initiative that would have contributed to reducing the effects of the pandemic the greater visibility of institutional initiatives for urban respondents is also explained by both the higher level of information and the more rigorously imposed and practiced distance in urban areas especially at the height of the crisis which made personal direct involvement more difficult conclusions the covid19 crisis tested social cohesion and the resilience of communities both locally and nationally despite the perception that romanians would rather be part of a culture of individualism in extreme situations it was found that their activity has never been more important the mitigation of the negative impact of the suceava crisis also largely depended on the ability of civil society to strengthen its role through its response and effective actions the analysis of the activity of the different components of the civil society from suceava county indicates a slight but certain tendency of the maturation of the civil society and of the diminution of the contesting character of confronting the civil society with the power thus more and more insistently the civil society was involved through its own specific ways in promoting the general interests of communities active involvement in the fight against the pandemic indicates a certain stage in the evolution of local civil society after 30 years of democracy although in many cases external solutions are still awaited there are still signs f a proactive attitude through which the individual and society can become relevant actors in crisis management the reaction and actions of the suceava community in the face of a major crisis demonstrate a tendency to crystallize the role of civil society and return to normal in the sense of consciously assuming its role and functions in a democratic society this partially confirms the first hypothesis that underpinned this study regarding the profile of the persons involved in diminishing the effects generated by the pandemic crisis it is to be appreciated that in general there was a more consistent involvement of females that the persons involved were more mature in terms of age compared to those who were not involved and contextual experiences and the existence of the disease in the vicinity generated a better mobilization thus the study indicates that the reaction at the individual or group level was nuanced by various variables thus confirming the second research hypothesis an important role in empowering the population to reduce the effects of the pandemic was also played by the way in which the media managed to present the reality of that period the publics trust in the activity of the local media and the favorable appreciations towards them were associated with the involvement of the population in this fight this confirmed the catalytic role that the local media played in mobilizing civil society although the survey involves a number of limitations due to the structure of the sample the results of this study suggest the existence of a potential for action at the level of romanian civil society at least in exceptional conditions and the reaction of romanian civil society in the current crisis of ukrainian refugees proves this in this context the analysis of the role of civil society in managing a crisis in suceava may be a starting point for further studies that will analyze other manifestations of civil society in romania in more or less similar conditions civil society played a key role through its actions at all levels offering a remarkable lesson in postdecember solidarity that reflects the idea of active united and inclusive citizenship funding this research received funding from the west university of timişoara institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the institutional review board of west university of timis oara data availability statement the data presented in this study are available upon request from the appropriate author the data is not available to the general public the approved public with competences in the analysis and interpretation of data from sociological studies will be able to request access to the study database informed consent statement informed consent was obtained from all subjects involved in the study

the covid19 pandemic and the lockdown have highlighted the growing awareness of the need to involve the population in solving problems that directly affect the existence and trajectory of the life of the individual and civil society in the local national and regional context the article aims both to analyze the reaction of formal and informal civil society in a context of major crisis and to analyze how the population perceives the involvement of civil society at the level of a county in romania and its county seat city the present sociological diagnosis used data that were collected through an online survey at the beginning of may 2020 among the population of suceava county it was sought to identify how the reaction of civil society was perceived and how it was mobilized as well as how the mass media contributed to reducing the effects of the pandemic after the elimination phase of noncompliant responses the volume of the sample included a total of 1231 people the results of the study indicate that this pandemic context which manifested as a major crisis also had positive effects in the sense of mobilizing latent but extensive energies at the local level whose manifestation contributed to diminishing and limiting the effects of the sanitary crisis the county faced the media as a component of civil society has managed to mobilize important segments of the population both in quarantined localities and in other localities in suceava county and moldova the covid19 crisis tested the social cohesion and resilience of communities and offered perhaps one of the most remarkable lessons of solidarity in the postdecember period both locally and nationally although the perception of romanians on the role of civil society would rather be part of a culture of individualism in extreme situations it was found that its activity has never been more important

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introduction selfreport measures are the bedrock of much research in the addictions 1 and it is generally accepted that this approach can be used as a reliable and valid method 23 by providing a systematic structured and guided format for recording drinking the timeline follow back interview for example is a widely used and highly regarded method for recording alcohol consumption by less structured approaches on the other hand ask that participants recall and record the total number of drinks consumed in a previous time period however the environments in which such retrospective assessments take place are often far removed from the settings in which the drinking occurs by nature of their post hoc design 5 accordingly the task of retrospective recall may encourage fabrication in an effort to satisfy the demands of the researchers 67 such a task may be particularly demanding cognitively as alcohol consumption can impair memory and because of the absence of environmental stimuli which may aid recall indeed research suggests that variations in response to alcoholrelated questions can be expected across contexts 11 12 13 and that both social and environmental factors are important determinants of a variety of alcoholrelated cognitions and practices resultantly retrospective accounts of alcohol consumption may be expected to differ from those obtained in real world drinking contexts with the possible weaknesses of selfreport measures in mind in recent times there has been an increased focus on invivo assessment of alcohol consumption the use of ecological momentary assessment in particular is thought to reduce the demands placed on autobiographical memory and removes the potential for parkinglot compliance 20 this approach also allows researchers to gather extensive data regarding respondents current behaviours and beliefs at different times over an extended period of assessment the use of ema to assess realtime substance use has been previously pioneered in the study of varying substance use providing episodebased reports of realtime smoking and drinking 21 22 23 24 25 26 27 28 this research has provided insights into the antecedents of realtime substance use as well as demonstrating that in vivo accounts may differ from retrospective reports this research has also paved the way for more systematic examinations of consumption patterns and impacts of contextual factors building on this design the purpose of this study is to examine and to compare possible variations between de facto realtime and retrospective recall of alcohol consumption by using smartphone technology we hoped to gather instantaneous and rich data that are electronically timestamped and help minimise reliance on retrospective accounts 2930 we expected ema using smartphone technology to be contextaware 31 and to enable us to keep track of changes which may be particularly useful for monitoring behaviours which are episodic and bound contextually 17 method following ethical approval from the universitys ethics boards participants were recruited though opportunity sampling on a university campus and through online adverts all participants gave fully informed written consent this research complies with the world medical association declaration of helsinki design a within participants design was utilised to investigate the difference between participants invivo recorded alcohol consumption and their daily and weekly retrospective accounts of consumption the environmental and social contexts in which participant responded and the type of alcohol consumed were also recorded participants 69 participants were recruited on a university campus the majority of this sample was white british students 59 were male participants were offered monetary reimbursement or course credit by way of remuneration prior to further analyses participants who failed to activate the application or failed to complete at least 2 full response sessions on a single drinking occasion were removed from the data file the data we collected on participant user experiences suggest that the majority did not find the app overly burdensome indeed over 80 either agreed or strongly agreed that the app was convenient and easy to use although there are clearly some time demands for taking part we have no data on those who signed up but then never activated the application this decision was taken as these cases contributed no data to the overall data set preliminary analyses revealed that there were no significant differences in demographic or baseline reports of alcohol consumption between these excluded participants and those who remained in the data set furthermore the structured nature of the data meant that despite this deletion there were a substantial proportion of data points remaining for analytical purposes data regarding the number of each presented drink type current social context and present environmental location were provided in each invivo hourly response session meaning that participants provided 12 pieces of information about their drinking and current location every hour that they responded given that participants completed an average of 4 sessions per drinking day all participants provided an averaged minimum of 48 data pieces of information during the research 22 participants provided responses for one days drinking 16 provided responses for two drinking days 8 provided responses for three drinking days and 4 provided responses for four days in short participants included within subsequent analyses provided 10 560 data points during their invivo responding assessment procedure following ethical approval participants were recruited though opportunity sampling on a university campus and through online adverts all participants provided fully informed written consent those who signed up to take part attended a briefing session where they were instructed how to download and use the application participants demographic details and information about their drinking were also obtained by way of an electronically administered questionnaire participants were asked to use the application to report as many separate drinking occasions as possible over the participation week once activated the application triggered hourly participation prompts asking respondents to record their alcohol consumption in the last hour these hourly prompts continued until participants indicated that they had finished the dinking session the research team emailed participants 24 hours after the drinking session had finished and asked them to complete a short online survey in which they were asked to recall their previous alcohol consumption on the previous day this process was repeated for every drinking occasion that the participants documented at the end of the participation week participants provided their weekly retrospective reports electronically measures prior to taking part in the research participants were asked standard questions about their age gender status on campus they were also asked questions about their drinking practices and related beliefs these were assessed using two standardised questionnaires first the alcohol outcomes expectancy questionnaire which is 34 item questionnaire asking about the positive and negative outcomes that participants expect to result from drinking a standardised average of participants responses to positive items was calculated giving a range of 16 second the audit was administered which is a well established standardized measure of alcoholrelated problems that is used in both clinical and non clinical settings its items assess 3 areas harmful alcohol use hazardous alcohol use and dependence symptoms and its raw score can be used to classify respondents based on their drinking a score exceeding 8 is considered indicative of hazardous drinking 33 the current participants mean audit score was 919 the application itself asked participants a number of multiple choice questions which enquired about the respondents current location and who they were with familypartner 1 friend 2 or more friends other the application presented numerous drink options these options were labelled pictorial representations of different drink types alongside a description of standard measurements once ticked participants could then record the number of that particular drink they had consumed using the same response format follow up emails for the purposes of retrospective selfreports also asked participants to record the type and quantity of alcohol consumed equipment a smartphone application was designed specifically for this research and it enabled participants to respond to questioning via the use of their own mobile phone the application and interface were built using html and javascript and javascripts jquery mobile library phone gap was used to convert the webbased application into a native application that could be downloaded onto the users own device by scanning a qr code local storage within the application was used to store temporarily all the users answers before data were remotely transferred to google analytics to facilitate data anonymity and allow researchers to track individual level data individual participants responses were tracked using a unique alias which was randomly generated by the application the application was carefully designed and piloted to make the user interface as intuitiveuser friendly as possible and there were no default answers set in accordance with recommendations participants were instructed to activate the application when beginning a drinking session it then provided hourly prompts that asked respondents to record what they were drinking hourly prompts elicited around 68 compliance rates drinking cessation was assessed by the application specifically the application required participants to indicate their immediate future drinking plans every time they responded here there were three options available to participants intend to continue drinking finish drinking for now but will continue later finish drinking for the day data selection and analytic strategy participants invivo records of the type and quantity of alcohol consumed were compared with their daily and weekly retrospective selfreports in order to facilitate this drinks of the same type that were consumed in different quantities were combined into broader categories for example ½ pint of beer or cider 1 pint of beer or cider and small or large bottles of beer or cider were combined into a single category the same was done to create a further 3 categories wine spirits daily and weekly overall totals were also calculated for both invivo and retrospective drinking records the average number of drinks consumed for these categories are summarized in table 1 invivo reports were taken every hour on days where the application was activated by respondents analyses of daily consumption here therefore represent the total number of drinks that participants reported consuming over the course of their first day using the application day 1 of participation was selected in order that the maximal amount of data could be included within the daily invivo vs retrospective analysesnot all participants took part for more than one day nonetheless weekly totals were calculated by summing the number of drinks recorded over every drinking occasion that was documented this does mean that in some cases participants realtime daily and weekly drinking totals were identical however these data are pertinent as they still allow for both daily and weekly invivo vs retrospective comparisonsshedding light on nature of selfreport data this was calculated by summing every hourly response participants daily retrospective accounts for that day then provided the daily retrospective measure for analytical purposes in the same vein weekly totals were calculated by summing the number of drinks recorded across every drinking occasion that was documented in realtime participants weekly retrospective accounts at the end of the participation process provided the weekly retrospective measure for analytical purposes initial analyses indicated that there were significant differences between participants invivo and retrospective drinking accounts of the number of drinks consumed in both daily 599 p 001 and weekly assessments 339 p 01 such that retrospective reports were lower than invivo accounts four sets of models were analysed using multilevel mixed effects linear regressions a set of models was produced for each of the following criterion variables daily difference score daily retrospective score weekly difference score and weekly retrospective score unlike retrospective scores for which models will show a direct relationship between recall consumption and the various predictors the difference scores represent the discrepancy between realtime and recalled consumption higher difference scores indicate greater discrepancies between realtime and recalled consumption positive relationships with any predictors suggest that those predictors increase that discrepancy whilst those predictors with negative relationships suggest that these variables reduce the discrepancy each model that was constructed followed the same analytical procedure model 1 overall invivo score model 2 individual variations in drinking typeas it possible that people who are more likely to drink certain types of alcoholic beverages experience greater difficulty retrospectively reporting their drinking behavior model 3 individual variations in drinking type social and environmental drinking locations and audit scores the final models are presented belowthe other models are provided in the supporting information results initial correlational analyses revealed that whilst daily in vivo reports were moderately correlated with daily retrospective reports there was no significant correlation between weekly in vivo and retrospective reports all preliminary correctional analyses are reported in table 2 daily difference score the initial model showed that overall realtime alcohol consumption was significantly related to the daily difference score suggesting that higher alcohol consumption results in a higher discrepancy with recalled consumption the individual variations in drinking type model showed the same pattern for all types of alcohol consumed table 3 shows that in the final model neither the context nor audit variables had a significant relationship with daily difference score while the individual variations in drinking type remained significant recall after 1 day overall realtime alcohol consumption was significantly related to recalled alcohol consumption after 1 day weekly difference score the initial model showed that overall realtime alcohol consumption was significantly related to the weekly difference score suggesting that higher alcohol consumption results in a higher discrepancy with recalled consumption the individual variations in drinking type model showed the same pattern table 5 shows that for the final model the individual variations in drinking type remained the same as in the prior model audit score was not significantly related to the weekly difference score for the where context variable both being at work or at a bar club or pub was associated with a significantly greater discrepancy in realtime and recalled weekly consumption compared to being at home for the who context variable being with family or with two or more friends was associated with significantly lower discrepancy in realtime and retrospectively recalled consumption compared to being alone recall after 1 week neither overall consumption or individual variations in drinking type were significantly related to recalled consumption after one week table 6 shows that of the individual variations in drinking type beer consumption is now significantly related to recalled alcohol consumption after one week audit score was not significantly related to recalled alcohol consumption after one week for the where context variable as compared to being at home both being at work and being at a bar club or pub were negatively associated with recalled alcohol consumption this perhaps suggests that being in these social contexts impairs later recall of the amount of alcohol consumed for the who context variable both being with family and being with two or more friends were positively associated with recalled alcohol consumption as compared to being alone model comparisons likelihood ratio tests were used to compare the models for both the daily difference score and recall after one day models there was a marginally significant difference between the overall invivo score model compared to the individual drink invivo scores model the model adding context information and audit scores was not significantly different from either the overall invivo score or individual invivo drink score models for both the weekly difference score and weekly recall models there was no significant difference between the overall and individual invivo models but the model with context and audit score was significantly different to the individual invivo model and marginally so when compared to the overall invivo model discussion overall the results from this research suggest that both daily and weekly retrospective reports regarding the quantities of alcohol consumed are not inline with records provided in realtime specifically participants appear to retrospectively underreport the number of drinks that they reportedly consumed in realtime although not discussed in this paper this was further supported by qualitative reports which declared for example i have no idea what i drunk last night examining these findings in more detail reveals a complex picture of alcohol consumption reporting specifically alcohol consumption reports may be impacted by the timedelay between drinking and recall the quantity and type of drink consumed and the social and environmental contexts in which drinking occurred analyses of accounts of the previous days consumption revealed that increases in realtime drinking were associated with increases in the number of retrospectively recalled drinks however difference score analyses indicated that higher numbers of drinks consumed in realtime were related with a higher discrepancy between realtime and retrospective accounts across almost all types of drink social and environmental contexts on the other hand were not significant predictors of daily retrospective reports or difference scores for weekly accounts higher invivo alcohol consumption also appeared to be related to a higher discrepancy in retrospectively reported consumption it is certainly the case that arithmetically there is more room for discrepancy when the quantities are larger however our findings raise the possibility that traditional retrospective report techniques may underestimate the consumption of heavy drinkers on the other hand when examining individual drink types this pattern was not evident for wine as greater effortful processing is associated with better task performance 34 the heightened difficulty of recalling weekly as opposed to daily drinking 35 may therefore be an important determinant of performance items which are more unusual within memory have been postulated to have an attentional draw 36 meaning that they elicit more detailed encoding for the purpose of long term memory 37 in the case of the current findings drinks which were less frequently recorded within this cohort may therefore be recalled more accurately because of their relative salience conversely more frequently consumed drinks may be less salient thus they be more poorly recalled and underreported there was also a variation between the findings of daily and weekly retrospective models when the effects of environmental contexts were included whilst these contexts were not significant predictors of daily retrospective reports their inclusion had a significant predictive value for weekly retrospective reports and difference scores here alcohol consumption across individual drinks ceased to be significant predictors in the model however being with two or more friends became a significant predictor that was associated with an increase in retrospective reports and with a decrease in the discrepancy between realtime and retrospective reports in this vein it is possible that in the time preceding the final weekly selfreport respondents had time to share and exchange accounts of their previously shared drinking experiences this sharing of past experiences is a highly valued part of the social drinking experiences 3839 and may in turn have contributed to the observed increase in retrospective reporting and the corresponding decrease in the discrepancies between realtime accounts this is clearly conjecture at this stage and further research is required to test this hypothesis nonetheless this process would also mirror the wellresearched phenomenon of social reconstruction and memory conformity in forensic psychology which indicates that those who share in an experience or witness an event will socially construct their memoriesaccounts of an event it is also interesting to note that whilst there was no significant interaction between social and environmental contexts the latter was a significant predictor of weekly retrospective reports here being in the pub was associated with a decrease in retrospective reports and a heightened difference score in other words the pub environment seemed to increase the discrepancy between realtime reports of consumption and weekly retrospective recall consumption one explanation for this finding may be offered by alcohol myopia theory 41 which suggests that contextual variations in attention impede later recall these findings are also inline with previous research indicating a contextual variation in alcoholrelated cognitions 1213 42 43 44 however the fact that this contextual impact was not evident in daily reports suggests that this contextrelated narrowing of perceptual and cognitive functioning may be exacerbated over longer time frames possibly as memory traces begin to fade an alternative explanation of the discrepancies between retrospective and real time recall may lie in differences in consumption as a function of contexts from this perspective contextual variations in reporting could be explained by variations in levels of alcoholinduced cognitive impairmentsby which certain contexts are associated with more drinking however preliminarily analyses indicated that there was no significant difference in the total quantities of drinks recorded in realtime between the home and pub contexts these findings may reflect predrinking loading practices in student samples in line with myopia theory the larger discrepancies between real time and retrospective reporting in pub relative to home contexts may therefore be attributable to impaired selfmonitoring in environments with a high salience of alcoholrelated stimuli in view of research indicating that recall is aided in contexts where encoding occurs 10 it is also possible that discrepancies arose because alcohol consumption in pubs was recalled in the home environment further research in regard to this discrepancy between weekly and daily retrospective accounts is strongly recommended as well as further research to support the development of realtime data collection methods extending this research to examine longer time recording frames may also prove beneficial as would further analyses comparing realtime accounts with retrospective reports elicited by the gold standard timeline follow back interview it must also be acknowledged that despite the high level of anonymity in the current research realtime reports may also be prone to biases owing to demand characteristics 6 it is asserted that judgment anticipation may increase the desire to selfpresent in a particular manner dependent on the context 34 realtime as opposed to retrospective reporting contexts may therefore result in differing levels of self presentation concern for instance recording the total number of drinks consumed over a past nightweek may heighten the perception of potentially negative judgementsassessments from othersas these numbers are likely to be higher than the number of drinks consumed in a previous hour in other words declaring that one has had two drinks is unlikely to elicit as strongly negative response but proclaiming that one has consumed 10 drinks may have negative connotations the psychological need to selfpresent may therefore be postulated to be stronger in retrospective reports nonetheless this does not preclude the potential for reporting bias in realtime reports and this must therefore be acknowledged as a potential issue in the current research finally access to a mobile phone was a prerequisite for taking part as mobile devices were not supplied it was considered prudent to maximise the usability of the application and we believed that participants familiarity with their own phones features and operating system would maximise their interaction with the application given that the majority of students now have mobile devices this was not deemed a large issue for generalisability however it should be noted that the present results can of course not be reliably believed to generalise to students without access to such technology it is also feasible that participants may have had difficulties in monitoring which drinks they had previously recordeda telescoping effect this leaves the possibility that some double counting of drinks may have occurred although it is hoped that the hourly timing intervals will have limited the severity of this effect 46 finally it should be noted that although these data were recorded in realtime this does not preclude the possibility that participants forgot to record every single drink similarly we cannot exclude the prospect that participants consumed alcohol on days when they did not use the application meaning that these data will effectively have been missed ann additional degree of caution needs to be exercised when assessing the relative quantities of drinking reported by the two methods as drinking occasions not recorded in realtime were not included in the dataset and it is feasible that they could have been included in retroactive recall sessions that said given that people recalled less drinking retrospectively than invivo it is indeed possible that retrospective reports underreport alcohol consumption to a greater degree than recorded in this study the use of both the application and follow up assessment on every week day may therefore provide greater data in this regard the additional use of objective measures of consumption such as a breathalysers or secure continuous remote alcohol monitors alongside invivo selfmonitoring is therefore recommended this would also allow for an examination of how intoxication moderates the impact of retrospective recall which cannot be assessed presently an expansion of the current research to increase the current sample size would also be recommended although it is believed that some of the potential concern in this regard has been ameliorated by the large number of data points supporting the current statistical analyses and the relatively strong effect sizes revealed utilising a wider number of non students would also be advisable as differences in the student drinking culture 47 may mean that results cannot be generalised to the wider population finally only four participants used the application for four days in order to assess longer drinking periods it may therefore be advisable for future research to increase participant recompense with a view to motivating respondents to extend their use of the application future research could also examine which factors motivate extended use of the application it is possible that some participants may for example have used the application to monitor their drinking in an effort to reduce their consumption overall the general discrepancy between invivo and retrospective accounts of consumption suggests that the use of selfreport measures requires careful consideration within alcohol research compared with that the introduction of novel and cost effective ways of measuring alcohol consumption appears promising this is not to say that realtime sampling is free from error however it may offer researchers a methodological tool which in conjunction with others may allow for greater insight into alcohol consumption in different environments it therefore constitutes a further step towards developing research methods that may prove to be more valid than retrospective selfreport measures given that the data set is not overly large the data will be made accessible via a supporting information file in accordance with your open access policy the application mechanism is available to freely download at declaration the authors declare no conflicts of interest this material has not been published in whole or in part elsewhere not is the paper being currently being considered for publication elsewhere all authors have been personally and actively involved in substantive work leading to the report and will hold themselves jointly and individually responsible for its content all relevant ethical safeguards have been met in relation to patient or subject protection or animal experimentation including with a full review by an appropriate ethical review committee this research complies with the world medical association declaration of helsinki supporting information

this research compared realtime measurements of alcohol consumption with retrospective accounts of alcohol consumption to examine possible discrepancies between and contextual influences on the different accountsbuilding on previous investigations a specifically designed smartphone technology was utilized to measure alcohol consumption and contextual influences in de facto realtime realtime data a total of 10560 data points relating to type and number of drinks and current social environmental context were compared with daily and weekly retrospective accounts of alcohol consumptionparticipants reported consuming more alcoholic drinks during realtime assessment than retrospectively for daily accounts a higher number of drinks consumed in realtime was related to a higher discrepancy between realtime and retrospective accounts this effect was found across all drink types but was not shaped by social and environmental contexts higher invivo alcohol consumption appeared to be related to a higher discrepancy in retrospectively reported weekly consumption for alcohol beverage types other than wine when including contextual factors into the statistical models being with two or more friends as opposed to being alone decreased the discrepancy between realtime and retrospective reports whilst being in the pub relative to being at home was associated with greater discrepancies

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introduction in 2015 i cowrote a piece about the significance of cultural competency in legal education 2 the paper focussed on the importance of law students becoming selfreflection and lifelong learning rather than mastery adopting cultural humility as a model for cultural learning can help students to not only anticipate difference but to respect it to reflect on it and to challenge inequities on a broader level than just oneonone interactions in this article i argue that cultural humility is a far more appropriate and sophisticated basis for teaching law students about culture and law the relationship of cultural humility to reflective learning makes it particularly appealing there is also great value in making links between the power imbalances that exist in cultural relationships and those that present themselves in the legal system cultural humility thus provides a lens in which to view and debate those issues as well for example we might not just analyse juvenile justice in australia but focus on indigenous juvenile justice through the frame of cultural biases and white privilege from there we are able to understand and challenge our own beliefs that might contribute to cultural inequality the article is structured in three main parts part one provides an overview of cultural humility its differences to cultural competency and its development in other disciplines such as medicine social work and nursing part two considers the relevance of cultural humility and cultural teaching more broadly to the discipline of law part three provides some ideas about how to unlock the power of cultural humility in course design a large part of this task at least in the short term might involve value adding to existing courses which already focus on inequality and injustice an ideal starting point would be clinical legal education a practical course that most australian law schools already offer and which provides a rich basis to consider issues of inequality and cultural disadvantage cultural competence seems to be the most commonly used 6 there is also a broader movement around teaching competencies in law school 7 which is likely fuelling the continued use of the term one of the problems with the vernacular and one that cultural humility takes aim at is that we can never really master anothers culture 8 in fact to strive for competence may be counterproductive and lead to practices of ignorance elitism and stereotyping the search for competence implies an end point and also ignores the dynamism of cultural practices and discrepancies that exist within societal groups australia for instance is home to several hundred indigenous groups many with their own distinct beliefs and practices likewise china australias largest trading partner has over fifty different ethnic groups 9 these factors make it difficult to generalise or to seek to master anothers culture it is a further problem that there are literally dozens of definitions of culture available in the 1950s kluckhohn and others proposed that culture might be defined as patterns explicit and implicit of and for behaviour acquired and transmitted by symbols constituting the distinctive achievement of human groups…the essential core of culture consists of traditional ideas and especially their attached values 10 a more recent definition from the 1990s suggested culture could include a pattern of shared attitudes beliefs categorizations selfdefinitions norms role definitions and values that is organized around a theme that can be identified among those who speak a particular language during a specific historical period and in a definable geographic region 11 an even more recent definition defines culture simply as a pattern of adopting a model of cultural humility can be beneficial in addressing some of these issues though cultural humility still contains the word culture at its core cultural humility reflects an approach which deliberately focuses on the unknown visàvis ones self it shies away from the how and focuses on the extent to which particular values and beliefs operate in institutional systems to the detriment of others the practice of cultural humility thus elicits a process of intense selfreflection from students it requires us to ask what is culture what is our own culture where does it derive from what are our own values and beliefs how might they differ to other groups in short cultural humility provides us a conceptual space to probe and challenge our own assumed values about the world in this way it has great relevance to deeper questions concerning privilege injustice power and inequality in society but is cultural humility an alternative or compliment to cultural competence there seems to be some disagreement to this question fisherborne et al positions cultural humility as an alternative learning model to cultural competence 14 others suggest it indeed might compliment or add value to competence discourses a few important distinctions are perhaps worth making for instance whilst the majority of cultural competence teachers envisage practitioners achieving some level of comfort with a culture15 cultural humility claims that being comfortable in cultural relations merely stands to reinforce existing power imbalances a move towards cultural humility therefore requires that negative cultural barriers which exist within institutions be critiqued and challenged rather than maintained in a comfortable status quo this is the so called transformative agenda that cultural humility lays claim to 16 in order to have a transformative effect however we must first develop a deeper and more critical understanding of our own privileges for many including myself this is often a confronting and uncomfortable process after all we all like to assume that we got to where we are through sheer hard work and merit alone we tend to ignore or take for granted the cultural interventions that have helped us along the way our parents our gender our race our peers our education our citizenship and so on cultural humility has great value in allowing us to step back and reflect on our cultural privileges and how they might contribute to or hamper the quest for a more just society to take a simple example through cultural humility we might critically explore the australian legal profession which largely comprise white middleaged middleclass heterosexual males this exploration would likely reveal a system that reinforces concepts like white male privilege to the detriment of minority groups 17 from there we might examine the beliefs and assumptions that lead to such privilege and investigate solutions on how to deliver a more culturallyegalitarian system the aim of such an exercise is of course not to shower guilt on the status quo but to have a transformative effect on lawyers and students to identify firstly that there may indeed be a connection between culture power and law and secondly to think of novel ways to address inequalities that said existing theories on competence might actually not be that far removed from what cultural humility seeks to achieve in 1997 for instance odonnell and johnstone sought to move the debate past mere competence to also consider relationships of power and social identity 18 similarly in 2002 silver enlarged the notion of competence to encompass a deliberate exploration of the deeply rooted cultural assumptions that claim us 19 such approaches align closely with the practice of cultural humility it may be then that humility advocates have oversold the benefits of humility by not acknowledging expanded notions of what it means to be truly competent be that as it may cultural humility has the distinct advantage of offering us a fresh starting point one that takes direct aim at cultural inequalities and puts individual accountability front and centre of the debate in the end perhaps the most significant distinction between competence and humility and one that suggests they are in fact alternative approaches is that humility involves a deep and consistent level of selfcritique and reflexive practice whereas competency doesnt ask the participant to selfanalyse 20 there is thus a greater focus on understanding oneself in the pursuit to overcome difference and build relationships including honestly critiquing ones own values and beliefs creating a healthy dialogue with law students about values and beliefs is thought to be crucial to producing resilient and thoughtful lawyers 21 there is no doubt still an old school view that such concepts shouldnt be taught as part of the curriculum and that they have lesser importance than being able to read and recite cases and form legal arguments it is to those concepts that is the relevance of cultural humility to the practice and teaching of law which i now turn part 2 culture humility and the law the teaching of any form of cultural skills to australian law students has a short and unremarkable history in fact there has been relatively little attention paid to developing cultural competence in australian lawyers particularly in respect of indigenous cultures 22 whilst a handful of works do exist on how to better implement culture into the law degree 23 it has certainly not become one of the core components of our legal teaching this is in stark contrast to other clientcentred disciplines like medicine 24 nursing psychology and social work 25 these disciplines have been working for decades now on developing culturally appropriate professionals that are able to provide culturally specific care in canada for instance it is mandatory for cultural diversity education to be taught within curricula at all accredited canadian medical schools 26 though the australian governments learning and teaching council has recently recommended more opportunities for cultural learning 27 there are currently no 20 nomikoudis and matthew starr above n 4 79 21 for a discussion of lawyers values see adrian evans lawyers perceptions of their values an empirical assessment of monash university graduates in law 19801998 requirements that it be taught as part of the law degree 28 nor are there for that matter any requirements for trainee solicitors undertaking practical legal training or practising solicitors completing continuing professional development to partake in any specific cultural training this is disturbing on many levels not the least because indigenous issues are emerging as one of australias biggest injustices 29 likewise australian law schools are also ignoring the rise of asia and the important opportunities with australias biggest trading partner china 30 though many law schools including my own do teach chinese law or chinese legal systems in some form most i would wager focus on substantive elements of chinese law and not the values or beliefs which distinguish our systems from one another if they are taught the discussion is likely to take place around the more limited cultural competence frame australia is not alone in its failure to embrace cultural training in law school beverley moran for instance laments how law schools in the united states have long lagged behind medical schools in valuing culture as part of the degree 31 in the united kingdom the situation is equally unimpressive with few reported success stories cultural humility offers something new where cultural competence was not able to succeed with its focus on critical reflection and institutional challenge it is a highly relevant and powerful notion for australian law schools to consider after all a large part of the law and the focus of legallytrained professionals is on issues of injustice and inequity in australia many of those issues have a strong cultural dimension and the ability of practitioners to appropriately reflect on them would add greater clarity and sophistication to the debate part three embedding humility in course design i have made arguments for an improved relationship between cultural learning and the discipline of law i suggest that cultural humility can be an extremely effective way for this to occur i now turn to discuss ways in which this might be achieved of course in all of this one needs to be realistic there is already a tendency for legal academics to resist engagement in broader curriculum development outside of their areas 32 the publish or perish dilemma increasing class sizes and ballooning administrative tasks all continue to put pressure on legal academics and their time with this in mind i suggest three simple things that could be done first we must be clear in explaining to students why we are talking about culture second we must adopt a sound conceptual framework for teaching the relationship between power and culture and third we ought to focus on units which are already closely aligned with the goals of cultural humility if i take the first point the evidence is increasingly clear that students particularly in law are concerned about future job prospects degrees including law must be relevant to the types of work students are likely to undertake law students certainly have that expectation and universities most certainly have an obligation to provide it a major concern of most law students is likely to be how is this course relevant to me and my future career it follows that there is a preliminary task of persuading students that culture is relevant to their degree i have briefly canvassed some of those arguments above but there are of course several publications which debate the issues of culture and law in far more depth 33 secondly as to a sound conceptual framework fisherborne et al provides what i consider the best and most easily translatable design their conceptual model provides example questions that can also serve as an assessment tool students can use the questions to not only better understand their own culture but to assess their field practicums as a space for organizational transformation around oppression and inequality 34 specifically fisherborne et als model is broken down into three components reflection institutional and individual accountability and systemic power imbalances 35 in terms of the first element students ought to be encouraged to understand that cultural humility is a process of lifelong learning and critical reflection it is certainly 32 mary keyes and richard johnstone changing legal education rhetoric reality and prospects for the future sydney law review 537 537 33 not something that can be achieved overnight perhaps the best and easiest way to adopt this is in the teaching of law to use reflective writing as a form of assessment during the course increasingly there are many law schools that already embrace reflectivewriting models of learning 36 elements and of the model might i suggest be taught together as substantive items what i mean by this is that whilst the first element reflection may take the form or method of assessment items and accountability and power imbalances might form the content of their writing tasks for example using a reflective writing model consider your own culture and the cultural practices you witnessed and discussed during the semester reflect on the extent to which cultural practices impact upon issues of justice in australia the task might be made more or less specific depending on the unit in which it is taught for example the last sentence might be changed to indigenous issues of justice or refugee isues of justice or youth issues and so on basic questions that could then be used to prompt students might include • what constitutes culture what are its main elements • what do you consider to be your culture • from where do your values and beliefs originate • what are the dominate cultures in australia what are their underlying values and beliefs • what values and beliefs underpin australias legal systems • which cultures might be most disadvantaged by this approach such a task might be post twice during the semester or indeed ongoing throughout the semester as a weekly journal the aim of this approach is to allow students the time to critically assess their own values those of the dominant legal institutions and to better understand the challenges of different cultural groups that might be disadvantaged by existing systems of law one final point i make about introducing models of cultural humility into legal curriculums is that we might utilise subjects that already have a strong cultural element or alternatively those units which allow an appropriate time to focus on selfreflection injustice and inequality plainly these will usually be courses which dont include many cases or legislative provisions clinical legal education for example is one area which could provide an appropriate platform in cle students are often placed with community legal centres which deal with a wide variety of cultural groups and their struggles with the legal system needless to say those circles reinforce cultural stereotypes and there are likely to be few if any wellconsidered views about race culture law and power we thus need to create a space for students and academics to consider the influence of culture on legal institutions the second pertinent question and one i pose towards the end of this paper is far more strategic how best should we go about it i have suggested that cultural humility offers a highly appropriate and sophisticated framework for teaching and learning about culture its predecessor cultural competence suffers from serious drawbacks including a misguided goal of competence that can never be achieved fortunately and somewhat ironically the teaching of law has never fully embraced cultural competence and so any transition to new and better approaches would likely be an easy sell this is especially true for models like cultural humility that align with existing practices of legal teaching such as reflective writing and units that already consider broader notions of justice power and inequality there are of course limitations to adopting a cultural humilitybased model critics point to a dearth of empirical data and a lack of a tested conceptual framework 40 another challenge is finding academics with appropriate training in cultural issues not to mention convincing law schools and students that culture is a worthwhile pursuit given the other more immediate concerns of an increasingly competitive job market on the contrary however a broader knowledge base and the development of softer skillsets serve to make students far more employable an increasing focus on selfreflection including of their own culture helps to nurture resilient and thoughtful lawyers in the end we would do well to better embrace concepts of cultural learning within the degree and cultural humility provides an excellent base on which to do so

cultural competency has proven less effective than its proponents had envisioned disciplines outside of the law social work health and psychology have turned to the more powerful theory of cultural humility a framework for lifelong learning and selfreflection cultural humility contends that one can never really master anothers culture but that we ought to remain respectful and reflective in our approach in this article i make the case for teaching cultural humility in australian law schools competent in culture and more specifically the importance of chinese culture since then i have been fortunate to be alerted to another powerful movementcultural humility 3 cultural humility as an alternative teaching framework has far greater value in contributing to proficiencies concerning resilience teamwork and design thinking 4 the language of humility as opposed to competence focusses on 1 evan hamman is a phd candidate and sessional academic at queensland university of technology qut he is involved in delivering quts clinical legal education program 2 felicity deane evan hamman and pei liping chinese cultural competency and australian law students reflections on the design of short term mobility programs 2015 40 4 alternative law journal 271 3 my thanks to professor phil crane at quts school of social work for those discussions for those unfamiliar with the term cultural humility the best explanation is provided in marcie fisherborne jessie montana cain and suzanne martin from mastery to accountability cultural humility as an alternative to cultural competence 2015 34 2 social work education 165

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introduction adolescence is a highly formative life stage for an individuals future health and wellbeing more than half of adult mental health problems have their onset in childhood and adolescence leading to adolescent mental health to be seen as a global and national public health priority previous literature has defined adolescent mental health as an overarching multifaceted concept that includes both mental health problems and the presence of subjective wellbeing in the present paper we focus on the latter aspect which we refer to as mental wellbeing which encompasses evaluations of life satisfaction and psychosomatic complaints nowadays adolescents report lower levels of wellbeing and more mental health problems than their peers one or two decades ago furthermore there is a lack of systematic evidence on trends in adolescent mental wellbeing from central and eastern european countries therefore this study seeks to fill in this data and knowledge gap by exploring the role of gender age and socioeconomic status in the recent trends in mental wellbeing in nationally representative cohorts of 11 13and 15yearold adolescents from the czech republic trends in adolescent mental health and wellbeing there is evidence pointing to a deterioration in the mental wellbeing of children and adolescents in developed countries especially among older adolescent girls however the findings reporting trends in adolescent mental wellbeing are rather mixed a considerable number of studies found increasing time trends in mental health problems especially internalizing problems among adolescents in many western countries however other studies exploring trends in adolescent mental wellbeing found rather a stable or a decreasing trend while others demonstrated either increase or decrease in mental wellbeing to illustrate a recent investigation in finland found an increase in the incidence of internalizing symptoms but only among girls however other studies in the united kingdom covering a similar time frame report some stability or even an improvement in mental health overall these inconsistent findings may be attributed to variation in survey methodologies employed but also due to country specific policies and culture around mental health most of the studies on trends in adolescent mental wellbeing have been conducted in mostly western societies and their findings may not necessarily be generalizable to other countries or cultures furthermore only a limited number of studies have explored these changes over time in adolescent mental wellbeing in centraleastern european countries this could be particularly of interest given that among adults the transition of central and eastern european countries from communism to capitalism in the 1990s and the subsequent decade was reflected by a decrease and then a recovery in life satisfaction which might have an impact on those age cohorts who are the parents of nowadays adolescents these transitions could have impacted the changes over time in mental wellbeing and indirectly may impact the health of contemporary adolescents for example cosma et al showed that among 36 european countries only in a few central and eastern european countries there was actually a linear improvement in adolescent mental health between 2002 to 2018 but this study did not explore whether the gender or socioeconomic gaps have increased in the aforementioned period gender age and socioeconomic differences in trends in adolescent mental wellbeing consistent gender age and socioeconomic differences in adolescent mental wellbeing trends were reported time trends analyses showed that compared to boys girls are reporting increasingly more emotional problems internalizing problems lower life satisfaction and more multiple health complaints furthermore a progressive decrease in mental wellbeing from early to late adolescence has been observed across different cohorts and these declines in wellbeing and the increase in internalizing problems over time were particularly stronger in older adolescent girls selfrating of health in adolescents was consistently found to worsen with age and girls showed a sharper decline than boys however there is limited evidence especially stemming from central and eastern european countries whether the gender and age gap in trends in adolescent mental health has increased over time consistent with the aforementioned findings in our study we would expect a stronger decline over time in mental wellbeing for older adolescent girls socioeconomic inequalities have a large impact on adolescent mental wellbeing compared to their peers from more affluent families adolescents from socially disadvantaged groups have higher rates of poor subjective health lower life satisfaction and higher load of multiple health symptoms and lower quality of life and wellbeing moreover previous literature indicates that there has been an increase over time in the social inequalities in adolescent mental health therefore exploring socioeconomic inequalities in adolescent mental wellbeing in a country like the czech republic that has experienced significant economic growth in the last decades could bring more clarity into this topic adolescent mental health in the czech republic recent international report places czech adolescents around the european average for their rating of satisfaction with life and the experience of multiple health complaints according to a recent unicef estimate based on a global burden of disease study about 11 of czech adolescents had a mental health disorder in 2019 which was below the european average on the other hand despite some positive recent trends czech youths have been constantly reporting more frequent risky behaviours when compared to their european peers also there has been a steadily increasing number of children and adolescents who received psychiatric care for instance in the last ten years the number of child and adolescent psychiatric patients has risen for one third from 67 to 87 thousands despite a good progress in implementation of the czech mental health care reform it is only a recent development that the czech government seeks to address child and adolescent mental health through the new mental health action plan 2030 as well as through the strategy for the czech education policy 2030 as such it is important to provide an overview of the situation at the baseline before these policies are implemented aims and research questions of the current study in sum while many studies have reported recent declines in adolescent mental wellbeing the literature stems mostly from western european and north american countries and it is limited in terms of the comparability of time periods examined methods used countries studied and outcomes measured the present study addresses these challenges by using national representative data from czech adolescents from 2002 to 2018 in this investigation we aim to address the following research questions materials and methods study design data were drawn from the czech health behaviour in schoolaged children study the hbsc is a world health organization collaborative crossnational study conducted every four years to monitor the health and wellbeing of adolescents using a standardized research protocol for each survey round the participating countries collect data from a nationally representative sample of 11 13and 15yearolds using a standardized research protocol stratified random cluster sampling is employed with classes within schools as the primary sampling units adolescents completed anonymous questionnaires in classroom setting questionnaires were translated from english into czech with backtranslation checks following a validated protocol participants and data collection this study used data from five czech hbsc survey cycles nationally representative samples of 11 13and 15yearolds were included in each survey cycle 2002 2006 2010 2014 and 2018 respectively resulting in a total sample of 29376 adolescents over the study period the response rate at the level of pupils ranged between 86 and 89 data were collected by trained research assistants all the surveys prior to 2018 employed a paper and pencil data collection while in 2018 the data was collected using an online survey no substantial differences in the results of the hbsc survey across paperbased and electronic administration have been reported the participants were assured of the anonymity and confidentiality of their responses the institutional research ethics committee of the faculty of physical culture palacký university olomouc approved the design of the study the course of preparation and execution of the research an optout method for collecting parental consent and the processing of the data on 4th march 2016 with the reference no 92016 similar ethical approvals have been granted for the previous surveys as well the standard procedure across all survey classes was that all the participants teachers and school management members received detailed information on the survey design and data collection plan detailed information about the survey and its design and content was sent in advance to the parents via the school management thereafter a passive parental consent was employed which implied that the adolescent was permitted to participate in the study unless the parentguardian indicated that the adolescent should not participate adolescents were assured that the data provided was confidential and anonymous in each cycle of data collection the participation of adolescents was voluntary and without any financial incentives instruments psychological and somatic symptoms the hbsc symptom checklist a nonclinical measure used to asses two different types of health symptoms psychological and somatic symptoms participants had to indicate how often they experienced these symptoms over the last six months response categories were about every day more than once a week about every week about every month and rarely or never this instrument has adequate testretest reliability and validity properties in our sample both these subscales had acceptable reliability items were reverse coded for each subscale a mean score was created which was used in the subsequent analyses with a higher score indicating more frequent incidence of the symptoms life satisfaction was assessed with the cantril ladder participants rated how happy do they feel about their life on a visual analogous scale ranging from the worst possible life to the best possible life for this study the scale was used as a continuous variable gender and age respondents were asked to indicate whether they are a boy or a girl as well as to report their date of birth socioeconomic status was measured by the family affluence scale a 4item composite measure developed by the hbsc network fas measures material family wealth as an indicator of socioeconomic position it asks about real possessions characteristics of the home and the number of family holidays in the last year the scores are summed up and this score was used in the subsequent analyses statistical analysis to examine to what extent the mental wellbeing indicators have changed over time the means were calculated per survey year for the total sample and each gender separately to test trends in adolescent mental wellbeing multiple regression analyses were conducted using the year 2002 as the reference year and the other survey years were added as dummies next we ran the same models while controlling for gender age and family affluence to investigate the extent to which trends in wellbeing have been different for girls and boys we added the survey year × gender interaction term in the model subsequently we explored if the age and the socioeconomic differences have changed over time by introducing survey year × age interaction term and survey year × family affluence interaction term respectively a final model testing whether the trends have been stronger for older adolescent girls was run in order to test for linear effects of time separate linear regressions with time as continuous variable were conducted all analyses were performed using statistic software package spss 24 associations and interaction effects were considered significant if p 005 results the sociodemographic characteristics of the sample are illustrated in table 1 the average age of the total sample was 1343 and 51 were girls across all survey years apart from life satisfaction in 2002 girls reported significantly higher levels of psychological and somatic symptoms and lower levels of life satisfaction overall mean scores for somatic symptoms were lower than for psychological symptoms trends in czech adolescent mental wellbeing changes over time were recorded for all three wellbeing indicators but these showed different trajectories compared to 2002 life satisfaction was significantly lower in 2006 2010 and 2014 but it increased in 2018 to levels similar to those in 2002 psychological symptoms compared to 2002 were significantly higher in all subsequent survey years with the largest difference being observed in 2006 and 2018 in contrast somatic complaints were significantly higher in the interval 2002 to 2010 were lower in 2014 and further in 2018 compared to 2002 only the decline in somatic complaints observed in 2014 did not significantly differ linear trend analyses revealed that there was a linear increase in adolescent life satisfaction and psychological complaints but no significant linear change in somatic complaints gender age and socioeconomic differences in trends in adolescent mental wellbeing compared to boys girls reported lower life satisfaction and more psychological and somatic symptoms during the study period the gender gap changes over time were not consistent across the mental wellbeing indicators to illustrate compared to 2002 the gap between boys and girls in reporting life satisfaction was significantly larger in all survey years except of 2014 on the other hand the differences between boys and girls in reporting psychological symptoms compared to 2002 were significantly larger over time in all years except in 2010 furthermore these gender differences in reporting somatic symptoms increased only in 2006 and 2014 threeway interaction analyses were run which confirmed that the increase in psychological complaints have been stronger for older adolescent girls in 2006 in 2014 and in 2018 overall with increasing age adolescents in the czech republic reported lower levels of life satisfaction and higher levels of psychological and somatic symptoms nonetheless the differences between younger and older adolescents have increased over time only for psychological symptoms for life satisfaction and somatic symptoms the age gap remained stable in the investigated time frame excepting 2006 when the age differences increased for life satisfaction higher family affluence was associated with higher levels of life satisfaction and less frequent psychological symptoms no associations between family affluence and somatic symptoms were found these socioeconomic differences remained stable over time except for life satisfaction where family affluence differences decreased in 2018 compared to 2002 2002 discussion the current study examined trends in three indicators of adolescent mental wellbeing using nationally representative crosssectional data from the czech republic importantly the study also investigated whether the trends in adolescent mental wellbeing were moderated by gender age and family affluence our first main finding indicates that in the czech republic the adolescent mental wellbeing has changed between 2002 and 2018 across all three mental wellbeing indicators but each indicator had a different pattern of change over time during this period a consistent increase in the prevalence of psychological symptoms emerged from 2002 onwards whereas for life satisfaction a decline was observed up to 2014 from 2014 to 2018 an increase in life satisfaction was observed for somatic complaints an increase was observed up to 2010 followed by a subsequent improvement over time these findings despite small in size are at odds with other studies that reported rather a stable state of emotional and behavioural symptoms between 2003 and 2013 in the netherlands or norway nonetheless the fact that we observed no further deterioration in life satisfaction and somatic complaints is in line with other recent studies that support either a stabilization or further decline of selfreported mental wellbeing in an international comparison adolescents from the czech republic and the united states were the only ones whose selfrated health worsened between 2002 and 2006 and then showed an increase from 2006 to 2010 our findings are comparable to this pattern and indirectly suggest the presence of potential buffering factors one would intuitively attribute the pattern to changes in social context among adolescents such as increase in family support improvement in communication with parents or higher school satisfaction however the last hbsc international report shows it is apparently not the case the rating of these factors rather worsened over the monitored period and czech adolescents ranked way below the average of their peers from other countries on these indicators future studies thus should explore this in more depth the diverging trends in psychological complaints somatic complaints and life satisfaction reinforce the idea that adolescent mental wellbeing is not a unidimensional construct and that its different components of mental wellbeing can show different trajectories and may have differential susceptibilities life satisfaction which refers to global cognitive evaluations about ones life can be considered a global construct of subjective wellbeing and may therefore be influenced by broader life experiences and relationships in contrast psychosomatic complaints may represent symptoms of more immediate stress which at the more severe end may impair everyday functioning and could be associated with problems from the internalizing spectrum furthermore emotional components of wellbeing tend to be more prone to fluctuations compared to life satisfaction which is usually described as a more stable component nonetheless these findings emphasize the need to view mental wellbeing as a multidimensional construct and suggest a need for greater understanding of the associations between risk factors and different aspects of mental wellbeing to address this the governmental council for mental health has been established and one of its aims is to monitor and promote the mental wellbeing of young people adolescent girls reported lower mental wellbeing compared to boys but this gender gap has not systematically increased over time this result confirms that girls are more likely to report poorer mental wellbeing outcomes and also supports a consistent body of research which found increasing trends in girls only for emotional problems or psychological and somatic symptoms this increase in gender gap over time could be explained among others by the exposure to gender role expectations and the socially defined roles for women and men in society together with exposure to genderspecific stressors as demonstrated by a recent largescale crossnational study the czech republic is among the countries where the gender gap in exposure to psychological distress is pronounced and unfavourable for girls furthermore there is considerable evidence that girls are expected to be more emotionally sensitive experience more restricted gender roles and body dissatisfaction are more likely to experience and communicate health symptoms or experience more school performance pressure which may all contribute to the gender disparities in mental wellbeing we observed in adolescents from the czech republic similarly to the consistent gender gap our results indicate that older adolescents were more likely to report low mental wellbeing and this age gap has increased over time but not across all outcomes the interaction analyses revealed though that these age differences remained stable across the survey years except psychological symptoms where the age gap increased in 2010 and 2018 as compared to 2002 nonetheless including a threeway interaction parameter in the regression model revealed that the increase in psychological complaints had been the strongest among older adolescent girls this is in line with the results reported by collishaw and as such is not something that would be a czechspecific phenomenon furthermore previous research argued that interaction of mental health outcomes and sociodemographic characteristics as gender age and socioeconomic status showed a large crossnational variability which may explain why the changes in associations over time were less emphasized in the czech republic these results do not follow previous findings which indicated that the decline in mental wellbeing is slightly stronger for older adolescents compared to younger ones in norway an increasing trend in health complaints among adolescents from 1994 to 2014 was found especially among older adolescent girls in sweden the increase over time in psychological complaints was seen in older adolescents whereas no significant change was seen in the youngest groups given these mixed results there is a need for a more comprehensive study which includes more countries over a relatively longer time frame and employs a uniform set of mental health and wellbeing outcomes for boys girls adolescents of different age groups and socioeconomic backgrounds interestingly the gap in mental wellbeing of czech adolescents coming from different family affluence remained relatively stable in the investigated time frame this is in line with previous studies that showed that the inequalities in adolescent health complaints in the czech republic has been stable from 1994 to 2010 and confirms that this trend has remained stable this could be partly explained by the demographic characteristics of the czech population according to the gini index the czech republic is one of the countries with the lowest income inequality worldwide in addition its population is also very homogeneous as regards nationalities of its inhabitants because only 5 of them are of nonczech origin and this has been quite consistent over time a key strength of the present study is investigating nationally representative samples of adolescents using identical study protocols across a 16year period nonetheless this inherently fosters the limitation that data collected across time is crosssectional and selfreported and no causality can be inferred the measures used were restricted to those available in the hbsc study since 2002 therefore providing a relatively limited perspective on adolescent mental health further research should include a broader range of mental health outcome measures and other potential drivers of mental health trends such as changes in the school or family environment or social media use which are required to better understand this complex issue nonetheless the present study provides essential and uptodate information about changing mental health trends in early adolescence from the central european region conclusions these results suggest that the increase in psychological health complaints should be considered a public health concern in the czech republic it is encouraging that no further decline in life satisfaction was observed but rather an improvement to better understand potential determinants of adolescent mental wellbeing longitudinal studies and continued tracking of health trends are needed besides school interventions that assist czech adolescents in managing psychological and somatic health complaints are vital furthermore our results also support a continuous focus on primary prevention and adolescent wellbeing promotion in the czech republic whilst considering the age and gender differences as well as initiatives aimed at increasing mental health literacy among young people conflict of interests none declared

objectives recent literature indicates a decline over time in adolescent mental wellbeing but results are inconsistent and rely mainly on data from western societies this study investigates time trends in adolescent mental wellbeing psychological and somatic complaints life satisfaction among czech adolescents and explores the moderating role of gender age and socioeconomic status methods nationally representative data from 29376 czech adolescents 508 girls mean age 1343 sd 165 across five health behaviour in schoolaged children hbsc surveys 2002 2006 2010 2014 2018 were used hierarchical regression models estimated national trends in adolescent mental wellbeing and established the moderating role of gender age and socioeconomic status results from 2002 to 2018 an increase in the psychological complaints was observed life satisfaction decreased over time up to 2014 only whereas somatic symptoms increased until 2010 followed by a decline in 2014 and 2018 girls older adolescents and those from low family affluence reported poorer mental wellbeing gender gap increased over time for psychological complaints and life satisfaction socioeconomic inequalities gap remained stable over the investigated timeframe conclusions our findings do not provide evidence for substantial temporal changes in mental wellbeing among adolescents in the czech republic yet the increase in psychological complaints has been consistent which is an indicator of a small decline over time in adolescent mental wellbeing furthermore the gender gap in mental wellbeing increased over time whereas the age and socioeconomic differences remained relatively stable this calls for the attention of public health professionals and policy makers from the czech republic

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introduction during the covid crisis nearly every aspect of healthcare organization was affected including research and development human resource management healthcare delivery and conduct of clinical trials 12 a major worry during this time was to protect the continuity of care of chronic disease patients one particular atrisk group was oncology patients who face increased risk of severe complications of covid due to a weakened immune system and because of their need for continued treatment to avoid disease progression and further complications 34 in france cancer care was the most disrupted during the first covid wave 5 which lasted roughly from marchjune 2020 with activity returning relatively to normal in the months following the medium and longterm impact on individuals including survival recurrence and aftereffects 6 in particular due to the disorganization of the circuit of care during the worst stages of the crisis will however need to be studied in the coming years at the current time the severe lack of healthcare staffin particular nurses and nursing assistantsis impacting the capabilities of the french healthcare system to completely recover from the crisis 7 in france a decision was made at the national level to prioritize continued treatment for cancer in addition some private nonprofit cancer centersas well as some specialized services such as pediatric oncologydid not manage covid patients and could therefore function relatively as normal even during the first wave albeit with some human resource and protective material shortages 8 furthermore to reduce the risk for vulnerable patients it was recommended that some treatment protocols be adapted to ensure vulnerable patients spent less time at the hospital or that triage protocols be put into place to ensure care for urgent patients these decisions were in coherence with recommendations published by expert societies but adapted for the context of each individual hospital 9 while all of these facilitating factors helped limit the impact of the crisis on cancer patients in france they do not show the whole picture the role of local actorsthose working at the individual service or hospital leveland the adaptations and innovations they put in place also played an important part in helping healthcare institutions to be able to continue care for their patients our studys ambition was to better understand what went right thanks to the capabilities of local actors and the changes they put into place that have had a durable impact on cancer care and research indeed while the crisis severely disrupted them it also provided an opportunity for action and adaptation 10 materials and methods the research to be discussed here was part of a three themed research project funded by the metropole de lyon that investigated how oncology care was impacted during the crisis three teams researched the crisis from different angles 1 patient perceptions 2 impact on patient level quality of care indicators 3 adaptations of hospitals during the crisis the overall project was coordinated by the regional cancer network the research to be discussed concerns the third theme which focused on organizational adaptations and innovations during the crisis it was developed by a threeperson multidisciplinary and international team a researcher in philosophy trained in social science methods a biobank specialist and a physicianscientist expert in translational research the methodology consisted of semistructured interviews of 22 healthcare and management professionals in both a university hospital and a nonprofit private hospital in the metropole of lyon the interviews were conducted by a researcher experienced in social science methods with an interview guide developed based upon the methods described by 11 that was first tested with a key person involved in the crisis at clb the criteria for selection of participants were 1 professionals working in an oncology care organization or in an oncology research organization at the time of the covid crisis 2 those who had decisionmaking authority in their service department or at the hospital level 3 professionals based in the lyon france 4 those working either at clb or hcl participants were sourced both from direct contacts of management staff and by snowball methodology 12 principally consisting of colleagues of the same specialties who recommended contacting other professionals in other hospitalssites these multiple sources to identify participants guaranteed that the researchers had access both to relevant persons as well as a diversity of professionals and specialties in cancer care and research in order to have a global view of oncology care participants came from different professions services and specialties this included 2 hospital directors 2 vicedirectors 13 heads of service and 5 persons working in research in addition participants came from a variety of different specialties and functions including department heads in head and neck stomach gynecology hematology pediatrics pneumonology endoscopy neurooncology as well as generalists in occupational medicine pharmacists nursing executive management and research the study was supported by the clb and hcl hospital directors who partook in the study as well as recommended further contacts in their hospitals where possible there was a first introduction by a key contact person to guarantee access to management staff all of the participants were informed of the aim of the research by written explanation and given an invitation to take part in the study the interviews lasted from 30 minutes to one hour participants agreed to the recording of the interviews the qualitative interviews were conducted until saturation the interviews were recorded and retranscribed directly by the researcher with permission of the participants in the transcriptions all data was anonymized to prevent identification including changing the gendernames the study was reviewed and approved by the ethical reflection group at clb in the interviews professionals were asked to describe how their servicehospitalresearch was impacted during the covid crisis from the beginning up to the present day they were then asked to describe the adaptations and innovations that they developed during the crisis and that continued to be used in the postcovid phase as well as their use of the guidelines published by expert societies this article will only discuss the results related to adaptations and innovations as the research was conducted during the chronic phase of the crisis this gave professionals the opportunity to reflect on what adaptations and innovations they put into place that have lasted in time the researchers analyzed the results using thematic analysis based upon an iterative and reflexive methodology 13 the researchers examined the transcriptions and a final set of themes and questions were derived from the data we also presented preliminary aspects of the research at 1 a national conference focusing on social science perspectives of the covid crisis 2 an internal meeting of a social science research group at one of the hospitals involved in the study 3 regular project meetings with members of the overall project team as well as the funder to discuss preliminary results 4 a national meeting on adaptations of the covid crisis in oncology in different french regions these presentations gave the research team the opportunity to discuss results with other researchers and to understand the complementarity of the results with the experiences of oncology care provision and research in other regions of france during the crisis results we were a little bit in a comfort zone covid is like sleeping on a nail board it taught us to be vigilant and to be efficient and to react to it this section will discuss the principal ways local actors adapted and innovated in their structures during the covid crisis while these innovations were designed for the first wave they were used throughout the subsequent waves of the crisis and had either become part of the normal provision of cancer care and research by the end of the research period or could be reactivated if needed for a new sanitary crisis by organizational adaptation the researchers refer to intentional decision making undertaken by organizational members leading to observable actions that aim to reduce the distance between an organization and its economic and institutional environments 14 while early scholarship has focused on how the institutionmanagement shape organizations more recent scholarship has shown the more reciprocal relationship between field workers and their institutional hierarchies 15 by innovation we refer to the definition introduced by 16 who propose that it be understood as changes that are original in context the innovations that we will discuss are not necessarily new in terms of developing a completely new product or service but they were original in context as they were new to services hospitals and networks and have had an impact on cancer care postcovid the results will be divided into two categories encompassing 1 new processes and resources to facilitate disciplinary and interdisciplinary work 2 harmonization and streamlining of patient journeys a summary of the results is detailed in table 1 new processes and resources to facilitate disciplinary and interdisciplinary work in this section we will show how new processes and resources were put into place during the covid crisis that enabled hospitals to be agile this permitted greater local national or hospitalwide coordination and helped professionals take collective decisions in the face of uncertainty and changing rules 311 knowledge sharing through epistemic communities healthcare as professionals were facing an unprecedent healthcare crisis in which decisions and information was updated almost everyday they faced considerable uncertainty in how to adapt hospital services one sustainable innovation to come out of the crisis was the creation andor consolidation of online epistemic communities this term can be defined as networks of knowledgebased experts 17 these communities were often organized in an informal spontaneous manner they were made possible via online networks in particular blogs whatsapp messaging services andor group emails at the end of the research period these epistemic communities continued to be active and enabled professionals to seek advice from colleagues they continue to be used in the postcovid period to share adviceexperience on other issues relevant to their specialties these online epistemic communities were original in context as they allowed a new means of interacting among professionals in ways in which there had been limited coordination before the crisis these epistemic communities have been important in particular for professionals who felt isolated notably those who did not have another colleague in the same specialty onsite for instance mark an occupational physician said that he was largely isolated at the start of the crisis as he was the only person with his specialty at the hospital during the first wave but also the more chronic phases of the crisis occupational physicians were obliged to make many complex decisions on how to protect hospital staff all the while ensuring sufficient human resources to continue cancer care mark describes the uncertainties faced by him due to constantly changing rules and procedures according to him we had to follow directives that were both vague and precise so for me it was a huge job because i had to look for regulatory texts that were constantly changing we were in a blur because the social security did not answer and attending physicians were overwhelmed at the beginning we knew nothing at all and so we were all alone all alone all alone to manage this and so there was a blog of occupational physicians we really exchanged a lot we supported each other i still get these messages now whenever theres a concern you can ask your colleagues we know that hospital occupational physicians in france supported each other like this for this professional the changing and imprecise nature of national directives 6 made it difficult to implement the recommendations given the necessity to guard professional secrecy to prevent identification of employees these professionals could not turn to upper management for help it is therefore not surprising that he repeats we are all alone all alone all alone to manage these urgent and difficult decisions the use of an online epistemic community with occupational physicians gave him the opportunity to share information with other professionals in the same situation all the while respecting his duty to confidentiality the blog continues to be used to help occupational therapists agree to common strategies other blogs were created at a more local level within the city such as between nursing professionals or to coordinate care among liberal nurses and general practitioners both groups still exist in the postcovid era chloe ´ a nursing manager describes her use of epistemic communities i remember creating a whatsapp group connecting all the care directors around us saying how do you do it what is the technique that you found and in fact there was a lot of communication between caregivers between care managers between us saying but what do you have in place and now youre closing visits what are you doing or how are you doing it we found that it connected us with the city like never before these kinds of epistemic communities helped the hospital to face the most severe and chronic aspects of the crisis to create a link between the hospital and the city and to exchange between healthcare providers of the same specialty promoting disciplinary and interdisciplinary exchange epistemic communities were also organized in later stages of the covid crisis by the regional health agency level to consolidate the link between the city and hospitals research epistemic communities also helped cancer researchers in particular those working on live tissue cultures who had little institutional guidance from their structures the need stemmed from isolation in particular for those researchers working in the hospital campus where other professionals were not necessarily aware of their specific concerns these researchers described how they often had to act alone in the face of uncertainty for instance etienne a researcher working with live tissue cultures who was concerned about the risk to his staff says i contacted the hygiene committee they had difficulty understanding the notion of cell culture and i checked with the virology reference laboratory and they confirmed to me that indeed if you have tissue that contains virus and you put it in culture the virus is also cultured so there is a risk in a lab there are still a lot of students a lot of people we cant control everyone and that to me seemed too great a risk but its funny well i found the health committee strange they hardly understood in fact they didnt measure the risk in any case internally there were no specific things for us so we went looking for them given the lack of guidance from his structure this researcher mobilized his epistemic community to find answers about how to continue research and minimize risk for his employees without this essential information sharing among equals it would have been difficult for etienne to make a decision about how to continue research during this time interdisciplinary and interservice coordination healthcare in all of the interviews conducted with healthcare providers and researchers new forms of interdisciplinarity interservice and intrahospital coordination were highlighted as a positive aspect to come from the crisis according to marie a pharmacist who worked in interdisciplinarity with several departments the crisis made room it broke down a lot of organizational barriers both professionals from public and private hospitals shared hospital resources including human and material resources they also responded to urgent needs such as vaccination by working between departments and specialties and took on cases from other hospital sites this coordination in particular worked well within the same hospital group where hub systems were put into place these hub systems helped services facing resource shortages to find beds and not to refuse patients in need interdisciplinary coordination also worked well at the national level in small specialties such as pediatric oncology which could more easily coordinate on a wider scale due to a small number of cases several examples of these new kinds of interdisciplinary work are still in place and their impact is summarized in table 2 covid reflection cells interdisciplinary coordination was also reinforced at the hospital level via covid reflection cells which helped to decide overall hospital policy and to collectively debate difficult cases during the crisis it was essential to have different professionals views and sources of information in these meetings according to anna a hospital manager these new forms of interdisciplinary coordination enabled hospital managers and heads of service to better coordinate decisions and regulations during the duration of the crisis as well as to find practical solutions through collective reflection at the end of the research period these interdisciplinary coordination meetings either continued to be active or were put on hold but it was believed possible to reactivate them quickly according to professionals this kind of interdisciplinary work and coordination permitted the hospital to have a certain agility during the crisis a capacity to act together which had not been present before and will be easier to reactivate in future crises one of the facilitating factors was the rollout and widespread adoption of teleconference technologies according to several professionals interviewed this technology has permitted better interdisciplinary coordination between large structures in particular between different sites at the large public hospital in this past the fact that professionals were spread across several campuses made it difficult to favor collective decision making however with the introduction of new teleconference technologies meetings can now be held more frequently allowing managers across services to be more agile and to take decisions together as a team this has impacted covid reflection cells but also regular multidisciplinary meetings as elsewhere 18 most of these meetings either continue in online or hybrid formats postcovid limitations of interdisciplinary coordination interdisciplinary and interservice coordination was more difficult to organize at the city and regional level particularly between different types of hospital structures as etienne a management professional describes the hospitals were all alone so we decided for ourselves i think this is the major lack during the crisis everyone organized by themselves all the hospitals have some capabilities to answer to the crisis but there is no coordination between all the healthcare organizations in the region in my opinion this is the most important thing to do in case of a large crisis like covid we have to organize differently the good level is not the hospital it is the region or the city but not the hospital as we can see from this quotation although online epistemic communities made it possible to share information at the city and regional level it was more difficult to share resources as hospitals had different functionsstatutes the interdisciplinary coordination we have described here is therefore principally centered at the hospital level research a new interdisciplinary work was also put into place during the crisis for research in clinical trials in particular via large european studies on covid which mobilized different structures and services at a hospital site in comparison to research on live tissue cultures those working on clinical trials benefitted from increased interdisciplinary coordination within their structures in the postcovid era this has helped research teams to structure regular research work and share human resources among teams according to martin a clinical research associate during the crisis we realized that we did not have an exhaustive vision of all the research personnel present at in order to redeploy these personnel correctly and efficiently in the services that needed them most since then we have been working on structuring ourselves and getting to know better the agents who work in research covid made us realize that we didnt have this exhaustive view especially of our research staff this restructuring led to a creation of a new hr policy in the public hospital to allow them to centralize information on their research personnel according to martin this will enable them to avoid skills loss and to better anticipate future research needs 313 telemedicine and teleconference technologies healthcare telemedicine was greatly expanded during the crisis at the time of writing in the lyon metropole it continues to be widely used in oncology care including by different categories of professionals table 3 summarizes the perspectives of the healthcare providers and researchers interviewed about teleconsultation its value for the healthcare provider and patient as well as the temporalitiesspaces where it was not recommended by the professionals interviewed while professionals interviewed differed in their perceptions of the benefits for patient care the crisis helped test the possibilities and limits and has had lasting effects into how cancer care is organized the difference between the precovid era and the postcovid era is flagrant according to anna a hospital management professional eight weeks before the first lockdown we did 25 teleconsultations eight weeks after we had done 5584 its something that has continued even today about 2025 of consultations have been teleconsultations it is almost paradoxical what i am going to tell you but we observed that many patients could reach us more easily on the national territory and even beyond in europe in particular they have transformed our practice and since then it has become common practice our results suggest specific temporalities in the care journey when telemedicine should be practiced by healthcare providers as well as when telemedicine should not be used such as breaking bad news these results largely concur with other qualitative research conducted in oncology on the use of telemedicine in france during the crisis 19 however further studies are needed to understand patient perspectives and to better understand how they differ from healthcare providers for instance a qualitative study on acceptability of video visits for serious or bad news delivered from the patient perspective has suggested that there was no consensus on patient preference for video or inperson visits 20 a finding that differs greatly from the perspective of all of the healthcare providers interviewed in this research project which were categorically against it research during the crisis and in particular during the first wave teleconsultation was also used in research to facilitate clinical trials whether it be for cancer research or for clinical trials for covid research teleconsultations were organized as a first step by the doctorresearcher with patients and in a second step by cras to answer further questions and permit patients to give their electronic informed consent this was permitted during the crisis because they had a special authorization from regulatory authorities to use electronic consent this allowed clinical trials to proceed even during the most acute part of the crisis trial modifications with the introduction of digital health technologies and trial decentralization were also used in other countries during the pandemic 102122 while the participants interviewed believe that this was a good possibilityalternative option they believed it is unlikely to be used on a wide scale in normal cancer research in france due to the reinstatement of regulatory restrictions they also said that seeing the patient inperson was the best way to ensure their informed consent international research 2123 suggests however that remote monitoring and econsent for clinical trials will be envisaged for future trials in particular as digital consent has been shown to increase participation among rural and minority populations 24 creativities in the care plan as in other sectors of healthcare during the crisis 25 this special period also led to new creativities in the care plan these creativities were seen in cancer care in the lyon metropole and this in spite of increased workloads this took the form of experimentations of arts methodologies to enhance dialogues with patients particularly among nurses and other paramedical professionals for instance according to chloe ´ a nursing care manager ive never seen so many caregivers show their creativity one started drawing and making comics for patients to explain their illness we made comics newspapers there was one person that made drawings with the patients and exhibited the drawings one started to make music and brought in instruments to give out to the patients im thrilled to see all the movement and talent coming out of our teams these new creativities were important not only to the patient who was able to experiment with art practices to find alternatively ways to express and understand their illness but also to healthcare professionals their quality of life at work and their sense of purpose in their professions according to this professional these creativities are part of an ongoing reflection on how to improve healthcare and will help work toward a more personcentered perspective in oncology in the years to come harmonization and streamlining of patient journeys healthcare professionals also took the opportunity during the crisis to find ways to better harmonize treatments and streamline procedures in their services while this was not a phenomenon across all those interviewed the crisis was an opportunity for a few heads of service in both the private and public hospital to improve their organization while harmonization and streamlining are related and may collectively increase efficiency in hospital organizations we define harmonization as a consistent approach to treating similar cases by streamlining we refer to changing processes to increase efficiency and reduce duplicative views 26 harmonizing treatment decisions the interviews showed that the level at which treatment harmonization was possible during the crisis was in an individual hospital service where there was a capacity to act quickly and with other professionals to harmonize treatment protocols while these adaptations were often initiated by the head of the service they worked on the ground because they were agreed and reviewed by the healthcare team in addition while these changes were made for the health crisis they also accelerated transformations in hospital functioning that have lasted in the services which experimented them as marie explains we were not really affected an explanation is that we reviewed our processes we said we clearly need to harmonize the prescription of treatment among mds we know that mds by definition have to have the freedom to decide what they do for their patient here we were in a crisis and potentially a big and long crisis so we needed to refine things we need to say sorry no lets everybody do the same depending on the urgency depending on the complexity of the pathology so we divided the treatment into four categories these were reviewed every morning we believe we did not put patients in danger we strongly believe it we all agreed together and everything was really smooth at the end as this example shows harmonizing treatments among professionals in the service was done both from a perspective of working toward equality but also with the ambition of improving organizational efficiency as maries example shows this adaptation put into tension the individual autonomy of clinicians with public health needs it is however telling that marie as head of service uses we in explaining the context of these processes of harmonization and puts an emphasis on collective agreement and review without which support for this harmonization would not have been possible improved processes to better support patients healthcare during the crisis hospital services sought to reduce the duration of hospitalization a process already underway that was accelerated during the crisis in the face of this new reality two heads of service adapted by initiating new or improved processes to better support patients in healthcare pathways according to colette a gynecologist this made us realize that there are many things that can be done more in an outpatient setting with covid we tried to shorten stays as much as possible it also forced us to anticipate and take care of things beforehand the woman who is going to be hospitalized and who is going to go home in the evening she cannot go to the pharmacy beforehand so we have intensified the prescription of medicines in advance so that she can go to the pharmacy before the operation so that when she goes home she rests and she has what she needs we also now call the patients back to see if theyre okay we accompany them according to colette although these procedures were beginning to be put in place before the crisis the crisis forced professionals to rethink their care plans to better support patients these new processes gave a realistic means of allowing patients to be able to transition to home care on the same day of the surgery while reducing hospital stays was a reality for many hospital services both leading up to and during the crisis this is not to suggest that replacing inpatient hospital surveillance with a hospital outpatient setting is necessarily the best option particularly in some procedures which may incur additional risk however the reality of the acceleration of these processes did enable a few professionals and services to adapt to better anticipate and accompany their patients pharmacy new processes were also put into place to support patients who normally received medication via the hospital these processes were put into place in both the public and private hospital given the necessity to put into place teleconsultation during the crisis this led to new care processes for patients according to benjamin a pharmacist it allowed us to think about how we can transmit information to patients when we are remote because we dont handle the medication box and so on to explain the intake plan it also allowed us to measure the proportion of patients who could be receptive or well equipped for remote consultations we switched to remote consultations for patients who were receiving treatment in clinical trials something we had never done before according to benjamin these adaptations and innovations are helping to rethink pharmacy care postcrisis and in particular the appropriate use of teleconsultation to reduce the burden for the patient and ensure they had the resources for responsible use of their medication this was also the case for research and followup of patients in clinical studies precovid it was not possible to get the treatment in the city pharmacy and it had to pass through the hospital pharmacy which resulted in considerable time burden for patients who did not come from the city during the crisis pharmacists set up networks to deliver treatments to patients via city pharmacists ensuring continuity of clinical trials during this time and giving benefits to patients in terms of medication access streamlining healthcare pathways two oncologists interviewed were able to use the covid crisis to refine their procedures in order to optimize planning schedules in their department this gave not only a clear plan of action for the patient but also helped to better organize their services to become more efficient for instance according to marie we said we need to streamline the day the patient comes to the ct he agrees and he will have his first treatment two weeks later its a different way of organizing it it was for me really big plus in the time of covid crisis and we still apply it today in other words by streamlining things by really maximizing the slots that we booked for a particular patient we minimize the losses and this was somehow macroscopically an advantage for department for me it was a really big plus in the time of covid we still apply it today as we can see from maries account the value of efficiency is prioritized to enable the department to minimize losses however for marie this streamlining also represents a benefit for the patient who knows concretely when they will be treated and therefore has a clearly defined care pathway by streamlining these processes in her services marie says they may also ensure greater equality as each patient now has the same treatment delay discussion healthcare professionals and researchers interviewed were surprised that they were able to be agile to change to innovate in their hospitals which had always been viewed as large bureaucratic machines according to marc a management professional usually we have the traditional picture of the hospital which is a big thing very difficult to move the covid crisis shows that hospitals are much more reactive than we thought they were we showed that we are able to adapt to face very unusual situations while the relaxation of certain rules and the prioritization of cancer care during this time were facilitating factors for innovation this is not enough to explain the creative period that was experienced in some structures and services in this discussion section what will interest us is how local actorshealthcare professionals management staff and researcherswere capable during the healthcare crisis enabling them adapt and innovate to ensure that patients did not lose out in this section we will articulate the project results with the capabilities approach an interdisciplinary approach developed in social sciences the capabilities approach is a social justice approach that seeks to better understand the real opportunities individuals have to act it was originally developed by the economist amartya sen and later conceptualized in philosophy by martha nussbaum the approach has been used extensively in health especially to develop new initiatives in health promotion 27 health indicators and interventions 28 and to think about care for minority populations 29 although to our knowledge it has not been used to understand the capabilities of local actors during the covid crisis in this section we will first of all give an overview of the approach and our use of it before articulating the approach with the project results first of all in the ca the level of analysis is what the individual person can actually be and do therefore in the approach we will only be interested in what a persons individual capacities are but their real opportunities to exercise these capacities in their environment an example in healthcare is in the doctorpatient relationship for instance patients may have adequate levels of health literacy to enable them to participate in shared decisionmaking however they need to be able to exercise these capacities during the consultation in other words the doctor must both be willingbut also have institutional supportto give patients the time and space for shared decisionmaking this is the difference between individual capacities and capabilities which takes into consideration how persons can realistically act in their social environment an influential thinker in the ca is the philosopher martha nussbaum her ethical and political project seeks to guarantee that a certain number of capabilities are enshrined in each countrys constitution and to put an obligation on governments to ensure everyone has the opportunity to develop their capabilities she argues that her list of capabilities are the minimum to guarantee a life with dignity 3031 her list comprises the capabilities of 1 life 2 bodily health 3 bodily integrity 4 senses imagination and thought 5 emotion 6 practical reason 7 affiliation 8 other species 9 play 10 control over ones environment while nussbaum meant this list to be holistic both research and policy orientations may focus on certain capabilities which may be more relevant than others in certain contexts therefore in order to articulate our project results we have chosen to focus specifically on three of the capabilities from nussbaums list these three capabilities include 1 practical reason 2 affiliation and 3 control of ones environment practical reason the first capability that will be important to our discussion is practical reason this capability involves critical thinking about what life we want to achieve and how to get there in an ethical perspective the capability to search for and pursue our version of the good is central to our selfworth it helps us to reflect on our personal and professional values and to plan our lives in coherence with them an important means of exercising our practical reason is a reflection on our personal and professional values in healthcare these values motivate workers in their relationships with colleagues and with patients and families and give them a sense of purpose in their professional lives as the project results show the crisis confronted local actors values with the realities of the sanitary crisis and led to what adam described as a scene of major questioning that has continued to this day according to chloe ´ a nursing manager we have never questioned values so much why we do the job what are the values that we have sought together the questioning of values in turn facilitated durable changes that will impact cancer care in the decades to come among the project results we can see that this questioning led to the development of arts methodologies thinking about equality which led to greater treatment harmonization or the creation of new epistemic communities with peers and new forms of interdisciplinary work in recognition of the importance of collective reflection while these values were present before it took the shock of the sanitary crisis to bring them to center stage and to create the space to experiment new methods therefore even with the healthcare emergency the capability of practical reason was important for healthcare providers and researchers to be able to adapt their care and research in line with their values however this practical reason this reflection about their values was not developed alone it needed collegial reflection to be successful the capability of affiliation was also essential during this time affiliation the most important thing if there is a crisis is to try and resolve the problem all together i am sure that to share the problem we can find the solution all together in the case of a crisis there is no other way in this second discussion we will elaborate the importance of thinking together or what the capabilities approach calls affiliation martha nussbaum defines this capability as being able to live with and toward others to recognize and show concern for other humans to engage in various forms of social interaction to be able to imagine the situation of another 30 p 34 this capability is associated with both being recognized and recognizing others while we have thus far discussed the importance of choosing our own lives the ca also recognizes that we need others to be able to live well what we can see from the project results is that the ability to improvise and solve problems creativelythe process known as bricolagewas made possible largely by affiliation as philosopher paul ricoeur 32 has proposed in decisions of uncertainty we can have recourse to a good advice cell which he defines as a community of equals where several points of view are in balance these good advice cells took the form of covid cells interdisciplinary coordination meetings and online epistemic communities they were a necessary factor in helping institutions to adapt and innovate and to develop collective practical wisdom etienne a management professional echoing ricoeur describes it as there was a lot of decisions to take but all the people were in this together and there is a lot of collective intelligence we had a lot of discussions together and we took the decisions all together similarly chloe ´ a nursing manager expresses it as covid changed something about the fact that we had the capacity to act together at the beginning each person was in his little corner but then we got into line very quickly we structured ourselves and we did it together while this affiliation this capacity to work together was a necessary factor in enabling professionals to be capable during the crisis this is not to suggest that the covid period was conflictfree or that this period did not cause value conflicts for instance marie although claiming that changing procedures in her department helped to better harmonize care this process took time to negotiate in particular with clinicians who continued to advocate for different rules for individual cases this conflict of values between the doctors autonomy and public health needs has also affected healthcare in the postcovid phase its longterm impact will need to be studied to better understand the capability of local actors in healthcare transformations the fragility of this affiliation should also be emphasized while in the interviews interdisciplinary coordination was a strong point in enabling hospitals to adapt during the most acute moments of the crisis there was an evident rupture that was described in all the interviews between the first wave of the crisis and the more chronic phases of the crisis when local actors were facing fatigue and burnout indeed due to the crisis facing hospitals due to lack of staff at the current time it is at its breaking point control of ones environment in this final section we will discuss the capability of control of ones environment this capability is closely tied to the other two we have discussed nussbaum defines this capability as being able to work as a human being exercising practical reason and entering into meaningful relationships of mutual recognition with other workers 30 p 34 in other words it combines the two previous capabilities mentioned with the possibility to have a certain among of control over ones environment as we can see from the interviews a facilitating factor in innovation was autonomy to decide how to best adapt care for their individual services this included innovating at the individual service level to experimenting new forms of coordination at the hospital or even city or national level it also involved experimenting with new technologies such as teleconsultation to find new ways to work with individual patients however as nussbaums capability has recognized control of ones environment also requires meaningful relationships and recognition from other workers in this case what healthcare managers needed was a certain amount of support from their hierarchies indeed literature on institutional resilience has shown that in order to facilitate quick adaptation a combination of decentralization selforganization and shared decisionmaking is needed 33 or as marie a pharmacist describes it the top management trusts us and its the same thing i am underneath but underneath me i have people i have effectors i have relationships that go up like that and then i have actions to carry out and work in collaboration with the people who are under me and again i entrust their actions cant decide on everything they cant be on the ground of everything it goes up down up down and we talk to each other on all the axes this shows the agility of the organization and thats why its successful based on this capability we can understand that innovation was facilitated thanks to 1 the existence of a semidecentralized hierarchy and 2 recognition of each persons specific expertise in the hospital structure in the first case this enabled local actors to have autonomy to make specific changes in their individual services this helps explain the number of innovations but also the variation in innovations developed during the crisis from changes in triage protocols to servicelevel decisions on streamlining and harmonization secondly recognition of each persons expertise also played an important role in helping healthcare actors gain the capability to act as we can see from maries quotation above we talk to each other on all the axes to be capable of acting even within a semidecentralized hierarchy there was a need of mutual recognition along the hierarchy from the top management to their local service managers from local service management to their staff furthermore outside of the individual service mutual recognition was necessary for covid reflection cells where all points of view were necessary to understand the situation and take a decision in these interdisciplinary groups each professional was in their role with a specific expertise to bring that was recognized and valued finally this mutual recognition was valued in online epistemic communities where individuals leaned on each for advice and support in conclusion these two factors a semidecentralized hierarchy and the ability to have mutual recognition from other colleagues enabled local actors to have a certain amount of control of their environment along with the capabilities of practical reason and affiliation this made them capable of innovation and creativity in spite of the sanitary crisis limitations this qualitative study was conducted in one french region therefore it cannot attest to the situation in other french regions although feedback on our research in national conferences suggest that experiences were similar elsewhere in addition as many of these adaptations and innovations discussed by professionals were practiced with professionals in other regions this does give us confidence that they were similar elsewhere in future studies it is suggested 1 to investigate how many of these themes corresponded with experiences across france in other regions of europe and internationally 2 to better understand how these changes have sustainably transformed healthcare and research practices another limitation of our study is that we chose to study our topic with managers there is however a need to better understand what paramedical professionals lived in particular given the current healthcare crisis which was described by most professionals as a bigger crisis than covid further research on the impact and repercussions of the lived experiences of frontline workers merits further investigation and public health attention drawn to the issue to prepare for future health crises and ensure that these innovations are not lost furthermore our study sought to interview senior staff rather than young who did not necessarily make management decisions although they were partly recognized in collective decisionmaking processes this group merits further research attention finally it will also be necessary to integrate the patient perspectives of these innovations to understand how they will change their longterm cancer care 34 conclusions many of the innovations and adaptations discussed in this article were implemented within the cancer care continuum during the covid19 crisis and are relatively simple to put into practice the creation of an online epistemic community to facilitate exchange collective agreement on healthcare pathways for the patient and new processes to better accompany patients in the transition to home care however they were made possible by three capabilities practical reason affiliation and control of ones environment healthcare institutions regional authorities and politicians need to help cultivate these capabilities in both their frontline and management staff to enable their healthcare institutions to be able to adapt be creative and continue to provide quality care in the postcovid period and especially to ensure that they can work in coherence with their values the data is attached as a supplementary file writing original draft brenda bogaert writing review editing zisis kozlakidis elodie caboux julien pe ´ron pierre saintingy

this article will elaborate how oncology care and research was adapted during the covid pandemic in the metropole of lyon france including the lasting innovations that came out of the crisis the research method involved 22 semistructured qualitative interviews of healthcare professionals managers and researchers in the lyon france region coming from both public and private academic hospitals the interviews took place from february 2021december 2022 in order to assess the longterm adaptations and innovations in cancer care organization in the postcovid era the main results show adaptations and innovations in 1 new processes and resources to facilitate disciplinary and interdisciplinary work 2 harmonization and streamlining of patient journeys in the discussion section we will mobilize the capabilities approach an interdisciplinary social sciences approach that focuses on the capabilities of persons to be and to do to elaborate the conditions by which local actors were able to be agile to adapt and to innovate in spite of the healthcare emergency and in coherence with their professional and personal values

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it was my first year having teacher candidates placed in this particular elementary school i was excited because this school was located in an urban area and the student demographics were predominantly black this was important to me because i am a black female teacher educator who very seldomly gets to work in predominantly black schools also i know that oftentimes a negative view of black students is held in the field of education black students are often perceived as disengaged from school resistant and oppositional in the classroom and not valuing education and achievement these perceptions can cause black students school experiences to be both challenging and harmful therefore i found having teacher candidates enrolled in my clinical course placed at a predominantly black elementary school for their clinical placements as an opportunity for them to explore their perceptions of black students and gain experience working with a group of students that most of them have never worked with national association of professional development schools recently revised their nine essentials to include this revised version of essential 1 a comprehensive mission which calls for the advancement of equity antiracism and social justice within and among schools collegesuniversities and their respective community and professional partners the work that i present in this article around preparing teacher candidates to address antiblackness fits into the call of essential 1 because when antiblackness is addressed equity antiracism and social justice can be part of the educational experiences of black children this article shares how providing teacher candidates experiences in a predominantly black elementary school for their clinical experiences highlighted a need to recognize acknowledge and address antiblackness 1 in teacher candidates clinical practice as well as a need to emphasize the brilliance and assets of black students additionally this article shares ways in which those involved in the work of schooluniversity or pds partnerships can incorporate practices that address antiblackness in clinical courses the clinical course setup there were 16 teacher candidates enrolled in my clinical i course and this was their first semesterlong clinical experience this course was offered in one of the largest teacher education programs in the midwest the education program was part of a predominantly white institution that has a total enrollment of approximately 22000 students the teacher candidates were paired by the college placement coordinator and assigned to one cooperating teacher in grades k5 the clinical course began with the first three weeks of the semester being oncampus and meeting three days a week for 35 hours during this time i was able to prepare teacher candidates for what they may experience during their clinical practice i was intentional about getting teacher candidates to gain understanding of the assets and conditions of the schools and community where they would be placed because i know that many of them have not been in predominantly black schools and communities therefore i arranged a field trip for teacher candidates to visit their schools to meet the administration get a tour of the school building and physically introduce themselves to their cooperating teacher prior to our visit to the school teacher candidates had already met with their assigned cooperating teachers virtually to discuss expectations and logistics in addition teacher candidates got to explore the community stopping by a few community organizations during the next class following the field trip i facilitated a discussion that required teacher candidates to critically reflect and share with the class their overall experience visiting schools and communities the assets and conditions of urban and black schools and communities before teacher candidates began their clinical practice i spent a lot of time getting teacher candidates to unpack themselves through the use of identity wheels cycle of socialization activity name stories where i am from poems and other activities teacher candidates focused on their biases and prejudices while participating in these activities and discussed how their biases and prejudices can impact the way they see black students and the way that they could possibly teach black students i provided teacher candidates instruction on topics regarding lesson plans classroom behavior guidance instruction assessments culturally responsive teaching funds of knowledge antiracist teaching creating equitable teaching environments selfcare to name a few things i asked teacher candidates to use a journal to jot down how they see what they are learning incorporated in their clinical classrooms as well as to process and make sense of their clinical experiences and what they are observing after the initial three weeks of the course teacher candidates spent two full days each week for 11 weeks in clinical placements with the exception of one on campus meeting during week 7 and week 11 during weeks 7 and 11 teacher candidates would meet on campus for a three hour course to debrief throughout the time when teacher candidates were in their clinical placement i observed them at least once a week and we would debrief immediately after their observation during the final week of the course we met back on campus for a three hour course debrief to discuss not only their clinical experiences but the course in general situating the clinical course the teacher candidates enrolled in my course were white monolingual females with little to no experience working with black students prior to my course like most white teacher candidates they felt unprepared to teach black students most teachers develop fear and inaccurate preconceptions about black students because of the overabundance of negative imagery contributed by the media this contributes to teacher biases towards black students the pairing of teachers unconscious biases and institutional racism is often what determines the kind of experience black children will have in school moreover it determines how successful students will be in school initially i believed that placing teacher candidates in a predominantly black urban elementary school was going to be such a positive learning experience for them and one where they would gain knowledge i felt this would be a positive experience because of what i remember as a teacher in a predominantly black elementary school when i was teaching elementary school i got to experience the brilliance of black children every day and they brought so much joy to the classroom with their swag 2 and perspectives after two weeks of observing the teacher candidates in their clinical placements i realized that some of the teacher candidates enrolled in my clinical course were not getting the positive learning experience that i experienced as a teacher some were placed with cooperating teachers that unfortunately did not see the brilliance and swag that their black students brought into the classroom like i once did unfortunately i witnessed many incidents of antiblackness through the ways in which students were instructed and discussed by some of the cooperating teachers 3 while there were cooperating teachers who did not exhibit antiblack behavior and created positive classroom environments where black students thrived i believe it is important to address the antiblackness that was observed during teacher candidates clinical experiences because this is not often a topic of discussion during clinical placement recognizing acknowledging and addressing antiblackness in clinical practice during my observation there was an incident when a cooperating teacher shared with me how several of the black students would do better in her class if they had parentscaregivers that were around and showed that they cared the cooperating teacher perceived students families as unconcerned about students and not being resourceful this was an outlandish assumption that was made about the students who all happened to be black during another addressing antiblackness in clinical practice observation i witnessed a different cooperating teacher heavily monitoring the black students in their classroom and always assuming that they were off task during instructional time when this was not the case another example of antiblackness with this same cooperating teacher occurred during an observation of a social emotional lesson that focused on bullying the teacher candidate asked students to share some of the characteristics of a bully several students responded using terms such as mean tough angry and selfish the cooperating teacher responded many of you have those traits and are learning to be nice and we are working on getting rid of aggressive behavior this comment was unsettling because the cooperating teacher was speaking to a class of black students and oftentimes black people have been stereotyped as aggressive tough and angry this cooperating teacher did not seem to take into consideration the possible impact of her comment throughout the semester there were several discussions where some of the cooperating teachers would share deficit thoughts about their black students with teacher candidates in most cases teacher candidates would share the discussions with me for feedback expressing how they were uncomfortable with what they were witnessing in their classrooms i would encourage teacher candidates to explore ways to acknowledge and address antiblackness in elementary classrooms i explained to teacher candidates how antiblackness often shows up in elementary classrooms through mistreatment or inequitable treatment over policing low expectations and not believing black students in addition i informed them of a few ways to address antiblackness in these classrooms by checking their biases daily taking time to get to know black students as human beings making sure that the black students in their classrooms see themselves in daily lessons in a nonstereotypical way encouraging black students and providing opportunities for them to thrive the observations comments from some of the cooperating teachers and discussions with teacher candidates caused me to realize that placing them in a predominantly black elementary school does not automatically provide teacher candidates with the skills knowledge and ability to effectively teach black students i failed to think about antiblackness antiblack racism microaggressions and other factors that often show up in clinical placements what i witnessed the first couple of weeks observing in the teacher candidates clinical placement caused me to think about the importance of preparing teacher candidates to recognize acknowledge and address antiblackness dumas suggests that it is important for educators to acknowledge that antiblackness infects educators work in schools and serves as a form of violence against black children and their families this acknowledgement is different from a broad stance against intolerance or racism or an admission of the existence of white privilege teachers administrators and district leaders should create opportunities to engage in honest and very specific conversations about black bodies blackness and black historical memories in and of the school and local community all those involved with schooluniversity partnerships or professional development schools specifically collegeuniversity faculty cooperating teachers clinical supervisors and administrators must address not only instructional practices lesson planning classroom behavior guidance classroom setup and assessments during clinical courses but they must address antiblackness microaggressions overt and covert racism and ways to create equitable teaching and learning environments for black students there should be intentionality regarding preparing teacher candidates to see black students as assets if black students are to feel seen free connected and perform at their highest potential in schools it is imperative for all those involved in schooluniversity partnerships or pdss to be intentional about recognizing acknowledging and addressing antiblackness in clinical practice preparing teacher candidates through clinical practice to address antiblackness pdsp 181 cannot be an add on but must be part of ongoing practices this may be complicated for those involved in schooluniversity partnerships or pdss because many of us that are involved in this particular work do not know how to recognize and address antiblackness ourselves american public schools were created first and foremost for the advancement of white children making antiblackness part of its foundation as those involved with schooluniversity partnerships or pdss we must first start by educating ourselves and making sure that we are in tune with what is happening with black children in schools and work towards using our positions to create equitable and safer learning environments for black children which is connected to how we prepare teacher candidates to effectively teach black students using the clinical course as an opportunity to address antiblackness and see the assets of black students once teacher candidates entered into their clinical placements i noticed areas where they were being challenged and would meet with them after their observation to debrief i took notes during the observations and recorded behaviors that appeared antiblack as a microaggression or showed prejudice in addition i would record behaviors that recognized students brilliance encouraged students and showed supportive and effective instruction during the observation debrief i would first ask teacher candidates to share what they found as positive in the classroom and for any instructional practices they believe will be useful in their future teaching secondly i would ask teacher candidates to share if antiblackness prejudice or inequitable practices were present during their clinical experience this was my way of getting teacher candidates to critically reflect on their clinical experience i wanted teacher candidates to not just focus on the ways and perceptions of their cooperating teacher but to begin considering their own ways and perceptions after teacher candidates shared i would share what i witnessed during my observation and we would unpack my observation during the on campus course meetings on weeks 7 and 11 i would always provide teacher candidates with writing time to share their experiences and free their minds all who felt comfortable sharing aloud would participate in a group discussion based on my observations i would create scenarios and have teacher candidates discuss the scenarios in small groups and brainstorm possible solutions each class my experiences in regards to how i was seeing black students being treated in some of the classrooms caused me to be intentional about helping teacher candidates define terms such as racism antiblackness prejudice microaggressions and provide examples of what this looks like in elementary classrooms these discussions about antiblackness were new to teacher candidates and caused some of them discomfort initially however this was necessary for making sure that teacher candidates were gaining preparation that would help them to effectively teach black students in addition to these discussions around antiblackness i would also have teacher candidates discuss the positive experiences they are having in the classroom this led us to discussions around how to incorporate practices that address antiblackness in the classroom incorporating practices that address antiblackness throughout clinical practice the work that i began doing with teacher candidates regarding recognizing acknowledging addressing antiblackness as well as seeing black students as assets came from my experience observing students in their clinical placements and the critical discussions i held with teacher candidates during our course meetings my experience teaching this clinical course confirmed for me that addressing antiblackness in clinical practice is necessary not only as an effort to create equitable and safer learning environments for black students but also to make sure that teacher candidates are fully prepared to be effective teachers of black addressing antiblackness in clinical practice students we cannot take for granted that cooperating teachers will operate in ways that promote inclusion diversity equity and antiracism collegeuniversity faculty school administrators schooluniversity partnerships and pds stakeholders must work collaboratively to develop systemic and sustainable ways to combat racial injustice in their respective programs and educational contexts with this in mind in order to prioritize recognizing acknowledging and addressing antiblackness in clinical practice i offer the following suggestions all those involved in schooluniversity partnerships or pdss should begin or continue to address their own personal biases i am reminded of flight attendants on commercial airplanes asking for passengers in the case of an emergency to apply their oxygen masks to their faces first before helping others apply their masks this same concept applies when addressing antiblackness in clinical practice before teacher educators clinical faculty clinical supervisors and others involved in schooluniversity partnerships or pdss can begin working with teacher candidates and addressing antiblackness they must start with themselves all who are working with teacher candidates should be doing selfwork this work on self should include reading books and listening to podcasts journaling as a means of critical reflection attending professional development that involves learning antiracist practices that challenge biases and stereotypes collegesuniversities and schools should establish a third space a less hierarchical space to prioritize addressing antiblackness within classrooms teacher educators school facultystaff and teacher candidates can work together to offer professional development and other opportunities that provide ways to combat antiblackness and teach antiracist practices placement coordinators for schooluniversity partnerships or pdss should be intentional about building relationships with schools who are open to antiracist practices and willing to address antiblack policies and practices logistics is not as important as being purposeful in choosing cooperating teachers that are willing to do the work to address antiblack practices and work on becoming antiracist teachers placement coordinators should end partnerships that are unwilling to prioritize antiracist practices and address antiblack practices that are observed in their schools district and school administrators need to be looking at disciplinary data aphonors courses data special education data and overall students performance data to gain insight on the percentages of black students this will give a glimpse of the educational experiences of black students in that particular district professional development for all educators and staff that focuses on addressing antiblackness and antiracist teaching and a review of curriculum to make sure that students are learning about the history and excellence of black people there should be a goal to make sure educators and staff have the knowledge skills awareness and dispositions to talk about antiblackness and address it work around addressing antiblackness in clinical practice should start immediately there is no time to wait for the opportune time to address antiblackness in clinical practice therefore all involved in schooluniversity partnerships or pdss should begin selfwork now as they move into having critical discussions around addressing antiblackness thoughts for the future recognizing acknowledging and addressing antiblackness in schools is not comfortable nor is it an easy task however if all those involved in schooluniversity partnerships or pdss begin holding space for this critical and necessary work we can change the ways in which some black students have been experiencing school and make sure that teacher candidates are prepared to effectively teach black students some of us may be in colleges universities or districts that do not have black students this does not excuse you from addressing antiblackness and conversations around seeing black students as assets our unified effort will make a change not only in clinical practice but also in the field of education notes 1 according to jenkins antiblackness is a socially constructed notion that black people are nonhuman inherently problematic and disposable 2 swag is slang for stylish confidence 3 there were eight cooperating teachers at the school seven of the cooperating teachers identified as white and one identified as black while the black teacher did not exhibit antiblack practices antiblackness can be carried out by anyone regardless of raceethnicity

purpose this article shares how providing teacher candidates with experiences in a predominantly black elementary school for their clinical experiences highlighted a need to recognize acknowledge and address antiblackness in teacher candidates clinical courses as well as a need to emphasize the brilliance and assets of black students additionally this article shares ways in which those involved in the work of schooluniversity or professional development school pds partnerships can incorporate practices that address antiblackness in clinical practice designmethodologyapproach conceptual paper sharing experiences addressing antiblackness in schooluniversity partnerships findings national association of professional development schools napds recently revised their nine essentials to include this revised version of essential 1 a comprehensive mission which calls for the advancement of equity antiracism and social justice within and among schools collegesuniversities and their respective community and professional partners the work that the author presents in this article around preparing teacher candidates to address antiblackness fits into the call of essential 1 because when antiblackness is addressed equity antiracism and social justice can be part of the educational experiences of black children this article shares how providing teacher candidates experiences in a predominantly black elementary school for their clinical experiences highlighted a need to recognize acknowledge and address antiblackness in teacher candidates clinical practice as well as a need to emphasize the brilliance and assets of black students additionally this article shares ways in which those involved in the work of schooluniversity or pds partnerships can incorporate practices that address antiblackness in clinical courses originalityvalue the author believes that this manuscript is appropriate for publication because it addresses a necessary shift that must happen in clinical practice by recognizing acknowledging and addressing antiblackness as well as making sure teacher candidates are prepared to teach black students this manuscript has not been published and is not under consideration for publication elsewhere the author has no conflicts of interest to disclose

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introduction religious change is one of the central focuses of social science from comte and durkheim to marx and weber the founding fathers of social science were philip s brenner is an assistant professor in the department of sociology and a senior research fellow in the center for survey research at the university of massachusetts boston boston ma usa the author thanks the editors and three anonymous reviewers for their helpful comments and suggestions on previous versions of this manuscript address correspondence to philip brenner university of massachusetts boston 100 william t morrissey blvd boston ma 02125 usa email concerned with the future of religion while they hypothesized varying causes and processes they shared a prognosis a future without religion or at least without religion in its current form of course social scientists working today have tools unavailable to the founders of social science among these tools survey methods in particular offer generalizable information against which the theories of religious change positive or negative or stability can be tested survey data have been widely used to investigate religious change through analysis of repeated crosssectional and panel data these research programs have been focused on change among individuals and within a population the population upon which much if not most of this research focuses is the united states this americancentric focus is encouraged by the paradigm of american religious exceptionalism the conventional wisdom that the united states is an outlier of religiosity in the developed world in contrast to western europe some social scientists cite evidence for the continuity or revival of religion and religiosity in the united states and many other countries across the globe from postcommunist eastern europe to developing countries in south america africa and asia this perspective twists the old theme of american exceptionalism characterized by the persistence of religiosity in the united states as an exception to the secularization rule to one characterizing europe as the secular exception in a stillreligious world with such a reorientation these scholars are less convinced than their 19thcentury forbears that the path of modernization will lead to a future without religion arguably neither of these exceptionalism perspectives is particularly satisfying to paraphrase demerath instead of asserting the exceptionalism of one or another country why not instead simply investigate their similarities and differences and use that information to extend our understanding thus this paper reviews recent research on trends in religious behavior crossnationally looking at the evidence for growth stability or decline a comprehensive review includes trends from rich highly developed democracies diverse countries of postcommunist eastern europe and developing countries from south america asia and africa such a landscape view provides insight into a central question of social sciencethe future of religionand evidence to the ongoing debate over secularization by reviewing trends in countries understood to be highly secularized highly religious and those somewhere in between thus the main questions addressed are what is the state of religious behavior are trends in church attendance waxing waning or stable and if there is evidence for a change where is the change happening and in which direction in answering these questions trends in survey estimates from recent research are reviewed for evidence of secularization sacralization or stability crossnational survey data and measurement equivalence in addition to theoretical reasons the american focus in the religioustrends literature is grounded in a more pragmatic concern the availability of survey data the ability of survey data to make comparisons across national boundaries is a relatively new development in the centuryold history of survey research the past two decades have seen dramatic growth in the number of crossnational surveys many of these studies have their roots in the european project including the eurobarometer sponsored by the european commission these studies began in 1973 in western europe but are now conducted throughout the european union with supplemental surveys in eu candidate countries the standard eurobarometer is conducted biannually in the 28 eu member states using personal interviews to measure core topics and some of current interest more recently the european social survey began in 2001 as an academically oriented omnibus survey measuring attitudes beliefs and behavior in countries across the continent ess is conducted biennially using personal interviews as these brief summaries suggest many of the crossnational survey programs are regional in the orientation rather than global other examples include additional freestanding barometer studies in asia the middle east and latin america but crossnational research in europe has played a key role in the development of more global survey programs originating with the european values survey which began in 1981 the world values survey has extended beyond europe to over 100 societies on every occupied continent the project uses a variety of datacollection methods including personal and phone interviews and web surveys wvs measures a variety of attitudes and behaviors including core scales to measure trends in modernization the international social survey program is a collaboration among social science surveys to jointly develop and administer questionnaire modules on topics of current interest from its beginning in the early 1980s as a joint project of four ongoing surveys from west germany the uk the united states and australia issp has grown to include over 50 countries datacollection mode varies by member survey and year other crossnational surveys have been conducted by nonprofit and commercial organizations the pew global attitudes surveys ongoing since 2002 have conducted surveys in 60 countries and the gallup world poll ongoing since 2005 covers over 95 percent of the worlds adult population from 160 countries religious service attendance has been a primary focus of social scientists using these and other surveys to study religious change a choice justified by two main considerations first in addition to religious affiliation religious service attendance is the most commonly included measure of religiosity on these crossnational surveys second attendance can be argued to be equivalent across countries and cultures in a way that religious beliefs are not until recently relatively few crossnational survey programs have allowed comparisons using identical questionnaires time frames datacollection methods and other survey dimensions even with these equivalences the sources of potential inequivalence may still be many first the application of standardized survey interviewing may differ across survey research organizations generating house effects that lead to variation in survey statistics second even a technically perfect translation may acquire subtle variations from the intended meaning moreover variation in language use across nations and subgroups can yield differences in the meanings crossnational comparisons of behaviors rather than attitudes or beliefs are more easily justifiable given the scalar equivalence of units of time and conceptual equivalence of religiosity between traditionally christian societies 1 while services may reflect different denominational traditionsvarying by degree of liturgy emphasis on emotionality leadership by clergy or laity and length of servicethey have a common conceptual core that permits the assumption of equivalence analysis of trends united states and canada much if not most of the crossnational research on church attendance focuses on the debate over the united states as an exceptional case however chavess recent summary of religious trends notes that americans attendance 2 since 1990 unambiguously has not increased…attendance has gone down or essentially remained stable trend analyses of the american general social survey demonstrate a modest but significant 025 percentage point reduction in attendance each year over the past three decades american national election studies data 1 see sasaki and suzuki for a perhaps unjustifiable assumption of conceptual equivalence between religious traditions 2 trends reflect populationlevel estimates not limited to only selfdescribed religious persons display an lshaped pattern with a period of unambiguous decline in attendance rates starting in the 1960s before reaching stability more recently over the complete time frame from the mid1960s until 2008 the selfreported rate of attendance from anes has declined from about 43 to about 38 percent brenner found a similar trend using anes agss and wvs data to paraphrase chaves whether these trends should be characterized as decline or stability can be reasonably argued but there is no evidence for increasing rates of attendance crossnational comparisons often start with the case thought to be most similar to the united states canada beyers analysis of gallup data found an overall reduction in weekly attendance of over 50 percent across five decades from 67 percent in 1946 to 30 percent in 1996 bibby similarly found a reduction in weekly attendance from 53 percent in 1957 to 19 and 21 percent in 2000 using 1985 to 2004 canadian general social survey data clark and schellenberg found that the percentage of weekly attenders declined from 41 to 31 percent and nonattenders increased from 31 to 43 percent eagle also used cgss and pcs as well as the canadian survey of giving volunteering and participating in his comparison of attendance rates he found reductions in weekly attendance rates from 30 percent in 1975 to 18 percent in 2008 and in the percentage of respondents reporting only monthly attendance in cgss from about 17 percent in 1986 to 10 percent in 2008 while each of these studies focuses primarily on canada others put canadian attendance in a crosscultural context reimer compared canadian and american attendance using the 1983wvs 1988agss and 1990 pcs data sets he found that weekly canadian attendance rates are nearly half those in the united states wilkinslaflamme compared monthly attendance rates in us uk and canadian regions using the agss cgss britishscottishnorthern ireland social attitudes surveys and northern ireland life and times surveys from the mid1980s through the early 2000s she found reductions in attendance in most from dramatic to moderate declines and low stability in others similarly aarts et al compared attendance across the united states canada and 11 european countries using 19812000 wvs data they found reductions in attendance across most of the countries included albeit slight in canada compared to relative stability in the united states these findings support the conventional wisdom that canadian and american societies are religiously different as canadians more closely resemble their european progenitors than their american siblings in summary attendance while likely in decline is still higher in the united states than in canada however this discussion introduces an important comparatoreuropeas the lower bound arguably only in a crosscontinental context can we make sense of north american trends it matters if europe is a single undifferentiated mass of secularity or if religious heterogeneity highlights important differences between countries moreover the extent and direction of religious change in europe will help make sense of the exceptionality or unexceptionality of north american patterns western europe americans report more frequent church attendance than do europeans on average and this crosscontinental difference is larger than the transcontinental difference between predominantly protestant northern and catholic southern europe using 19992001 wvs data andersen et al found 36 and 27 percent monthly or more frequent attendance in southern and northern europe respectively compared to 60 percent in the united states this categorization of western european countries presents the major determinants of difference in attendance rates as southern and catholic countries like italy spain ireland and portugal tend to have relatively high attendance yet these categories may hide important differences in none of the traditionally protestant nor the traditionally mixed countries did aarts et al find increased attendance declines in attendance ranged up to 8 percentage points although in denmark and iceland where attendance rates are so low as to have bottomed out no further trend was detected examining wvs and ess data from 10 western european countries kaufmann goujon and skirbekk found that attendance has declined over the past four decades the lowest weekly attendance rates primarily in protestant northern europe are at or approaching a floor of about 5 percent while catholic countries in europe typically demonstrate higher attendance rates than protestant countries no consistent evidence emerges even in these countries for upward trends in attendance using wvs data aarts et al compared attendance trends from 11 western european countries to those from the united states and canada in four of the five traditionally catholic societies weekly attendance declined between 4 and 14 percentage points from 1981 to 2000 in belgium the decline in attendance started in the late 1960s and todaybelgian attendance resembles the low attendance rates of neighboring countries like france germany and the netherlands the decline in attendance in ireland is more recent where greeley found high stable rates of attendance conway and others discovered a precipitous decline in irish religious practice beginning in the 1980s analyzing eurobarometer and issp data nic ghiolla phádraig found a decline from nearuniversal weekly attendance in 1973 to 40 percent in 2008 adding ess and wvs to these trends brenner found a reduction from about 90 percent in the 1980s to about 45 percent in 2006 a similar decline in religious behavior emerged in spain as regular mass attendance plummeted from about 60 percent in 1975 to 28 percent in 2002 but has attendance increased anywhere in western europe some evidence has emerged for a revival of religious practice in italy aarts et al found an increase in attendance only in italyby about 6 percentage points introvigne and stark found an increase in weekly attendance at mass from 32 percent in 1981 to 40 percent in 1999 primarily using wvs data in their analysis of more than 30 european countries in five categoriesnorthern western central eastern and southern europeusing evs data voas and doebler also discovered evidence for a small uptick in religious attendance in italy and other southern european countries in addition to an unlikely location the nordic countries using the past two decades of evs and ess data burkimsher also discovered an uptick in denmark the only such increase in the 14 european countries analyzed neither increase however appears to be a substantive change in the pattern of religious decline voas and doebler argued that the small uptick they discovered is likely a combination of a sampling artifact and a period effect noting that the effect was temporary and disappeared in the late 2000s this conjecture is confirmed in a series of additional studies analyzing evs ess issp and eurobarometer data brenner also found an increase in italian attendance but characterized it as a shortlived uptick in the middle of an sshaped function a finding replicated by vezzoni and biolcani by the turn of the millennium attendance rates had resumed their decline andersen gündelach and lüchaus analyses of panel data also confirmed that no religious or spiritual revitalization has occurred or is occurring in denmark in sum there is no consistent evidence of increasing rates of attendance in western europe or north america quite the oppositeattendance is either declining or has bottomed out in the single digits however western europe is not where growth has been hypothesized to occur by critics of secularization rather some expected that the removal of impediments to the free exercise of religion with the fall of communism would spur religious revival across eastern europe but did this revival actually occur eastern europe the fall of communism in eastern europe created the possibility of increasing rates of religious behavior in an examination of 1991 issp data gaultier argued for a religious resurgence in eastern europe given the opening of the religious marketplace after decades of artificial constraint this supplyside paradigm viewed the decline of communist regimes in eastern europe as an opportunity for the revival of previously regulated or banned religious practice gaultiers limited evidence suggested that the resurgence was underway in the early 1990s characterizing polands increasing mass attendance as a paradigmatic example but in his analysis of issp data from the 1990s greeley found evidence to the contrary uncovering relative stability for most eastern european countries and even declining attendance in poland counter to the trend in poland greeley also found evidence of increasing attendance in irreligious russia and east germany expanding on these analyses reitsma et als investigation of 42 countries in evs and ess from 1981 to 2007 found some evidence for increasing attendance in eastern europe however their decision to pool countries together rather than analyzing them separately adds a strong caveat to their findings this decision washes out many of their unique histories and religious idiosyncrasies grouping together countries as varied as religious populous poland and secular sparsely populated estonia other research treating countries individually rather than in large categories found low and declining attendance rates across eastern europe pollacks findings based on an analysis of political culture in central and eastern europe survey data suggest that eastern european attendance has either remained low or declined he found similar patterns in many eastern and western european countries noting that the czech republic east germany estonia and russia are highly secularized similar to their counterparts in western europe and demonstrate very low andor declining rates of attendance in subsequent analyses of church and religion in an enlarged europe survey gallup wvs and eurobarometer data pollack found evidence for declining attendance in eastern europe linked to birth cohorts as younger generations are less likely to attend pollack however also found evidence for a small temporary reversala period effectfor some eastern european countries as some briefly returned to the church after the fall of their communist regimes this slight uptick in attendance was also detected in analyses of hungarian attendance rates from wvs and issp by froese who noted that this period effect reversed itself relatively quickly burkimshers analysis of evs and ess data for 24 european countries found evidence for increasing rates of attendance in russia and to a lesser extent romania and bulgaria but also decreasing rates of mass attendance in poland and slovenia and low and stable attendance in other postcommunist countries like estonia and the czech republic thus in summary findings in eastern europe also fail to demonstrate any strong and consistent pattern of increased attendance most eastern european countries resemble those in western europelow and stable or declining attendance others with relatively high attendance like poland have attendance rates similar to higherattendance western european countries and demonstrate similarly negative trends only in three countries namely romania russia and bulgaria is there somewhat consistent evidence of increasing attendance notably the latter two of these countries have very low attendance rates on par with those in northern europe australia and new zealand australia and new zealand could be readily grouped with canada and the uk unsurprisingly perhaps given their shared history and culture however somewhat fewer crossnational comparisons include these southern hemisphere countries norris and inglehart place australian and new zealander attendance near protestant europe and canada as highly secularized and lowattending countries trends in australia demonstrate longterm reductions in the attendance rate inglehart and baker noted dramatic change in australian attendance over the 1980s and 1990s about 40 percent of australians reported at least monthly attendance in the 1981 wvs but this rate was reduced to 25 percent by the mid1990s smith found monthly attendance in the same data set and years declining from 28 to 17 percent weekly attendance trends are less clear analyzing 1981 wvs data campbell and curtis reported a weekly attendance rate of 17 percent and smiths analysis of 1991 and 1998 issp data reported weekly attendance rates of 13 and 19 percent respectively new zealand shows patterns of low stable attendance similar to those in western europe in an analysis of 1991 and 1998 issp data vaccarino kavan and gendall found that about 20 percent of new zealanders attend regularly defined as once a month or more often using 2008 issp data ward found this rate stable for the following decade smiths analysis from the 1991 and 1998 issp found weekly attendance in new zealand at 17 and 13 percent respectively in sum like the european countries that colonized them neither australia nor new zealand demonstrate evidence of increasing religious behavior rather trends suggest reductions in already low rates of church attendance latin america subsaharan africa and asia unfortunately little can be said about trends in attendance rates outside this list of western democracies and postcommunist european countries while crossnational survey projects have begun collecting data in latin america africa and asia little published work has analyzed trends in the religious behavior measured by these studies this oversight is especially troublesome given recent research linking religiosity and religious behavior to existential security this revision to modernization and secularization theories posits that as material needs are met in a society existential security rises the compensatory need for religion is diminished and attendance is reduced smith and inglehart and baker presented rates of attendance from countries with available data in wvs seven from latin america one from asia and one from africa the south american countries in wvs demonstrate a set of mixed trends argentina has participated in four waves of wvs1981wvs 84 1990wvs 93 1995wvs 97 and 1999wvs 2004longer than other south american countries from the earliest two surveys31 and 32 percent respectivelyto the latter two24 and 25 percent respectivelyargentinian weekly attendance trends look somewhat similar to catholic countries in europe with declining attendance over these three decades inglehart and baker found a similar trend in monthly attendance for argentina using the same wvs data data are available for brazil and venezuela at two points and for each country these two points show relative stability 4 in brazil weekly attendance increased negligibly from 33 percent in the early 1990s to 36 percent in the late 1990s whereas in venezuela attendance remained stable at 31 percent over the two surveys in the late 1990s and early 2000s analyses for chile columbia and peru are also limited to only two data points similarly stable although at a higher level of attendance monthly attendance in chile declined negligibly from 47 percent in the early 1990s to 44 percent in the late 1990s weekly attendance rates in columbia and peru remained stable 45 and 43 percent respectively in the late 1990s and 47 percent for both countries in the early 2000s mexico and puerto rico show some evidence of increasing attendance rates mexican wvs data show increased attendance from 43 percent in the early 1990s to 46 percent in the late 1990s to 56 percent in the early 2000s although inglehart and baker found that monthly attendance declined from 74 percent in 1981 to 65 percent in the late 1990s weekly attendance in puerto rico increased from 52 to 57 percent from the late 1990s to the early 2000s two countries one each from africa and asia round out the discussion of trends from outside the west these are the only countries included as both are predominantly christian and thus comparable to the countries previously discussed wvs data from the late 1990s and early 2000s show stable attendance rates in south africa 54 and 52 percent respectively also using wvs inglehart and baker found increased monthly attendance over a 4 inferring trends from two data points is unwise so this discussion should be taken with the necessary caveat longer span from 61 percent in 1981 to 70 percent in the late 1990s the highest current rates of attendance of all the countries reviewed here are from the philippines in the late 1990s and early 2000s weekly attendance rates reached 84 and 80 percent respectively explaining patterns in attendance religious tradition was previously introduced as a potential cause of variation in attendance rates and trends pollack found that predominantly catholic countries like poland and romania demonstrate relatively high attendance comparable to their western european catholic peers using esrc eastwest programme data need and evans examined attendance in 10 postcommunist countries five predominantly orthodox and five predominantly roman catholic their analyses found that catholic countries tend to have higher attendance than the orthodox countries with poland demonstrating far and away the highest rate of attendance bruce examined 17 postcommunist countries using 19951996 wvs data he found that predominantly catholic countries like croatia slovenia and lithuania have higher rates of attendance by around 30 percent than do traditionally orthodox countries like russia and serbia and pluralistic countries like latvia and estonia comparing evs data for postcommunist countries titarenko also found evidence for higher although declining rates of mass attendance in catholic countries than in predominantly orthodox countries she argues that this distinction is due to catholics ability and desire to educate adherents belief systems and the inability or lack of desire in orthodox churches to do the same halman and pettersson agree that european religiosity is related to religious tradition rather than an eastwest dichotomy protestant and orthodox countries are more secular and catholic countries remain more religious halman and pettersson performed a cluster analysis of church attendance and religiosity with 1990 evs data from 23 countries they summarized eight postcommunist countries in five clusters most secular more secular middle more religious and most religious in addition to denomination modernization also emerges as a useful concept in explaining bycountry differences in attendance using evs data conway linked slovenias pattern of declining mass attendance first to the communist regimes enforced secularization and later to a spontaneous secularization caused by modernization and its concomitant effects of urbanization and 5 the authors note that ukraine is orthodox in general expansion of education that started before slovenias integration in the eu norris and inglehart too argue that the predictors of religiosity based in modernization theory used in western europe work in the east too attendance is well explained using human development factors at the societal level as well as the individual level notably they included religious factors like religious tradition as well as demographic factors in their explanatory model one such demographic factor gender is often linked to differentials in practiced religion as women are more likely to attend religious services yet this gender gap does appear to be shrinking as gender loses its causal or at least predictive value voas mcandrew and storm compared about 40 countries using evs ess and issp data to determine whether the gender gap in attendance was shrinking growing or stable there is some evidence that the gap in europe is narrowing likely a function of womens increasing material security measurement error overreporting but can we take these estimates at face value in each country examined the trends discussed all rely on survey selfreports whether the respondent is reporting his or her frequency of attendance to an interviewer on the telephone or facetoface across a diningroom table or by writing on paper or clicking on a radio button on a website selfreported rates of religious behavior can include measurement bias moreover even if questions are deemed equivalent errors may not be survey error may be random in one country but systematic in another most of the analysis of measurement error of religious service attendance has focused on the united states this research program has compared survey estimates to those based on data collected by the religious organizations themselves and investigatorinitiated counts at churches on sunday mornings in each of these investigations survey reports of attendance were found to be about double the actual rate of behavior in the face of critiques of these methods of validating the survey report other studies have turned to timediary data as a potential comparator unlike conventional survey questions chronologically based datacollection procedures like time diaries eschew direct questions about specific behaviors of interest avoiding prompting selfreflection on the part of the respondent and arguably yielding less biased and higherquality data presser and stinson compared diary and survey estimates from the united states in the early 1990s their analysis supported the findings of hadaway marler and chaves arguing that misreporting error produces an increase in attendance claims of almost 50 percent brenner extended the work of presser and stinson comparing four decades of data from the multinational time use study with survey data from 14 countries brenner found evidence of large and consistent overreports in the american survey data varying between about a quarter and a half of the survey report depending on the survey and year he also found an overreport in canada although less consistent and somewhat smaller than that found in the united states italy 6 and ireland also demonstrated statistically but not substantively significant rates of overreporting as the effect sizes were negligible subsequent work using a more complex method for computing overreporting has supported the existence of an overreport in italy and the united states finally little research exists testing the validity of selfreported religious behavior outside europe and north america however findings from brenner suggest that overreporting of religious behavior does occur in nonchristian societies as well summary of attendance rates and trends in summary acknowledgment of measurement errors makes us attendance look more like that in europe on par with italy and spain when placed into the spectrum of european attendance rates with ireland and poland near the top and estonia and scandinavia near the bottom the united states looks unexceptional moreover a review of trends in attendance rates shows little support for widespread sacralization most countries reviewed here fall into one of two types low and stable attendance including many northern european countries as well as some from eastern europe and declining attendance including most of europe as well as the united states canada australia and new zealand a smaller set of countries trends primarily from south america could be described as stable but somewhat higher than the european average only three countries romania bulgaria and russia can be described as having increasing attendance and the latter two have low attendance rates on par with countries in northern europe conclusion and future directions to further elucidate the future of religious service attendance the continued extension of this research program into the developing world is desperately needed the lowesthanging fruit are the traditionally christian countries of 6 in the case of italy the sample sizes approximately 10000 and 16000 could cause a finding of statistical significance where no meaningful difference exists west asia while included in relatively few crossnational religious comparisons these countries could be readily compared to other postcommunist countries of eastern europe other convenient comparisons can be found in central and south america many of these countries have recently joined one or more of the crossnational survey programs and even more are members of a regional survey program the latinobarometer the region includes highly developed countries rapidly developing countries and one of the worlds poorest least developed countries other predominantly or majority christian countries in subsaharan africa some of which participate in the crossnational survey programs outlined here should also be included these include south africa which was included in a study discussed here but also ethiopia ghana zambia rwanda and zimbabwe which were not a somewhat more difficult to include but just as important extension to this research program would include nonchristian countries starting with the other abrahamic religions israel would be relatively easily included as it participates in a number of crossnational survey programs and the nature of the practice of judaism may lend itself well to a comparative analysis with predominantly christian countries equally or more important would be an malaysia research could readily compare religious behavior between these countries and with care those on which this synthesis has focused additionally religiously pluralist countries like burkina faso nigeria and tanzania could also be included in analyses and perhaps quite productively so being certain to account for religious affiliation both within and between countries other asian countries in the hindu and buddhist traditions as well as other religious traditions that inglehart refers to as confucian as well as vietnam may be quite difficult to compare with operationalizations of western religious behavior however some enterprising social scientists with deep knowledge of one or more of these cultures may find or create equivalent measures up to such a task certainly the continuing development and extension of these crossnational survey programs is far too great an opportunity to allow to pass religious service attendance is not inherently more important than other ways of operationalizing religiosity like affiliation other behaviors or beliefs it is only used here given its relative ease and ubiquity of measurement and potential for validation other research could use alternative operationalizations to pursue a similar question of the comparison of crossnational trends affiliation given the attention paid in the research literature to the growth in the unaffiliated in the united states and elsewhere may be a particularly fruitful research focus crossnational comparisons even those limited to traditionally christian countries may still encounter inequivalences first countries included here differ greatly in their wealth with north american and european countries australia and new zealand being more wealthy and many african asian and latin and south american countries being less wealthy measures of country wealth including gross domestic product are one factor considered in recent research by inglehart and his colleagues linking changes in traditional religiosity to human development factors however additional research could be undertaken to understand the causes of differences in religiosity that are associated with variations and change in gdp and other measures of country wealth second religion has played different roles in the political environments of the countries included here including differences in the regulation of the religious marketplace and relationships between religious and political groups relatedly some differences between countries may be linked to evangelical movementswhere they have arisen and where they have notas well as the differences between these evangelical movements and countries traditional denominations these traditional denominations and evangelical movements may have different relationships with political systems and parties and these affiliations add additional sources of inequivalence between countries perhaps because of these countrylevel idiosyncrasies it is difficult to consider politicalreligious associations as part of a crossnational analysis like this one future research whether singleor multicountry should to the extent possible understand that these histories have purchase in understanding religious trends future research may also examine an important topic not included in the current review the effect of immigration on religiosity in both sending and receiving countries research by van tubergen and colleagues and others suggests that religious affiliation is linked to immigrants origin and destination however future research could examine whether and how this has changed over time moreover many sending and receiving country pairs have long unique histories and should be considered in future work these limitations and caveats of the present research notwithstanding crossnational comparisons like these are arguably useful the landscape view presented here can be an effective call for future research to dig behind these trends and better understand the nature of religious behavior in each of these countries comparisons of the trends between countries that take their differences and similarities into account allow us to better understand their causes for instance by understanding trends in three societies with a shared history language and culturethe united states canada and the ukas well as the similarities and differences in these countries we can begin to understand why the united states is the most religious the uk the least and canada somewhere in between while they share many of the factors often considered when differences in religiosity are explained they have important differences including some of the factors mentioned in the previous paragraphs by looking to both the similarities and the differences we can better understand not only the religiosity in these countries taken together but also religiosity in each country individually in conclusion this landscape view further reduces american religious exceptionalism as well as european irreligious exceptionalism as descriptive tropes to again paraphrase demerath the united states and european countries are no more or less exceptional than any other country discussed here all in terms of kind rather than degree moreover to extend chavess comment about american trends whether the overall trend as well as those from some individual countries should be characterized as decline or stability can be reasonably argued but there is no widespread or consistent trend of increasing attendance in the countries and studies reviewed here

the nature of religious change and the future of religion have been central questions of social science since its inception but empirical research on this question has been quite americancentric encouraged by the conventional wisdom that the united states is an outlier of religiosity in the developed world and more pragmatically by the availability of survey data the dramatic growth in the number and reach of crossnational surveys over the past two decades has offered a corrective these data have allowed research on religious trends in the united states canada and europe putting american trends into comparative relief this research synthesis reviews the past quarter century of crossnational comparative survey research on religious behavior focusing on religious service attendance as a commonly measured behavior that is arguably more equivalent across societies and cultures than other measures of religiosity the lack of evidence for religious revival is highlighted noting instead declining rates of attendance in the united states and canada and either declining rates or low bottomedout stability in western europe most of eastern europe and australia and new zealand finally countries in latin america africa and asia are discussed to the extent that research allows before a call for future researchin these places in particularis made in order to correct for the western and christian focus of much of the research on crossnational religious trends

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introduction overview currently within the united states more than 20 of adults are living with some form of disability 1 as defined by the centers for disease control and prevention a disability is any condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them 1 although living with a disability can impact participation in many parts of your life it does not prevent most persons with disabilities from participating in information sharing participating in community engagement and providing support on social networking sites in fact research suggests the use of sns is generally high among persons with disabilities 2 which includes sns such as online discussion forums chat rooms and facebook with developing technology and sns the ease of communication has drastically increased over the last few years and the internet has become an increasingly common platform for the formation of electronic peertopeer or online communities 34 online communities are social networks formed or facilitated by means of a technical platform through which groups of people with similar interests can establish social relationships and connect and interact with one another 35 through the development and utilization of online communities we have seen a shift in the way social support is sought organized and communicated resulting in online communities that function similarly to physical or inperson communities 67 social support and online communities social support is a theoretically complex and multidimensional construct that is often defined as the aid and assistance exchanged through social relationships and interpersonal transactions 8 9 10 although inperson social support has been of interest to researchers for several decades a shift toward investigating and understanding social support in an online context has begun to occur online social support has been defined as the internetfacilitated receipt of both tangible and intangible assistance from people in ones social network 611 numerous studies have found that online communities provide a platform for social support to be communicated 45 12 13 14 and that similar types of social support found in offline settings also exist in online contexts 461314 social support whether inperson or online can generally be divided into structural and functional aspects 61516 structural aspects include the extent to which individuals are situated within or integrated into social networks this can be the size and structure of a social network such as density and composition social integration or embeddedness 15 17 18 19 functional aspects include the psychological and material resources available from an individuals interpersonal relationships functional aspects refer to the types of social support such as esteem and emotional informational instrumental support and belonging 46 9 10 11 15 17 18 19 definitions for each type of social support can be found in table 1 the provision of social support is considered one of the important functions of social relationships 910 which can be measured by structural support functional support or a combination of both table 1 social support types and their accompanying definitions definition type of social support communications from others that convey being held in high esteem offering help with ones emotional state or expressing acceptance caring liking respect concern empathy or sympathy 69101920 esteem and emotional support offering help in the form of advice constructive feedback or affirmation new information or perspectives or references to new resources 69101920 informational support provision of tangible aid and services such as offering financial aid providing material resources or taking on a responsibility 691019 instrumental support conveys a sense of social belonging and having others to engage with in shared social activities 69 belonging support the benefits of social support have been repeatedly affirmed in the literature 13 social support has been associated with predicting and promoting good physical and mental health reducing and preventing illness moderating life stress and improving quality of life 815171821 in general however persons with disabilities are more likely to have limited access to social support and its benefits they may experience a lack of access to social support because of misconceptions about disabilities stigma surrounding disability feelings of embarrassment or social isolation and physical barriers 1622 the internet could circumvent these barriers by providing a useful alternative for persons with disabilities to access social support and interact in a way that may not be possible offline 131422 due to the availability and proliferation of online communities a new outlet for social support can be accessed persons with disabilities can utilize the internets extensive communication capabilities to access information and develop online support groups with other persons with disabilities through online platforms 1322 the formation of these groups may not only offer support and communitybuilding but also link users to an increasing amount of resources knowledge services shared experiences and social exchanges 3 4 5 in addition computermediated environments afford them the ability to break down physical and geographic barriers to participation including the constraints of time and distance which might otherwise exist 1623 objective although it is known that persons with disabilities utilize sns 2 it is still unclear how they utilize the various forms of online communication for support there is a lack of research qualitatively assessing the interactions occurring among individuals within these online communities as well as the variation of quality and content from site to site 13 with the rise in popularity of online support groups and the everchanging nature of the internet there is a need to explore the experiences of persons with disabilities in various supportive communication settings the objective of this study was to explore and compare the interactions and connections among online support groups to understand how persons with disabilities are utilizing different sns to gather and disseminate information and foster community support specifically 3 sns were selected for comparison facebook groups online discussion forums and online chat rooms these platforms were selected because of their popularity as platforms for the formation of online support group communities 351420 all 3 platforms offer users distinct environments for various types of social support to be exchanged in addition social support has been shown to exist among each of these online platforms to some degree 451820 methods description of social networking sites due to its popularity and accessibility facebook has become a common platform for the organization of online support groups 24 facebook offers both synchronous and asynchronous features to its users such as the ability to react to comment on or share a post compared with online discussion forums and online chat rooms facebook is a less anonymous platform although the use of facebook as a means for webbased interaction has increased in popularity over the past decade online discussion forums are still regularly used by approximately 20 of online users in the united states 25 discussion forums are an asynchronous communication platform whereby one person writes a post which is then answered by other members thus creating a thread of posts related to one subject 14 discussion forums are a common platform for online support groups they have been shown to be a useful source of support 1425 and to be helpful to users because they can provide connections to others with similar experiences 26 online chat rooms that cater specifically to persons with disabilities also exist 22 chat rooms are a synchronous form of communication that is communication occurs in real time and simultaneously between users both discussion forums and chat rooms afford their users anonymity 25 data collection the study was approved by the institutional review board of the university of florida during the approval process the information being obtained for this study was deemed public record and therefore exempt from informed consent all data were deidentified before being analyzed by the researchers facebook groups general disability support groups were targeted for the study to increase the generalizability of the information posted these were groups that did not identify themselves for a specific disability the term disability support group was searched using the facebook search bar function the facebook groups had to have at least 6 months worth of data to collect to be included in this study in total 3 disability support groups on facebook were initially identified according to group type and group size names of the specific groups have not been included to protect all individuals identities upon review of the identified support groups only 1 group fully met our inclusion criteria of having at least 6 months worth of data to collect therefore the other 2 groups were excluded from this study the included facebook group had 11765 followers at the time of the study and was an online support community for anyone who had a disability or supported someone with a disability screenshots of posts comments to posts and reactions on posts were captured to assist with analyses after 6 months worth of data were collected retrospectively there were a total of 133 facebook posts all of which were analyzed all postings were deidentified to protect participants identities discussion forums the discussion forums were selected through the google search engine using the keywords disability and disability support group the discussion forums had to be publicly available and have active discussion to be included in the study out of the 4 discussion forums initially identified only 2 met the inclusion criteria there was no set time period for data collection from the forums discussions from the designated forums were chosen based on high activity levels discussions from the forums were copied and pasted verbatim for analysis a total of 116 discussion forum posts were collected and analyzed all postings were deidentified to protect participants identities chat rooms similar to the discussion forums selection online chat rooms were chosen through the google search engine using the keywords disability and disability support group chat rooms had to be publicly available and have active participation to be included in the study a total of 2 chat rooms were selected both meeting the inclusion criteria it was predetermined by the researchers that a minimum of 60 hours of live session chat room data should be collected chat room data were collected during live sessions at various times on weekdays and weekends to ensure that all forms of conversations and all active participants were captured in the data collection process to capture an accurate representation of communications occurring among chat room users the researchers collected live session chat room data at different times of the day 20 hours of data were collected in the morning and early afternoon 20 hours of data were collected in the midday and evening and 20 hours of data were collected at night each of these time points were collected on each day of the week discussions from the online chat rooms were copied and pasted verbatim for analysis all postings were deidentified to protect participants identities data analysis the constant comparative method was used to analyze the content from the facebook support group discussion forums and chat rooms to reduce the data into manageable units and coded information 27 28 29 to begin this process trained researchers independently opencoded the facebook posts and the discussion forum and chat room posts open coding has been defined as the process of breaking down examining comparing conceptualizing and categorizing data 27 28 29 upon completion of open coding major themes and subthemes were carefully and purposefully developed from these codes for the facebook discussion forum and chat room posts coding was continued until saturation of the data was met and no new themes emerged 27 28 29 to accurately represent the discussions persons with disabilities had on each platform the information users posted was not factchecked by the researchers this was decided as acceptable by the researchers because of the focus of this study being on the content of what was being posted and shared and the ways persons with disabilities utilized platforms not on the accuracy of what was being posted results facebook support group all facebook support group posts were deidentified and no user names were included instead quotes are presented as blockquotes with the participant identifier as user post after the quoted text to indicate an original comment quotes taken from the facebook support group underwent minor modifications such as corrections to spelling or grammatical errors and removal of explicit language the researchers decided to modify posts in this way to enhance readability of the posts alleviate any confusion to the reader and protect the privacy of all users quotes were only modified as long as the context of the post did not change among the 133 posts analyzed the constant comparative method revealed 4 major themes as displayed in textbox 1 the 4 themes that emerged through analysis of the facebook support group included mutual and shared experiences societal concerns awareness and health care policy mutual and shared experiences mutual and shared experiences posts centered on participants sharing details regarding their own disabilities and personal stories this was often as a way to inspire motivate and relate to others the following is an example of 1 of these posts by a facebook group member just societal concerns posts classified under societal concerns included participants expressing their concerns regarding societys interactions with their disability group members posted about concerns or excitement they had regarding inclusivity and accessibility in society i online discussion forums all posts from the online discussion forums were deidentified and no user names were included in this paper quotes are presented as blockquotes with the participant identifier as user post after the quoted text to indicate an original post by a forum user the same steps taken for the modification of facebook posts were also taken for the modification of discussion forum posts from the 116 discussion forums posts analyzed 3 major themes were revealed emotional outlet and support health and quality of life emotional outlet and support the theme of emotional outlet and support was characterized by participants using connections provided through the forums for social support advice seeking and expressing emotions forum members posted about psychological stress and emotions and often received feedback and advice from others for example 1 member used a discussion forum as a space to express their process of selfrealization to other members people health the theme of health can be described as participants utilizing the online discussion forum to share any physical mental or health carerelated stories it was common for forum users to post about their specific disability and the symptoms they experience many users were shown discussing health by describing their medical interactions medical interactions ranged anywhere from their disability diagnosis by a professional to symptom management in the forums participants also shared their personal medical diagnosis stories for example 1 user described their injury and disability sustained from a drunk driving incident i have four tbi traumatic brain injury ptsd herniated disks throughout my back and most of my neck alone with a variety of knee hip injury the joys of being hit by a drunk driver user post in addition many users mentioned mental health and mental illness in their posts these posts comprised mental diagnosis disclosure the emotions associated with such diagnoses and seeking support from others with similar mental health experiences well i have a learning disability quality of life discussion forum members posted on discussion boards about their perceived quality of life and how their disabilities affected their daytoday lives in both positive and negative ways forum members also shared about how accessibility could be positive or negative structural and environmental changes to make places more accessible for persons with disabilities were perceived as positive but the lack of accessibility in most places was perceived as negative i am lucky enough to have moved in when the big adaptations were in place i am extremely grateful for a fabulous wet room that i can access even on a wheelchair the only addition made to this after i moved in was a bio bidet this is a godsend for me with the personal problems i have the simple act of being able to attend to your own toilet needs is a great boost to ones self esteem user post in addition discussions forums were used as a way to share information with persons with disabilities about opportunities to participate in various activities and hobbies such as jobs sports or entertainment illustrating a willingness to help one another online chat rooms the same steps taken for the modification of facebook posts were also taken for the modification of chat room posts in addition for chat rooms specifically it was common for multiple conversations to be going on at once to eliminate confusion the researchers deleted any comments not relevant to the ongoing conversations quotes from the online chat room data presented in this section are accompanied by anonymized identifiers these were created to protect the identities of users from the 60 hours of data collected from the 2 online chat rooms 3 major themes emerged chat room interactions for emotional outlet and support health and quality of life emotional outlet and support the theme of emotional outlet and support was characterized by chat room conversations where participants sought social support and interactions for physical mental and environmental struggles from other participants the chat rooms served as spaces for participants to vent to one another share feelings of distress and coping mechanisms and receive feedback and advice from others when solicited moreover they offered spaces for support through small talk and member interactions participants engaged in exchanges with other members by sharing information regarding everyday life such as this interaction in one of the chat rooms seeking experiential advice about finding a job as a persons with disabilities did you have a bad experience trying to find a job user a i was being thrown many curved balls user b that with determination user b sometimes people take my kindness as a weakness and they get surprised user a it can be done user b some people do use peoples kindness to gain from user b especially the people around my neck of the woods give them an inch and they take a lightyear user c yeah i admit i lost a lot of my confidence when i became disabled but just running this household i am getting it back user a health the theme of health in online chat rooms was characterized by participants posting their daily physical medical and mental signs and symptoms of disabilities as a way of sharing their health experience with other users participants engaged in the online chat rooms by describing their specific disability the symptoms associated with it the way they managed their symptoms and their interactions with medical professionals the discussion below demonstrates the backandforth between users about their disability stories are collect proof first without letting on that you know user k especially among participants in the chat rooms personal information regarding family relationships and significant others was shared chat room members expressed how certain factors relating to family relationships and significant others influenced their quality of life discussion principal findings in this study we explored the ways in which online communities were utilized by persons with disabilities to facilitate communication interchange disseminate information and foster community support the results indicate that persons with disabilities are utilizing the 3 platforms for various interactions on the basis of the findings of this study the medium with which the individual is interacting influences the individuals interactions they are likely intentionally choosing to interact on a platform based on the functions it offers it is possible that specific platforms serve specific purposes that may not be interchangeable 25 the facebook support group for persons with disabilities emphasized mutual and shared experiences societal concerns raising awareness and concerns about health care policy in the united states people in the facebook group seemed willing to be somewhat vulnerable within this online community setting sharing stories of personal distress independence and support however interactions within the facebook group appeared much more structured and superficial than discussion forums or chat rooms the perceived injunctive norms might contribute to the structure and superficiality among facebook support groups 3031 in addition the facebook group provided a safe space for users to respond to news stories and articles about abuse violence and discrimination against persons with disabilities as well as share their concerns or excitement regarding inclusivity and accessibility in society it is possible that this platform allows people to share about certain topics without fear of criticism negativity or backlash from others this may not be the case if one of them were to post similar content on their personal facebook timeline the most common forms of interaction between members of the facebook group included requesting and providing information sympathizing with other users raising awareness and advocating for persons with disabilities and generating support through shared experiences and concerns the interactions between members correspond to both informational and esteem and emotional social support these findings align with research conducted by mustafa et al 24 who found that facebook support groups for parents with autism spectrum disorder were commonly used for informational support emotional support and sharing of personal experiences the findings are also in line with a different study which found that facebook as an sns was an online environment well suited for the exchange of informational support 20 although not as common instrumental support was sought by some facebook group members this was exemplified by members sharing their financial support pages most likely as a request to receive instrumental support from the online community in comparison the interactions within online discussion forums and chat rooms were less structured than the facebook support group and more similar in the way persons with disabilities utilized them the same 3 themes emerged in both the platforms emotional outlet and support health and quality of life both platforms were most commonly used as venues for persons with disabilities to relieve psychological stress express themselves emotionally and share and vent about their experiences in hopes of receiving positive support feedback and relief from others members seemed especially grateful for the existence of a safe space where mundane everyday interactions could take place and yet the individuals still felt a sense of belonging and support by their community although both platforms exhibited interactions characterized by members responding both positively and negatively to others these types of interactions were most common among online chat room users these interactions seemed accepted and expected by members of the chat room exemplifying a comfort among chat room users to offer support in the most candid ways possible this familiarity seemed to encourage real and honest connections between users similar to a group of tightknit friends these findings demonstrate the existence of esteem and emotional belonging and informational social support among discussion forums and chat rooms interactions in discussion forum and chat room settings are anonymous a feature that has been found to be valuable to persons with disabilities on these platforms 14232532 anonymity is not a feature of facebook as your profile is linked to your name and usually includes a picture of yourself it is possible that interactions are more candid and unstructured among forums and chat rooms because of the comfort and protection anonymity can provide for users 14162532 this could also explain the prevalence of discussions surrounding mental health issues on both forums and chat rooms and the lack of such discussion on the facebook group members of the forums and chat rooms mentioned their experiences with mental health almost daily whereas members of the facebook group seldom posted about mental health and mental illness mental health and mental illness discussions were most prevalent among chat room users compared with any of the other support groups in general chat room discussions of mental health and mental illness were more indepth and descriptive with participants offering more personal details participants logged into the chat room would respond to others in supportive consoling ways and attempt to offer helpful advice to disclosing users discussion forum posts were more surfacelevel in their discussion of mental health and mental illness with participants offering little insight into their own personal experiences facebook group posts were mostly aimed at spreading awareness as opposed to disclosing ones own personal experience with mental illness these findings suggest that a safe and anonymous online environment might help facilitate engagement in discussions about commonly stigmatizing and taboo topics limitations this study is not without limitations first the data are subjective based on the researchers interpretations as is the nature of qualitative research the importance of using qualitative methods for this study however should not be understated the content gained from a qualitative process provides a more indepth and nuanced understanding of how facebook support groups discussion forums and chat rooms are used by persons with disabilities although qualitative studies are relevant and important in their own right quantitative research is also necessary as a next step future research could investigate how the effectiveness of online social support can be maximized for persons with disabilities second as only 1 facebook online support group was analyzed in this study we cannot generalize these findings to all support groups on facebook discussion within this facebook group was not necessarily encouraged between members which might indicate a more passive approach to participation among facebook support group users this could potentially limit the usefulness of support offered through this domain or influence the type of support that is perceived or received it is possible that users seek out support groups on facebook because of this type of participation however further research is required to understand how and why users seek out certain forms of online support and the roles active and passive participation play in the overall perception and reception of social support third because of the predetermined date constraints and the difficulty collecting data from live chat rooms only a few groups for each type of sns were analyzed and compared as this was a pilot study the number of groups per sns needed for the researchers to capture a snapshot of what was occurring in online disability support groups was small in the future more groups should be analyzed and compared to enhance the explanatory power and generalizability of the study it might also be important to investigate online social support among sns groups as it relates to specific disabilities future studies could compare online support groups among these 3 sns by type of disability to understand the similarities and differences of how individuals with varying disabilities interact this could provide an even more nuanced understanding into the ways sns are used for social support by persons with disabilities implications of findings this study allows us to focus on and determine beneficial ways to incorporate sns into treatment foster social support and develop awareness among the community of persons with disabilities future directions highlight the potential to intervene with this population through social network mediums future interventions can be developed utilizing facebook discussion forums and chat rooms as mediums depending on the desires and needs of the population of persons with disabilities moreover the reach of these webbased interventions and groups can be easily assessed because of increasing ease of access to the internet online support groups are not bounded by space constraints they are a medium where perspectives experiences and viewpoints are welcomed and diversity is encouraged while also promoting a feeling of universality among members 32 online support groups offer the ability to increase support for persons with disabilities while simultaneously breaking down the geographic transportation and stigmatizing barriers this population faces facebook support groups discussion forums and chat rooms represent 3 unique platforms where social support can be facilitated via social networks interactions on each of the platforms displayed elements of each of the 4 types of social support 69 indicating the ability for social support to be facilitated among sns as social support is being provided on each of the online platforms studied xsl • fo renderx online social support has been suggested to have similar benefits to those of inperson social support including benefits to health and wellbeing 616182533 disability research has shown that social support has the ability to either alleviate or exaggerate disability symptoms depending on several factors 34 according to the 3 theoretical models of social support 910 social support can influence health in many ways as the nature of the study was qualitative we could only speculate how the interactions of persons with disabilities via these platforms might have positively influenced their health the stress prevention model posits that social support may provide an individual with resources to avoid or reduce exposure to certain stressors reduced exposure to stressors in turn is associated with enhanced health 910 through the facilitation of social support among online communities group members may be able to provide other persons with disabilities with the resources they need to avoid or reduce their exposure to some types of stressors this could be by influencing cognitive processes encouraging proactive coping or decreasing exposure to secondary stressors 9 there is also the stress buffering model which proposes that social support can act as a stressbuffering agent in this model social support provides resources that help an individual appropriately cope with stress which buffers the association between stress and healthrelated outcomes 91015 the provision of social support from online support group members could enhance ones coping resources and interpretation of their stressful situation thus weakening the harmful effects of stress on health and wellbeing 915 finally the direct effect model suggests that social support is effective in a more general sense regardless of stress this model is concerned with the ways in which membership in a social network and an individuals sense of connection has an overall beneficial effect on their wellbeing health and healthrelated outcomes 91015 by being a member of an online support group persons with disabilities might have overall a greater sense of connection and feel cared for and supported by others 9 sns allow persons with disabilities to mobilize social support in ways similar to traditional offline settings and in ways that are unique to online contexts as social platforms continue to develop grow and evolve they have the potential to help reduce and possibly eliminate many of the barriers to social support experienced by persons with disabilities in doing so these platforms could have lasting impacts on both their health and wellbeing conflicts of interest none declared abbreviations

background approximately 1 in 5 adults in the united states are currently living with a form of disability although the americans with disabilities act has published guidelines to help make developing technology and social networking sites sns more accessible and userfriendly to people with a range of disabilities persons with disabilities on average have less access to the internet than the general population the quality content and medium vary from site to site and have been greatly understudied due to this it is still unclear how persons with disabilities utilize various platforms of online communication for supportthe objective of this study was to qualitatively explore and compare the interactions and connections among online support groups across facebook discussion forums and chat rooms to better understand how persons with disabilities were utilizing different sns to facilitate communication interchange disseminate information and foster community support methods facebook groups discussion forums and chat rooms were chosen based on predetermined inclusion criteria data collected included content posted on facebook groups forums and chat rooms as well as the interactions among group members data were analyzed qualitatively using the constant comparative method results a total of 133 facebook posts 116 forum posts and 60 hours of chat room discussions were collected and analyzed in addition 4 themes were identified for facebook posts 3 for discussion forums and 3 for chat rooms persons with disabilities utilized discussion forums and chat rooms in similar ways but their interactions on facebook differed in comparison they seem to interact on a platform based on the specific functions it offers conclusions interactions on each of the platforms displayed elements of the 4 types of social support indicating the ability for social support to be facilitated among sns however the type of social support varied by platform findings demonstrate that online support platforms serve specific purposes that may not be interchangeable through participation on different platforms persons with disabilities are able to provide and receive social support in various ways without the barriers and constraints often experienced by this population

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which ended the threeyear bosnian war analysis of state department documents released under the freedom of information act and interviews with key architects of the dayton peace accords suggest that a small informal war crimes working group of lawyers and midlevel officials emerged within the lower bureaus of the state department in the early 1990s these social actors analysed and interpreted war crimes as human rights claims they redefined mounting human rights atrocities as breaches of political citizenship by the perpetrator state this distinctive political construction of hard human rights by this particular group of us elites had the effect of shifting the human rights narrative away from a victimcentred framework based on dignity or frailty to one that was perpetrator or state focused in this way midlevel state department officials social agency served as an important location or site of human rights construction and embeddedness we draw primarily on us state department documents un commission of experts reports and indepth interviews with thirteen individuals including key architects of the dayton process and us human rights policy state department archival documents regarding us bosnia policy between december 1991 and february 1997 and released under the us foia contain 213 reports policy analyses internal memos telegrams and legal briefs concerning human rights and war crimes they are a partial release of a larger repository that remains classified so we stress that our assessments are necessarily limited and tentative in anticipation of the full archival release our approach was premised on the assumption that the practice of human rights lies in their embeddedness in social locations of political power and in the ways in which this power is exercised legitimated or constrained put differently we sought to examine the political culture and institutional locations that shape the categories available for the construction of expertise and knowledge around human rights and war crimes how do structures of power deal with evidence of mass atrocity and in particular how did the state department become a site of human rights knowledge production after a theoretical contextualization we explore the social agency of this war crimes working group and their application of putting cruelty first first in terms of an interpretive narrative of the perpetrator then of the victims and finally through their construction of war crimes as politicallyinflected human rights violations a perpetratorcentred framework and agency in human rights theorizing sociological scholarship working toward a sociology of human rights has explored among other things the power or organizational arrangements underpinning human rights claims human rights universalist foundations its discursive dimensions the normative nexus between human rights and citizenship its potential for a developing a public sociology of human rights and the theoretical and practical implications of qualitative versus quantitative approaches to human rights and yet it has paid comparatively little attention to the ways in which social agency can define human rights and produce a social knowledge around them that is to how rights may be interpreted and embedded by social actors our data suggests that a particular interpretation of human rights emerged in a particular social context as a value constructed and defined by a key social constituency one whose role in interpreting and shaping rights was determinative more specifically a group of internationalhuman rights lawyers in midand lowlevel bureaus within the state department effectively merged war crimes and human rights by viewing them through a politically universalist statecentred prism that made the prevention of cruelty a policy priority while this interpretation reflected a distinctive social contract rights culture as vernacularized through the us legal profession in the early and mid1990s in practice it also constructed a narrative around war crimes evidence that moved away from a universalist focus on victims human dignity and towards a more perpetratorcentred political narrative in which citizenship rights were violated by a state held to be accountable so in sociologically acknowledging the utility of human frailty or vulnerability as an embodied universalist foundation or framework for human rights by conceptualizing how the precariousness of citizens rights can be related to the human rights of individuals this framing might also address the values that arise from the recognition of shared vulnerability in the face of organized killing and systematic or extreme violence it suggests therefore a distinctive theoretical lens with which to view social agency within a broader sociology of human rights it does so by opening the possibility of viewing agency through a particular normative lens here we draw on shklars concept of putting cruelty first a concept that is tethered to the prevention of perpetrator stateled human rights atrocities and premised on the recognition that the ability to inflict certain levels of fear intimidation and violence often rests uniquely with the state and its agents institutions or instruments of coercion shklar begins with the empirical observation that the power to govern is the power to inflict fear and cruelty we must take this power seriously or hate cruelty cruelly because of its profoundly corrosive social moral and political effects putting cruelty first is premised on an assumption that the actualities of statedriven fear coercion and abuse are so abhorrent and their consequences so grave and dehumanizing that they must be prioritized and prevented before all other considerations on this view the prevention of the fear caused by state brutality is itself irreducible and requires no further justification this is not the liberalism of natural rights shklar observes but it underwrites rights as the politically indispensable dispersion of power which alone can check the reign of fear and cruelty ultimately of course this requires some version of representative constitutional democracy with institutional checks and constraints against state brutality but in the immediate context of war crimes and genocide the urgent aim is to protect the most vulnerable against appalling cruelties and to limit the ability of those who hold these coercive instruments of physical brutality from using them with impunity to be sure putting cruelty first as a way of actualizing hard human rights claims involves ethical and political compromises and practical policy limitations as we will see but it nevertheless offers a useful analytical framework for articulating an agencycentred sociology of hard human rights that is as focused on the perpetrators capacity for cruelty as it is on the victims human dignity or vulnerability in practice this articulation of human rights and indeed its instantiation involved three closely related interpretive moves by the lawyers in the state department which redefined war crimes qua hard human rights abuses first hard human rights claims were instantiated and concretized when the victim was conceived not simply as a moral being but as a political being whose political agency in the conflict needed urgent articulation second just as the human rights victim was seen as a political being a human rights claim for social protection was reconceived as a political claim reliant on state institutions or agents for its enforcement or denial treating the victims rights claim for protection as a constitutively political demand suggested a broader sociological conception of human rights that began to move away from its moral universalist apolitical mooring around human dignity into the politicized and violent space between the victim and the perpetratorstate as a consequence this implied thirdly that if the human rights claim was not to remain abstract or disembodied but actualized and instantiated then protecting vulnerable citizens from the states instruments of cruelty required something more than a moral legal framework or liberal legalism but also a framework that offered a politically legitimate constraint on the states power to brutalize ie a theory of the states ability to commit mass atrocity in effect us officials analysed hard human rights through a social contract or rightsbased prism which defined the responsibility of government to its citizens and articulated a basis for legitimizing a human rights claim for protection based on the properties and practices of the perpetrator a domestic human rights constituency emerges following the breakup of yugoslavia and the secession of croatia and slovenia in 1992 a threeyear ethnic conflictlargely orchestrated by an aggressive nationalism in serbia and a response by croatiaspread into bosniaherzegovina among bosnian serbs croats and muslims the violence resulted in the deaths of more than 250000 bosnians and the forcible displacement of 22 million from the first hostilities a number of us eu and un peace attempts had triedand failedto bring an end to the violence but in november 1995 the usled dayton peace accords resulted in a permanent cease fire and a politically redesigned bosnian state the defining feature of the war had been ethnic cleansing a term that originated during the conflict and that referred to the mass rendering of an area ethnically homogenous by use of force or intimidation and involving various tactics to effect population displacement such as laying siege to cities and indiscriminately shelling civilian populations starving populations of food and supplies executing noncombatants establishing concentration camps where thousands of prisoners were summarily executed and tens of thousand were subjected to torture and inhumane treatment employing rape camps as tools to terrorize and uproot populations and razing entire villages 2 initially the clinton administrations policies were confused ineffective and characterized by a palpable sense of drift but the horrific nature of the mounting atrocities were being documented in real time from early 1992 by the state department through refugee interviews and satellite images as a result us policy began to develop around efforts to set up a war crimes tribunal something that human rights organizations had also been advocating these efforts were the product of a particular set of individualsor a human rights constituencythat emerged within the smaller bureaus of the state department and whose interpretation or official narrative of bosnian violence was to construct it as a politicallyinflected fusion of war crimes with human rights the clinton administrations policy drift and its inability to bring an end to the ethnic violence had however led to frustration among midlevel officials and balkan specialists and eventually to the protest resignations of several junior state department policy officers who were intimately familiar with the evidence of widespread brutalities 3 but james obrien a junior staff lawyer in the state departments office of the legal adviser had been given the usually quiet war crimes portfolio in early 1992 as the bosnian war exploded and as he read the first press and intelligence reports detailing evidence of atrocities and ethnic cleansing he consulted with state department language officers for translations and he began to voice the argument that these were in fact war crimes obrien felt his unique vantage point at the war crimes desk allowed him to see nuremberg as the policy precedent for moving on the material 4 under the direction of his superior michael matheson then principal deputy legal advisor and with a small group of junior staffers they guided this idea through political channels and sought the assistance of other countries they proposed a tribunal under a un security council mandate and obrien and state department attorneyadvisers robert kushen and david scharf drafted its statute in early 1993 the ad hoc international criminal tribunal for the former yugoslavia was established 5 it was criticized as both an instrument of us politics and as a weak substitute for a determined military or diplomatic response to the atrocities though more narrowly it was hoped that it might deter further human rights violations raise the costs of noncompliance and lay the ground for postconflict accountability importantly however war crimes were becoming bound to a human rights framework through the interpretive work of the war crimes working group in fact the tribunal also crucially laid the premise for the emergence of a new narrative of the conflict within the state department and gradually for a more explicit policy around war crimes as human rights atrocities as the cumulative stream of evidence of atrocities and ethnic cleansing filtered its way through the state department and intelligence agencies the idea emerged that war crimes evidence and support for the tribunal could be vehicles for gaining leverage over the war this idea gained momentum in a particular social location among a small human rights coalition or war crimes working group that informally coalesced among midlevel officials and lawyers in the state department legal advisers office and its human rights bureau a number of whom were active in setting up and supporting the icty arguments were made that human rights could be used as a pillar of geopolitical diplomacy that peace and justice were not mutually exclusive and as obrien would maintain that they effectively needed a realist school of human rights 6 the prosecution of war crimes and hard human rights abuses would not simply be moral idealism but part of a realpolitik strategy to push obstructionists and perpetrators to the side in order to end the war un ambassador madeleine albright was a strong supporter of the idea secretary of state warren christopher broadly backed it and soon deputy secretary of state strobe talbott and anthony lake at the national security council also approved its thrust it created tensions around tactics just as it raised ethical legal and political ambiguities about whether to link war crimes to sanctions relief or to the substance of the peace negotiations but as john shattuck assistant secretary of state for democracy human rights and labor later wrote human rights were by definition at the center of every issue that the dayton peace conference would face so us policy was to give hard human rights atrocities a role in the political strategy to end the conflict this framing derived in part from the composition of the policymakers themselves a number of officials responsible for bosnia policy had personal family backgrounds in east central europe or the balkans albrights aggressive activism for instance was intimately bound to her own personal experiences as an émigré from east central europes ethnic violence and from close family connections to yugoslavia 7 holbrooke was of mixed central european jewish background and paul szasz who had served the un as an expert on international law and became a legal adviser to the lawyers crafting dayton 8 was a hungarian refugee from 1939 but more generally many were young lawyers with backgrounds in human rights law or activism international law and diplomacy or constitutional law and civil rights 9 in fact of the forty people working in the tribunals office of the prosecutor twentytwo were lawyers and investigators sent by the us they had deep experience in human and civil rights activism in and out of government and they contributed a key leadership cohort to the ictys distinctive angloamerican atmosphere the lawyers and lowlevel officials that loosely comprised this war crimes working group produced a statecentred narrative of ethnic cleansing and hard human rights atrocities focused on the perpetrators this was informed by three factors first moravscik is right that american exceptionalism with respect to human rights is contingently dependent on specific domestic political cleavages and especially on the presence or absence of a domestic liberal constituency around human rights such a constituency emerged in the early 1990s within the lower levels of the state department bureaucracy second these officials experiences reflected a normative commitment to the rule of law within a liberal legalist interpretive framework as epitomized by their strong and unqualified support for the tribunal and third their understanding of the violence in bosniaherzegovina was explicitly political not merely legalist they interpreted evidence of war crimes as a series of politically orchestrated ethnic policies not just as legal human rights violations they viewed ethnicity as the content not the driver of political atrocities 10 they built a conceptual framework around the perpetrator the dynamics of the atrocities and the politicallyconstituted violent and dynamic space between perpetrator and victimhighlighting the importance of understanding the social locatedness of the construction of human rights the application of putting cruelty first our research suggests that us war crimes policy involved three related elements the use of war crimes as evidence of political culpability to exclude indictees from negotiations and as postconflict lustration the collection of refugeeidp interviews to support the icty and the construction of a political framework around ethnic cleansing a narrative of the perpetrators if pleas to make human rights central to us policy had been dismissed as idealistic by some administration officials with the collapse of five different peace plans the use of war crimes indictments to remove radical or obstructionist leaders likely to derail future negotiations began to look quite realist this amounted to what shattuck now refers to as warcriminalectomy 11 as a matter of formal policy the us leveraged the ictys july 1995 indictments of radovan karadžić and ratko mladić to exclude them from the dayton process indeed the tribunal worked on the same principle politically isolate indicted war criminals from positions of power even if they were not in custody but this was not pursued consistently or unambiguouslyhighlighting some of the problems inherent in a putting cruelty first framework holbrooke had been trying to isolate the bosnian serb leadership from the final dayton negotiations since early 1995 both for their extremism and for tactical reasonsto reduce the number of parties at the table given that this was one of the reasons for the failure of previous contact group efforts 12 so a warcriminalectomy was one way to do it and yet us negotiators had met with mladić and karadžić several times before dayton and the fact that they were negotiating with slobodan milošević was itself seen as both subverting the work of the tribunal and legitimizing his complicity if not culpability in the mass atrocities moreover excluding mladić and karadžić from negotiations might also have been illegal under international law because they had only been indicted not convicted 13 to all of this the response was pragmatically realist no amnesties were offered as a condition of negotiations and as holbrooke argued only the parties to the terrible conflict could end it…you cant make peace without milošević war criminalectomy defined politicalnot just legalculpability this also had secondary lustration effects although here too the impact was mixed the civilian implementation annex of the dayton agreement gave the newly established office of the high representative the authority to prevent indicted war criminals from holding political office and it had a certain utility together with the work of the tribunal lustration constituted a wider attempt at transitional and restorative justice and it helped introduce new rules into postconflict political culture it was thought that by removing the former communiststurnednationalists from political life the indictments could create space for more moderate forces to emerge but nato did not want responsibility for arresting war criminals so in the first several years very few were indicted much less arrested and tried after dayton suspected war criminals remained at the heart of a network of criminal activity that made postwar reconciliation exceedingly difficult dayton did not provide enforcement authority the 1997 bonn powers allowed ohr to continue war criminalectomies by dismissing public officials for treaty noncompliance or for war crimes indictments 14 but the bonn powers did not have a legal basis in dayton and in fact elements of this lustration policy have been successfully challenged in bosnian courts on human rights grounds 15 the failure to arrest more war criminals had enormous implications for the return or resettlement of hundreds of thousands of forcibly displaced persons daytons annex seven had outlined extensive protections for refugees and idps including the rights of return and for the first time in international law property restitution support for the view that significant returns were possible was available in numerous state department reports indicating that even the most traumatized refugees wanted to return to their homes as long as it was safe and war criminals were prosecuted indeed most blamed political elites for the brutalities not their neighbours 16 so there was a brief postwar psychological window of time in which substantial return might have taken place 17 but involuntary return was also protected ie the right not to return to the same conditions that had caused one to flee so safe return was deeply affected by whether or not suspected war criminals were removed from a particular area 18 but because the tribunal was too slow to indict and because the first indictment duško tadić was a largely symbolic lowlevel perpetrator the failure to indict quickly and arrest moreand more high profilewar criminals meant that substantial refugee return never materialized in summary then the exclusion and lustration of indicted war criminals was considered politically necessary and state department press guidance reports emphasized that prosecuting war crimes was in the long term interest of peace in the region 19 despite its potential policy usefulness in the prevention of atrocities as implemented it was insufficiently mindful of the underlying power structures of bosnian politics and society and of the politics of displacement and return war criminalectomies were not targeted enough to subvert or dismantle the centres of power and patronage apparatuses in bosniaherzegovina that had been the institutional support for the war this would become something of a lessonlearned 20 although they had not crafted a specifically tailored balkan instrument the effect of the war crimes working groups attempts to put cruelty first had shifted the policy centre of gravity from the humanitarian universalism of human rights to a politically inflected universalism focused on stateled atrocities war criminalectomy policies were framed around perpetrators political culpability as much as their legal violations of human rights a narrative of the victims in 1992 the un security council established a commission of experts and a special rapporteur of the commission on human rights both were charged with collecting and investigating evidence of war crimes so a second us policy component was to enhance these evidencegathering bodies by directly commissioning us embassy officials and investigators to conduct interviews in refugee camps in for instance ankara vienna zagreb bonn and belgrade the state departments human rights bureau deployed officers to collect evidence and interview refugees and in one year alone it produced five human rights reports based on embassy field reports interviews with refugees and the findings of human rights organizations by mid1995 the us embassy in the hague had become a transfer point for information to be passed to the tribunal just as us intelligence agencies forwarded information to the legal advisors and lead prosecutors offices at the office of the prosecutor one of the most important sources for state department interviews was the kirkareli refugee camp in turkish thrace emboffs were able to enter where the icrc was not and their interviews with bosnian muslim refugees carefully documented the most horrifying specific and gross human rights abuses people burned out of their homes concentration camps for the systematic rape and impregnation of girls and women beatings mutilations and decapitations all manner of humiliating torture summary executions of civilians and other hard human rights atrocities importantly credible witnesses were able to name specific perpetrators as people that they knewjust as many owed their survival to the assistance of lone serbsand they provided crucial information on chains of command in the detention and rape camps 21 reports from belgrade zagreb and vienna emboffs similarly documented details of brutalities including fatal beatings male rape and sodomization corpses and mutilated bodies loaded into trucks descriptions of grave site locations and in one interview the fatal beating of a six year old child 22 admitting the difficulties of keeping up with the enormous magnitude of human rights violations 23 us officials forwarded these details and the names of credible witnesses to the commission of experts and to the otp with the explicit purpose of preparing for the war crimes trials 24 because the prosecution of war criminals was an important us policy objective 25 corollary practices involved tracking the movements of refugeeswitnesses willing to testify safely airlifting the most vulnerable to the tribunal and commissioning a us department of defense airlift of the bosniak delegation to discuss war crimes investigations 26 for instance in march 1994 obrien drafted a memo to request that a us interagency team be sent to interview refugees from brčko which had been ethnically cleansed in apriljuly 1992 the proximate aim was to work under the auspices of the un war crimes commission and to assist the work of the tribunals chief prosecutor but the wider hope was that our trip to interview witnesses in germany and denmark will prompt host countries to work actively in preparing information for the prosecutor 27 the effect of these policies was twofold most immediately the experiences of war crimes victims were inserted into the conflict into the work of the tribunal and into the broader us diplomatic strategy toward bosniaherzegovina us officials interpretation of victims narratives offered them a degree of political agency in a moment in which it was existentially threatened and secondly a particular narrative among state department officials was consolidated it held that these war refugees were not merely abstract victims of human rights abuses but more substantively they were viewed as victims of nationalist policies this strengthened the narrative of the war as politically manufactured and driven by the perpetrators capacity for cruelty war crimes as politically inflected human rights as the survivors accounts came in and as more reports from human rights organizations and the icrc were made available desks within the state department including its intelligence bureau or the bureau of intelligence research added this evidence to their own internal field reports the documentary evidence suggests that they continually reassessed the fundamental political and policy dynamics of ethnic cleansing including with the use of ethnographic mapping and satellite imagery analysis these assessments were folded into eight comprehensive war crimes reports 28 the result was a set of discrete assessments that were fundamentally political in their human rights implications the narrative was politically universalist war crimes as human rights violations were political atrocities that illegitimately victimized citizens the assessments concluded that the policies of ethnic cleansing involved victims of nationalist policies 29 efforts to destroy social structures 30 the rape and abuse of women as an instrument of war 31 a coordination scale intensity and orchestration of violence that was not reversible 32 brutalities that did not arise spontaneously or by happenstance 33 evidence of high level complicity in the cruelties 34 acts of genocide 35 and the use of various forms of ethnic cleansing as deliberate levers of policy 36 in other words this was a war and it was fought with ethnic strategies for icty purposes us reports of refugee interviews generally organized the substantive violations under legal human rights categories and subcategories but the organizing analysis was political not legalistic so for instance a november 1994 draft report noted that ethnic cleansing…bears attributes of all categories of human rights abuses but concluded that this was fundamentally driven by serb military and paramilitary atrocities and acts of violence that were a matter of lowlevel loss of control or highlevel policy 37 the diffuseness of this kind of political analysis was most evident in three key substantive areas first state department analysts concluded that the vast majority of the hard rights abuses were attributable to bosnian serbs with complicity from belgradecountering both the european view of the conflict as a civil war and the human rights ngos tendency for apolitical balance based on a number of field reports state department analyses highlighted bosnian serbbelgrade command structures systematically executed policies methodical planning and patterns in the violenceall of which helped to establish not only criminal liability for the tribunal but also political responsibility 38 jon western an inr analyst revealed american thinking milošević was never going to call up his henchmen and say go commit genocide we had to develop the case by showing the systematic nature of the campaign only by working backwards could we show genocidal intent second was the conclusion that ethnic cleansing involved a routinized campaign to destroy the bosnian muslim community 39 that community leaders were systematically targeted based on municipal lists both to send a message and to figuratively decapitate muslim society and that patterns of clearance displacement and resettlement reflected orchestrated policies 40 and third they repeatedly characterized the multiple rape and abuse of girls and women in at least sixteen rape camps primarily as an instrument of war not simply as a human rights violation this prompted usaid to mobilize very specific interventionslearned in part from the treatment of trauma following the vietnam warto support the immediate and longterm needs of victims through inter alia support for local private voluntary organizations hospital partnership programmes and programmes to train and upgrade the treatment of trauma and by making available child psychiatrists 41 in short the state departments internal analyses were conceptually anchored politically not in the legal language of human rights the analyses focused on the dynamics of that violent space between perpetrator and victim it was an interpretive formulation of hard human rights not based on universalist constitutive properties of the victim but one that rebalanced the conceptual focus to a perpetratorcentred political universalism because of a recognition of the states ability to inflict mass atrocity conclusion our evidence suggests that key lower level us state department officials of the informal war crimes working group constructed a narrative of hard human rights violations in statist terms of bosnias victims as citizens requiring political agency in the face of atrocities and of their human rights claims for protection as politically constitutedall anchored around a putting cruelty first policy focused on the states singular capacity for organized brutality and on an interpretation of war crimes qua human rights abuses war criminalectomies were used to remove indicted war criminals ethnic cleansing was interpreted substantively as an organized stateled effort to destroy the social structure of nationality groups rather than as a series of human rights abuses 42 and the political agency of bosnias refugees and displaced was under illegitimate political threat and in need of urgent articulation and protection in short these putting cruelty first interpretations had the effect of building a narrative of hard human rights atrocities around the perpetrators political culpability not simply around the human dignity of victims of rights atrocities they empirically acknowledged shklars admonition that the power to coerce to inflict fear violence and cruelty rested disproportionately with the state and its agents and institutions in short their putting cruelty first policy was as concerned with defining state cruelty as it was with articulating victims vulnerability or dignity it had important limitations of course as a way of actualizing hard human rights claims it was prescriptively sobering because it involved ethical contradictions political compromises and the practical tradeoffs of imperfect policy choices 43 and while a perpetrator focus did accord political voice to rights claims in moments of mass atrocityprecisely when those voices were the most existentially threatenedit nevertheless moved away from the moral universalism that usually anchors human rights discourse yet more importantly this particular vernacularization of human rightsby this particular group of social actorsalso demonstrates the value of better understanding the role of agency in a broader sociology of human rights the determinative social agency of the war crimes working group exemplified the social situatedness or locatedness of human rights in that moment particularly as they constructed hard human rights as a set of normative political values and with a greater sensitivity to the perpetrators of atrocities put differently a richer and deeper sociology of human rights requires a more rounded appreciation of human rights as socially situated and reflective of the subjective experiences interpretations and indeed agency of key social actors in those social locations in which rights are actualized and socially embedded biographies liliana riga is lecturer in sociology at the university of edinburgh her research is focused on the sociology of assimilation her recent book is the bolsheviks and the russian empire she is currently working on a project exploring ethnic cleansing postconflict ethnic displacement and lives of placelessness james

this paper contributes to an understanding of the role of agency in a sociology of human right by examining how a small group of individuals interpreted defined and instantiated hard human rights or those atrocities associated with war crimes and crimes against humanity using political theorist judith shklars perpetratorfocused framework of putting the prevention of cruelty first we explore the role of agency in the construction of human rights through the empirical lens of us war crimes policies around the 1995 dayton peace accords for bosniaherzegovina we draw on us state department documents and on interviews with key participants in the accords to argue that a richer sociology of human rightsseen as socially situated and embeddedrequires a fuller appreciation of the experiences of key social actors in those social locations in which human rights are articulated interpreted and actualized

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introduction on december 31 2019 the who china country office was informed of cases of pneumonia with a then unknown etiology the chinese authorities identified the etiology a new type of corona virus which was isolated on january 7 1 in the first two months after the first report 79968 persons in china were infected by the virus 2 the number of confirmed cases across the globe on march 1 2020 was raised to 87137 with respect to the spectrum of the disease covid19 caused by the new corona virus wu and mcgoogan 3 reported that based on the 44415 confirmed cases in china 81 was mild 14 severe and 5 critical the overall casefatality rate in china was 23 meanwhile the corona virus outbreak also severely affects the production facilities transport the global economy and financial markets to prevent and reduce infection by the new coronavirus health organizations such as the who governmental health agencies and journals offer information about possible preventive measures 1 2 3 4 5 the cohort study of pan and colleagues 6 among 32583 confirmed covid19 cases in wuhan reported between december 2019 and march 8 2020 showed that series of multifaceted public health interventions were temporally associated with improved control over the sarscov2 outbreak these interventions were aimed at control of the sources of infection medical resources patient triage blocking of transmission routes and prevention of new infections to target and implement interventions to stimulate preventive behavior against infection more insight is needed in how people perceive the risks of being infected by this new coronavirus if they use of preventive measures and especially which preoutbreak factors determine the perceived risks and measures taken 7 the study of wang and colleagues 8 using a snowball sampling strategy in mainland china with surveys at the end of january and the end of february 2020 showed that 112 and 91 did find it very likely contracting covid19 during the pandemic in addition 119 and 89 did find it not very likely or not likely at all surviving if infected by covid19 both variables were associated with current anxiety or depression symptoms in total 598 and 732 did always wear facemasks regardless of the presence or absence of symptoms 666 and 739 did always wash hands after touching contaminated objects the frequency of used preventive measures was negatively associated with current mental health problems however to the best of our knowledge to date prospective studies conducted among random samples of the general population assessing the perceived risks of corona infection preventive measures taken and preoutbreak determinants of perceived risks and measures taken are absent aim of the present prospective study based on a random sample of the general population is to shed light on this gap of scientific knowledge with respect to perceived risks we made a distinction between risk for infection and risk of becoming ill when infected 9 with respect to potential determinants we first focused on preoutbreak respiratory heart problems and diabetes because they increase the risk for severe health problems when infected 10 we furthermore assessed preoutbreak anxiety and the liss panel started in 2007 and is based on a large traditional probability sample drawn from the dutch population the netherlands organization for scientific research funded the setup of liss panel members receive an incentive of €15 per hour for their participation and those who do not have a computer andor internet access are provided with the necessary equipment at home further information about all conducted surveys and regulations for free access to the data can be found at the liss panel has received the international data seal of approval all data of studies conducted with the liss panel are anonymized data on coronarelated questions will be added to the open access data archive soon depression symptoms and loneliness because they may impact the perceived threat of infection and perceived likelihood to become ill when infected 11 12 13 14 we assessed demographics such as age and gender because older people and males are more at risk to become ill 67 we finally assessed preoutbreak employment status such as having paid employment being a job seeker or student and having a work disability because although employment status is associated with mental health the extent to which employment status is associated with perceived risks and preventive measure taken is unknown this study is conducted in the netherlands and during the data collection period the number of confirmed cases in the netherlands increased rapidly from 10 to 1715 and 43 infected people died until march 17 materials and methods procedures and participants the study was conducted using the dutch longitudinal internet studies for the social sciences panel 15 the liss panel started in 2007 and is based on a large traditional probability sample drawn from the dutch population the netherlands organization for scientific research funded the setup of liss panel members receive an incentive of €15 per hour for their participation and those who do not have a computer andor internet access are provided with the necessary equipment at home further information about all conducted surveys and regulations for free access to the data can be found at the liss panel has received the international data seal of approval all data of studies conducted with the liss panel are anonymized data on coronarelated questions will be added to the open access data archive soon the data collection with respect to the coronavirus started on march 2 2020 because of the rapid developments of the corona outbreak we choose to use the data collected until march 17 2020 1100 am a reminder was send on the 10th day data on physical and mental health problems and loneliness of the respondents before the corona outbreak were extracted from two surveys conducted at the end of 2019 these are social integration and leisure survey and the health survey the data of the three surveys were linked and in total 3540 adult respondents participated in all three surveys we furthermore assessed 16 exclusive demographic profiles among the total adult dutch population 2019 based on data of statistics netherlands the 16 profiles were constructed using the following demographic characteristics gender age categories and marital status totaling 2 � 4 � 2 16 exclusive demographic profiles in case a profile in our study sample differed from the general population a weighting factor was computed and applied all results are based on the weighted sample and across tables total numbers may slightly differ because of the weighting ethical approval and informed consent according to the dutch medical research involving human subjects act the present study did not require ethical approval in accordance with the general data protection regulation participants gave explicit consent for the use of the collected data for scientific and policy relevant research measures perceived risk corona infection the corona survey started with the following brief introduction the next question are about the new corona virus there is currently an outbreak of this virus in china now also people in the netherland and in other countries have become ill we administered two questions developed for this study to gain insight in how adults perceived the risks of the coronavirus respondents were asked what do you think is the chance that you in the next two months 1 become infected with this coronavirus and 2 get severely ill if you become infected with this coronavirus both questions had a 7points answer scales preventive measures against corona after completing these questions respondents were asked in the past two months did you do things to prevent infection by this coronavirus as much as possible in case respondents answered yes they were asked to indicate what they exactly did the answer categories were based on who recommendations places 4 cancelled a journey 5 otherwise namely when respondents answered no they were asked why not for both questions respondents could choose for more than one answer preoutbreak physical health problems the health survey assessed several physiciandiagnosed diseases in the past year and health problems respondents regularly suffer from for the present study we focused on reported 1 respiratory problems or 2 heart problems or and 3 diabetes preoutbreak loneliness loneliness at t1 a was assessed using the sixitem de jong gierveld loneliness scale 16 respondents are asked to rate items such as i often feel deserted and there are enough people i can count on in case of a misfortune on threepoint likert scales we calculated the total score after recoding the three negative formulated items and lower scores reflect more loneliness for the present study we dichotomized scores into low and high loneliness about 20 of the respondents have scores of 14 or lower preoutbreak anxiety and depression symptoms anxiety and depressive symptoms in the past months were examined at t1 b using the 5item mental health index or inventory 1718 the mhi5 ask respondents to rate the presence of symptoms during the past month on 6point likert scales a cutoff of � 59 was used to identify respondents with moderate to high anxiety and depressionsymptom levels 19 demographics and employment status preoutbreak demographics and employment status assessed in octoberdecember 2020 were used in the present study participation period we monitored when respondents completed the corona questions we distinguished three periods period 1 period 2 and period 3 data analyses chisquare tests and multivariable logistic regression analyses were conducted with preoutbreak medical health problems symptoms loneliness demographics employment status and participation period as predictors and perceived risks and measures taken as dependent variables due to low cell counts in the extremes of perceived risks we recoded the perceived risks into the following three categories to optimize readability hereafter we label these three categories of perceived risks as low medium and high after this recoding we assessed to what extent the predictors were associated with the perceived medium and high risk a similar strategy was used to assess which factors were associated with whether respondents took preventive measures people may perceive the risks as high and therefore take measures but the opposite may also be true people may perceive the risk as lower because they take measures since the perceived risks and preventive measures taken were assessed at the same time we therefore did not add the perceived risk to the list of predictors in the multivariable logistic regression analyses predicting preventive measures taken all analyses were conducted with ibm spss version 26 results characteristics respondents table 1 provides an overview of the characteristics of the weighted study sample eg the prevalence of preoutbreak health problems symptoms loneliness demographics and employment status the increase in respondents after day 9 can be attributed to the reminder mail perceived risk of infection and illness in table 2 shows that a minority perceived the risk of being infected as high a somewhat lower proportion perceived the risk for becoming ill when infected as high on the other hand very few respondents perceived the risk of infection and becoming ill as zero predictors perceived risk of infection corona the results of the chisquare test and the stepwise multivariable regression analyses are presented in table 3 we focus on the results on the stepwise regression analyses they show that respondents with preoutbreak heart problems more often perceive the risk of infection as medium and high than respondents without these health problems anxiety and depression symptoms and loneliness were not independently associated with the perceived risk older and low educated respondents less often perceived the risk of infection as high than younger respondents and higher educated respondents respectively respondents who participated later more often perceived the risk of infection as high than those who participated in the first 4 days females more often than males perceived the risk of infection as medium those with paid employment did not more often perceive the risk as medium or high than the other employment categories except students who less perceived the risk as a medium risk respondents who participated later more often perceived the risk of infection as medium and high predictors perceived risk for becoming ill when infected table 4 contains the results of the same analyses but with the perceived risk for becoming ill when infected in the next two months as dependent variable on a bivariate level almost all predictors were significantly associated the multivariable analyses showed that respondents with preoutbreak physical health problems anxiety and mental health problems and loneliness more often perceived the risk for becoming ill when infected as high than others older respondents more often in contrast to the perceived risk of infection perceived the risk for becoming ill as medium and high than younger respondents preventive measures taken and predictors of the total study sample 438 took preventive measures such as washing hands more often and longer not going to work of avoid certain places purchase of mouth masks and cancelled a journey of the respondents who did not take preventive measures 425 reported that they find it nonsense or useless 249 that maybe will do this still 204 have not thought about it yet and 154 that they do not know what they should do table 5 shows which factors predicted the use of preventive measures against infection by the coronavirus with respect to preoutbreak physical health problems only respondents with heart problems took preventive measures more often females more often took preventive measures and medium and high educated respondents more often than low educated respondents finally respondents who filled in the survey more recently more often took preventive measures with respect to employment status no differences were found between respondents with paid employment and all other employment categories we repeated the regression analyses among those who participated 1015 days after the start of the corona survey showing almost similar results having heart problems was no longer significantly associated with preventive measures while respondents in the age category 3549 years old more often took preventive measures than the youngest subgroup of respondents plos one discussion main results of this prospective population basedstudy are that during the 2week study period the number of respondents who perceived the risk of being infected by the new coronavirus sarscov2 as high increased sharply multivariable logistic regression analyses showed that respondents with preoutbreak respiratory and heart problems diabetes anxiety and depression symptoms and loneliness and older respondents more often perceived the risk becoming ill when infected as high although older respondents compared to the youngest respondents less often perceived the risk of being infected as high compared to the youngest adults they more often perceived the risk of becoming ill when infected as high the last finding is in line with the general information provided by governmental health agencies and media before and during our study period suggesting that this information reached these specific groups in line with the increased perceived risk to be infected the number of respondents who took preventive measures increase too however respondents with preoutbreak respiratory problems and diabetes did not more often take preventive measures than others although they perceived the risk of becoming ill when infected more often as high a similar remarkable pattern was found for preoutbreak loneliness and anxiety and depression symptoms in addition analyses of respondents who participated 1015 after the start of the study showed that respondents with respiratory problems heart problems and diabetes did not differ in the proportion of people who took preventive measures with respect to employment status the multivariable logistic regression analyses furthermore showed that students more often perceived the risk of infection as medium but not more often as high compared to respondents with paid employment respondents with work disabilities compared to those with paid employment more often perceived the risk of infection and becoming ill when infected as medium and high nevertheless those with paid employment did not differ in the prevalence of preventive measures taken from the other employment subgroups our findings are somewhat similar to the results of a study reported by the who regional office for europe 6 this serial crosssectional study conducted in germany in almost the same period as our study showed that the prevalence of respondents who perceived the risk to be infected by the coronavirus as high increased from 168 to 214 they furthermore reported like us that older respondents felt less likely be infected in the study by wang and colleagues 8 about 10 did not found it very likely or not likely at all to survive covid19 we have no data to compare these findings with importantly in our study the effects of other factors that are associated with the perceived risk of corona infection were controlled for such as preoutbreak respiratory and heart problems and education level asmundson and taylor 20 reported that according to polls in the us 56 was very concerned about the spread of the virus and in that canada 7 was very concerned about becoming infected the prevalence of respondent participating in the third and last period who used preventive measures slightly approximated the prevalence found by wang and colleagues 8 to date many studies on our research topic are initiated and conducted however when finalizing this study we were unaware of studies based on random samples among the general population published in peerreviewed journals on the perceived risks the use of preventive measures and their preoutbreak determinants to compare our findings with strengths and limitations strength of the present study are the use of a large traditional probability based sample drawn from the dutch population the prospective studydesign data on preoutbreak physiciandiagnosed diseases and use of well validated instruments on anxiety and depression symptoms and loneliness we deliberately choose to use the data that was collected in the first two weeks of the survey to be able to share our results rapidly given the threatening global developments however although we distinguished three subsequent periods during these two weeks suggesting an increase in preventive measures taken we do not know from this study if and when all respondents have taken preventive measures in addition we do not know from this study to what extent respondents who have taken preventive measures will continue to comply with protection guidelines from governmental health agencies another limitation is that we not were able to include children it is unknown to what extent childrens perceptions of the risks and the measures they taken resembles those of adults and especially parents and other family members we did not systematically examine whether respondents were in quarantine eg were separated and restricted in movement because they had been potentially infected by the coronavirus and their effects on perceived risks 21 the present study does not provide information on this topic nor how quarantine affects postquarantine preventive behavior finally it was beyond the scope of the present study to assess perceived risks and preventive measures taken as well as its preoutbreak predictors among the workforce when returning to work after a lockdown for this purpose we refer to the study of tan and colleagues 22 nevertheless we believe that our results are also of relevance for future sarscov2 outbreaks as well as other outbreaks future research future research on the perceived risks and preventive measures should among many other important questions focus on to what extent people continue to take the proposed or required preventive measures which physical psychological financial and societal factors do influence compliance to preventive measures on the medium and long term which interventions to stimulate constant preventive behavior are most effective these questions are highly relevant because to date there are no indications that this pandemic will end soon furthermore taken preventive measures should be assessed more in detail and selfreports on measures taken should be complemented with peerreports in addition future studies should pay special attention towards children and how they perceive the risks for coronavirus infection and if and how they protect themselves conclusions the results of this study based on a random sample of the general adult population are partly reassuring and positive and partly negative positive is the finding that the number of respondents who have taken preventive measures during the brief 2weeks study period increased while taking other significant predictors of the use of preventive measures into account it is very likely that the daily stream of information about the pandemic and advice on this matter provided by dutch governmental health agencies physicians and media contributed to this finding a negative finding is that respondents with respiratory problems and diabetes who are considered groups at severe risk for complicated health problems when infected did not take preventive measures more often than others in addition we found no indications that people took preventive measures irrespective of their education level and gender the last findings suggest that specific education level and genderrelated interventions should be developed and offered to increase preventive behavior among men and those with a lower education level the study was conducted using the dutch longitudinal internet studies for the social sciences panel 13 use of preventive measures should pay additional attention to physically vulnerable patients males and those with lower education levels formal analysis peter g van der velden marcel das investigation peter g van der velden miquelle marchand boukje cuelenaere marcel das methodology peter g van der velden miquelle marchand boukje cuelenaere marcel das supervision peter g van der velden validation peter g van der velden miquelle marchand boukje cuelenaere marcel das writing original draft peter g van der velden writing review editing peter g van der velden miquelle marchand boukje cuelenaere marcel das

assess how people perceive the risks of coronavirus infection whether people take preventive measures and which preoutbreak factors contribute to the perceived risks and measures taken such as preoutbreak respiratory problems heart problems diabetes anxiety and depression symptoms loneliness age gender marital and employment status and education leveldata were collected in the longitudinal liss panel based on a random sample of the dutch population the coronavirus survey started on march 2 and the data collection ended on march 17 2020 data were linked with surveys on health and social integration conducted at the end of 2019 n study sample 3540 about 15 perceived the risk of infection as high and 11 the risk becoming ill when infected multivariable logistic regression analyses showed the following older agegroups perceived the risk for coronavirus infection as lower all adjusted odd ratios aor � 070 in total 438 had taken preventive measures especially females aor 146 95 ci 126170 those with lower education levels less often used preventive measures aor 055 95 ci 045067 those with preoutbreak respiratory problems aor 275 95 ci 211357 heart problems aor 197 95 ci 134292 and diabetes aor 312 95 ci 202482 perceived the risk becoming ill when infected as higher than others however respondents with preoutbreak respiratory problems and diabetes did not more often take preventive measuresvulnerable patients more often recognize that they are at risk becoming ill when infected by the coronavirus but many do not take preventive measures interventions to stimulate the

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introduction over the last few decades there has been a considerable increase in the popularity of international education worldwide the number of international students more than doubled in the past 20 years increasing from two million in 2000 to 53 million in 2017 about 75 of mobile students choose countries in the organization for economic cooperation and development to pursue their education canada has also experienced an increase in the number of international students in the tertiary education system since the 1990s with international students representing 165 of the total number of students enrolled in canadian schools in 2018 currently canada is considered a top destination country for international education along with the usa the uk china and australia in 2018 572415 international students were enrolled in canadian postsecondary institutions and this number is projected to grow the economic contributions of international students to the canadian economy reached 15 billion in 2017 in both direct and indirect costs canada is attractive to international students due to its highquality education system and its international reputation of being a safe country that promotes tolerance and takes pride in cultural diversity some researchers suggest that students choice of university and host country may also be impacted by the ease of obtaining a permanent residency status thus it is possible that canadas immigration policies have become an added attraction to international students an ongoing commitment to promote international education was demonstrated by the canadian government in the 2019 budget which dedicated 1479 million over 5 years to the international education strategy while international students are considered to be visitors to canada some of them may decide to stay in the country upon graduation the results of the 2018 survey of the cbie showed that approximately 70 of international students planned to stay and work in canada upon graduation and 60 intended to apply for permanent residency international students have been described as designer immigrants due to their familiarity with canadian culture and locally obtained training although canadian policy makers are cautious about actively recruiting international students to stay in canada due to ethical concerns related to such practices favorable immigration policies may indirectly entice international students to stay in canada upon graduation canadian immigration policies support the integration of international students into the labor market by allowing students to work onand offcampus additionally graduating students can apply for a postgraduation work permit which in some cases is valid for up to 3 years work experience gained while studying enables interested students to apply for permanent residency utilizing the path for canadian experience class canadian education may provide international students with a higherranking position in the express entry candidates pool and speed up the process of receiving permanent residency given the growing interest from many countries including canada in providing education to international students and the possibility that some of these students may decide to stay in the receiving country upon graduation it is important to understand how international students arrive at the decision to go back home or stay in their country of education this knowledge can inform human resources and immigration policies as well as aid with developing supports for students planning to permanently stay in the country of education while the factors influencing migrationrelated decisions of international students have been explored to some extent in the literature most of them have been derived from quantitative studies consequently they show associations between variables shaping students decisions but do not shed light on the decisionmaking process moreover most of the literature conceptualizes students migratory transitions as unidirectional which simplifies the potential complexity of migration pathways available to international students who may decide to move to another country upon graduation we also know little about the meaning that students attach to the decisions related to migration and how this meaningmaking process impacts their migration choices the goal of this paper is to address these gaps by exploring how international students think about and arrive at a decision to stay in canada or go back home after graduation international students decisionmaking at present there is no consensus in the literature about how and when students make decisions about immigration although lu et al found that students original intentions regarding permanent migration prior to relocating largely predicted their intention to stay other work has shown that students feelings change and may alter their intentions most likely students decisions are made on an ongoing basis whereby students assess and reassess their migration options midway through their programs many students studying abroad find themselves considering their migration decisions postgraduation furthermore the final migration decisions of students may differ from their previous intentions altogether while students may or may not change their mind migration is a dynamic process which most likely cannot be reduced to a single definitive decision it seems that the decision to immigrate is a complex transition that may change over time this study aims to explore this process by offering insights about the meaning international students attach to migration pathways available to them upon graduation migration studies often classify students options regarding migration as either shortterm stays or longterm permanent moves this can create challenges for studying the sequential movement of students as they are a highly mobile group that may not fall into these two categories for example it is possible that after graduation students choose to move to a third country neither staying in the country of education nor going back home the assumption that students either permanently reside in their receiving country or leave it to return back home after graduation also neglects the fact that some international students may choose to stay in the receiving country for only a few years after finishing their degree students may want more time to make decisions or they may stay to gain work experience and save money before returning home additionally some students plan to stay in the receiving country for shortterm work experience as a continuation of their graduate degree in the form of professional development whether or not a student decides to stay or leave upon graduation could entail a wide variety of migration plans and is likely linked to the meaning students attach to migration their relationships with significant others in the receiving and home countries and a variety of professional and personal circumstances in order to understand the decisionmaking process of international students some researchers utilize the pushpull factors model which contextualizes migrationrelated decisions as an interplay of factors that deter people from home countries and attract them to receiving countries the pushpull model has been also applied to analyze migration of canadian international students for example the retention of englishspeaking students in quebec was explored using a pushpull model which enabled researchers to identify a variety of factors that shaped students decisionmaking including good job opportunities as a factor that may push students to leave the province and cost of living as a factor that may pull them to stay understanding the decisionmaking process and utilizing the pushpull model are complementary and have been used congruently to explore the choice of graduate school by east asian students in ontario while the pushpull model has provided useful insights into social political and economic factors that shape students decisions it has been criticized for providing an overly simplistic model that does not account for characteristics of the individual or their social relationships this paper will build on this knowledge by exploring the microlevel process of decisionmaking overall a growing body of literature shows the complexity of migration intentions of students researchers quantified the outcomes of students decisions to migrate postgraduation and identified and measured factors considered by students making their decisions qualitative studies contributed to this body of knowledge by exploring the interplay of microlevel factors weighed by students making decisions about migration there appears to be some consensus that migration decisions of international students are made over time and may unfold as a process but very little is known about students experiences of going through this process and the meaning they assign to it to address this gap and explore the process of decisionmaking employed by international students this study uses a symbolic interactionist approach symbolic interactionism posits that individuals are engaged in the meaningmaking process through social interactions and that they continuously assess the situations to determine their own interpretations of their circumstances and to form their actions the meaning that individuals attach to any social process is of particular importance in symbolic interactionism as perceptions about social phenomena are seen as products of everyday interactions the focus on meaningmaking processes and microlevel understanding of individuals actions make symbolic interactionism a suitable approach for understanding how international students in canada approach decisionmaking about staying in the receiving country or going back home employing symbolic interactionist theoretical perspective the goals of this paper are to explore how do international students make decisions about staying or going back home or another country upon graduation and what do they see as pivotal in shaping their decisionmaking processes methodological approach after receiving ethics clearance from blinded for peer review participants were recruited from two universities located in two different canadian provinces by placing advertisements about the study on university campuses and utilizing snowball sampling in total 60 participants took part in the study we aimed for diversity in our sample recruiting undergraduate and graduate students who selfidentified as female male or nonbinary individuals in order to explore how the field of study may shape migrationrelated decisionmaking process for international students we purposively recruited 20 students per field studying in the general fields of social sciences and humanities health sciences and stem our participants came from 23 different countries with the highest number of students coming from china india and iran all participants were in their last year of study table 1 provides a summary of a demographic profile of our participants trained research assistants conducted semistructured interviews with the students during 20172018 utilizing an interview guide which explored students decisionmaking prior to coming to canada their experiences in canada and their considerations about staying in canada or returning back home upon their graduation all interviews were conducted in english as an incentive to participate in the study students were offered a 30 gift card to a local grocery store the interviews were recorded transcribed verbatim and analyzed using nvivo 11 software for qualitative data analysis the qualitative data from this study were analyzed inductively utilizing charmazs guidelines we felt that charmazs focus on inductive openended coding fits well with symbolic interactionists theoretical lens by enabling us to explore the process of students decisionmaking while also learning about their experiences and the meaning they attach to it we started the process of data analysis with two researchers independently coding the data and moving from open linebyline coding to more focused coding after coding five interviews we developed a coding scheme that was subsequently applied by all the researchers to code the interviews and modified a number of times during the process we then proceeded with the development of analytical categories identifying the relationship between them and seeking to derive a more nuanced understanding of the processes employed by the international students in making decisions about staying in canada or going back home in what follows we summarize the findings related to the way in which international students conceptualized the decisionmaking process focusing on the complexity and uncertainty of this endeavor we assigned pseudonyms to all the participants to protect their identities due to concerns with confidentiality we do not always reveal some of the characteristics that can hint at the identity of the participants however where possible we provide some demographic details about the participants to help the readers place the quote in context results broadening the meaning of staying the vast majority of students who took part in our study had some plans in place following graduation to either stay in canada or return back home with most hoping to stay but the meaning of staying varied considerably among the participants ranging from shortto longterm planning while over 50 students planned on staying only 10 of them saw staying after graduation as permanently relocating to canada conversely over onethird of the participants planned to stay in canada for a few years and then move back home for example alix a 23yearold undergraduate student from china said as alix suggests while she has a plan to stay in canada she is not set on how many years she will be hereher plan is flexible with the possibility that it will change considerably as she continues to live and work in canada her notion of staying is not linked to the permanent desire to remain in canada rather it is built on her intention to prolong her stay for a few additional years similarly chang a 24yearold stem graduate student talked about staying for a period of time in canada before going back to china as a general plan that does not have specific welldefined timelines i being undecided fig 1 process of decisionmaking of international students so i think ah yeah for short … period of time i will… like find a job and … get more working experience here in canada and maybe in two years i will return to china to … build my career back there because all my … family are in china and many of my friends are also in china so i hope i can return there the uncertainty of changs plan is evident in his hesitation to define what staying means to him he refers to thinking about maybe staying in the receiving country for a period of time but is also hoping that eventually he will go back home like chang many participants talked about their intention to stay in canada for some time in order to gain work experience or pay off studentrelated debts prior to returning home signaling a possible desire to return home in a position of improved financial security or increased employability for more than half of participants staying in canada included a plan to apply for permanent residency at some point following graduation the students often identified a few benefits of obtaining pr status including improved access to scholarships education and increased job opportunities students also discussed how obtaining pr status would increase flexibility in decisionmaking and their ability to move in and out of canada thus applying for and getting pr status in canada was seen as a way to keep the doors open but did not necessarily indicate a firm decision to stay in the country betty a 25yearold from england working on her phd research in a stem field noted i mean i would… ideally like a form of residency that allows me to leave canada and come back… cause like work in academia is an inherently transient career … it would be nice to have the option to kinda go and do a postdoc you know say somewhere in europe or something bettys account suggests that the meaning she attached to getting permanent residency cannot be equated with a decision to stay in canada full timeher goal is not to continuously and permanently live in canada but to expand her options for future travel and perhaps come back to canada later bettys position was similar to the sentiments shared by most of our participantsstaying in canada was not defined as a unidirectional trajectory of permanently settling in the new country for some students the meaning of staying meant delaying the return home for a few months or a few years for others staying signified obtaining permanent residency and having a legal right to stay and work in canada in both cases however students wanted to keep the door open and their view on staying or going had been sketched only using general contours reflective of the uncertainty about their future plans making decisions about staying our analysis revealed that there was considerable variation in how international students made decisions about staying in canada four students had contractual agreements with their countries that necessitated their return a handful of students remained adamant that they had always planned to go back home after completing their education these students usually cited family reasons and financial obligations as key factors in going back home hung a 22yearold undergraduate student in the health sciences field from vietnam said i know like some of my friends even though they wanna stay they cant really stay because… their familytheir family dont support them staying and they have a business in the country and they want the kid to come back to take over the business according to hung students personal desires are not necessarily a key factor in their ability to stay in the country coming from cultures that emphasize filial piety some students saw their familial obligations as pivotal for their decision to go back home even when their own preference would be to stay in canada as such the mobility of these students was not necessarily defined by the decisionmaking process but by a set of obligations related to students family roles for others the autonomous decisionmaking was still a part of the process even when it included familial pressures im really torn i… want to stay i do but i also made a vow to my parents years ago that i would take care of them as they were aging noted layla a 30yearold graduate student in health sciences field from the usa reflecting on this personal struggle while some of our participants did not plan to stay in canada upon completion of their degree ten students had a strong desire to remain in canada which was formed long before their arrival for this group the decision to immigrate upon graduation played a key role in choosing canada as a country of destination rania a 22yearold female student from malaysia studying in social sciences and humanities field explained i think ive made up my mind even before i came here for my first year… because i visited canada back in 2009 when i was still in the middle of high school… i really like it here so…thats whythats alsobig reason why i chose to study at university is to… stay close to family and also stay here as rania pointed out her decision to stay in canada was made prior to arriving in the country participants who said they had made a firm decision to stay in canada even before they arrived often entwined the decision to study in canada with an intention to emigrate from their home country marina a 25yearold social sciences and humanities student from russia explained my original purpose was actually to immigrate to canada and i was trying to find the best or the easiest way of doing it and after doing some research i realized that one of the best strategies for me would be to come and study here for marina studying in canada was a means for obtaining permanent residency later in the interview marina also explained that in canada the partner of an international student can get a work permit whereas in other countries she explored this option was not available as a result marina and her partner decided to choose canada for their studies marinas decisionmaking process about immigrating to canada therefore was the one that prompted her to choose to study in canada as an international student mei a 30yearold graduate student in the field of social sciences and humanities who came from china said i know some of my classmates just come here for the pr and the degree is just a way to get the pr suggesting that marinas immigration strategy is not unique for students who arrived in canada with a plan to stay in the country the perceived complexity of the path from international studies to permanent residency was a key consideration in deciding to study in canada and the decision to immigrate was made prior to becoming a student although nearly a quarter of the students made the decision about immigration prior to arriving in canada most students who took part in our study were not entirely certain what their plans for the future were before they had a chance to live in canada exploring life in canada while adapting to the local education and culture was seen as a strategy to make a more informed choice lin a 28yearold social sciences and humanities phd student from china recalled i guess in the first… two years i wasnt sure if i wanted to stay becausewell that was my first two years and i was still doing a lot of adjustments and everything and so i was thinking maybe other options are okay as well but then… after things got settled down i just um i just started to like this place and just wanna stay lins description of her decisionmaking process is typical of the majority of students whom we interviewed most of our participants were not necessarily settled on a decision before arriving in canada and felt that their experiences in canada would provide a better platform to make an informed decision arriving at the final decision was tied to a number of factors that we describe in the following section confirming changing or delaying the decision nearly twothirds of our participants noted that while they had made an initial decision to staygo back home before arriving in canada these decisions were either reaffirmed or changed after they began their studies for instance moon a 20yearold female health sciences student from bangladesh said that her decision to stay in canada solidified after she arrived in canada and saw firsthand that this really is a great country and it really is you know quite welcoming twentysixyearold arjun an engineering student from india noted that his desire to stay in canada has actually increased over the period of time wei a 20yearold female undergraduate student from china explained um i will say over the time i… willing to stay get stronger and stronger yeah hmm i think the more i learn the more i find … like opportunity i have is in canada but not all students had positive experiences some students found that canada lost its initial allure reflecting on the change in his decision to stay in canada diego a 27yearold male phd student from brazil commented you know … before you come you have this romantic view… i will never leave… before you start you dont know exactly how things are going to go and you think its going to be… you know smooth forever you know i wasnt exactly aware that canada wasnt one of the biggest countries in my field you know to stay after graduation so yes inin the beginning i thought wow canada forever um but then again im maybe too pragmatic as diego pointed out with time his view of canada has changed from being romanticfeeling committed to stay in canada foreverto a more pragmatic view which considers opportunities for future employment in the hightech industry for diego therefore the decision to stay in canada was altered by his view of the employment opportunities in canada and in the global hightech industry and opportunities available to him for professional growth for other students the decision to leave canada upon graduation was tied to their experiences of social interactions with others mary a 27yearold health sciences student from ghana said okay so… initially when i came i was thinking of staying because i felt this place was more peaceful and then you have the opportunity to develop yourself you understand but then as time went by and then i became exposed to the realities here i feel very discouraged from staying here in her interview mary talked about the difficulty of fitting in as a visible minority student she recalled her challenges of getting used to what she termed a canadian culturea type of social interaction that mary interpreted as distant and impersonal totally different from the community based culture that was familiar to her mary felt that in canada people are in their individual space which she admitted came to her as a shock learning about canada through social interactions with other students mary felt that she might not be welcomed in canada as with some other students who selfidentified as members of visible minority groups mary recalled a number of instances where she experienced racism and discrimination these encounters prompted her to reevaluate her initial decision to stay in canada and consider going back home students identified a plethora of factors that shaped their decision to stay or go these included ties to family members who were either in canada or abroad perceptions of employment opportunities in canada and in ones home country and the perceived complexity of the immigration process some students also talked about feelings of social isolation and loneliness that they experienced in canada chun a 21yearold female stem undergraduate student from china recalled the first year which is thethe year that i got homesick… its my first year leave my parents and living alone… is hard for me so at that time i was wish ing … after i finish my university here… go back to china im gonna stay with them my parents well after the first year everything is getting better cause like i get into like local environment i get used to speak up to local people and i got used to the lifestyle here ah its getting easier for me to… enjoy the life here so after i get into university i found that wow its a nice place i want… i want to like stay over longer similar to some other participants after spending the first few years in canada chun found herself to be more immersed in the local lifeshe got used to the local environment and adapted to the canadian culture by learning to speak up and to communicate with local people chun noted that being in university made her realize that she likes canada and as a result chun has been leaning towards staying in canada for longer than she originally planned while some students attributed their decision to their feelings towards and attitudes about canada for others the decision was linked to the economic and social conditions in canada quality of life is way better here and quality of educationthat was my first priority why i came over here noted aisha a 20yearold undergraduate health sciences student from pakistan banhi a 26yearold from india studying towards the completion of a health sciences graduate degree identified another factor that swayed her decision in favor of staying in canada initially i was like ill complete my degree ill go back but then like after my first year perhaps halfway into my second year i was like its good opportunity over here like its different but its good so i want to stay thatsthats kind of when i started appreciating the system and the health care benefits i got banhi described how her growing knowledge about canada has shifted her decision about returning back home this process is similar to the gradual change that was described by jessica a stem phd student from zimbabwe first year i was there i said … im not staying and my friends were all laughing at me the zimbabweans are like uh huh but thats how we all were when we came but after you know so many years then they… want to stay so i think mine decisions about staying have changed cause now im no more so… im going back now im like okay… i think theres lots of possibilities… which is different from when i came over although jessica is not completely sure that she is planning to stay in canada her initial conviction that she wants to go back home after completing her phd has somewhat faded similar to banhi her experiences in canada compelled her to reevaluate her original decision finally eight students felt that making decisions about staying in canada or going back home can or should be postponed adaku a 20yearold social sciences and humanities undergraduate student from nigeria noted adaku discusses her thoughts about staying in canada or going back home but is somewhat reluctant to arrive at a specific decision reflecting on her experience adaku is questioning if her personality of liking to plan things and having lists can outweigh her appreciation of the fact that the future is very uncertain comparing a migrationrelated trajectory to the journey of studying which often takes students onto unanticipated paths adaku suggested that the decision about migration may not be feasible during the time where students experiences are rapidly changing for some the refusal to commit to a decision was tied to the uncertainty about their legal status or family roles for others the lack of clarity about future employment was the reason for why the decision was not made reflecting on this state of uncertainty mary a 27yearold health sciences masters student said at this point… its very blurry it depends on what will happen okay because i feel … when im done with my masters degree getting that canadian experience before i go home will be helpful right but then if you dont get any opportunity out there then its better you go marys feeling that her future plans are blurry is consistent with what some other participants described when they discussed their thoughts about migration although about half of our participants kept an open mind about the possibility of migration students like mary were uncertain about whether or not they will be relocating to canada making decisions about their prospects of staying in canada seemed pointless to these participants given the fact that they had no knowledge about their chances of getting permanent residency or their opportunities for gaining employment in canada in this context the decisionmaking process involved not committing to any decision leaving it for the time when the overall picture of the future would be more complete discussion in this paper we explored the meaning that international students attach to the decisionmaking process of staying in canada or going back home upon graduation we showed that the meaning of staying was defined by students in a multitude of waysstudents saw staying not only as a permanent migration but also as a temporary stay or a possibility of coming back to canada as a permanent resident hence staying and going back home were rarely seen by students as firm decisions with fixed definitions attached to them rather students considered them as possibilities or opportunities which could represent shortterm plans or longterm migration decisions our findings also demonstrate that international students decisionmaking process regarding migration is complex and can change over time students migrationrelated decisions can be understood as falling into three broad categories figure 1 summarizes these categories and demonstrates how students initial decisions may be altered by the contextual factors that they encounter in canada consistent with the findings from the literature we found that some students arrive in canada with a firm decision to immigrate in our study only ten students had an initial strong desire to stay in canada that remained unchanged while they studied for these individuals the very decision to get an international education was a means to immigrate to canada these students therefore could be regarded as potential immigrants who chose a unique patheducationfor obtaining a permanent residency status the other small group among our participants was comprised of those who planned to go back home upon completion of their education four of these students had contractual obligations with their governments other students within this group cited familial and personal obligations as the reasons forcing them to go back home in this context the decisionmaking process was not free and autonomous as some students felt that their family needs are the ones that define their future place of residence for these students international education was an opportunity to enhance their social or employment status in the home country however once coming to canada some of these students may have changed their views on the possibility of migration and some planned to prolong their stay after graduating to gain some employment experience before going back home most of our participants however came to canada with only a general idea about their future among the students we interviewed approximately 23 thought about staying in canada for at least a few years and over a half planned to apply for a permanent residency status none of these participants had a firm stance on either staying in canada or going back home and their experiences in canada such as difficulties with obtaining permanent residency status lack of employment opportunities or experiences of racism and discrimination shaped their decisionmaking process securing employment upon graduation was seen by international students who took part in this study as pivotal in shaping their decision to stay in the country given the interest of some countries to attract and retain international students to fulfill local human capital needs it would be beneficial to establish clearly defined pathways that facilitate acquisition of work visas or permanent residency status for international students our study showed that some students choose to study in canada because it offers options to either work or apply for permanent residency upon graduation other top destination countries for international education have similar policies for instance australia allows international students to apply for temporary graduate visas which may simplify the pathway to permanent residency germany provides international student an option to secure a temporary residence permit which gives them 18 months to find a job in their field however as we indicated elsewhere blinded for peer review information about immigration opportunities for international students is usually managed by hosting institutions with some universities providing more access to information than others therefore the process of obtaining work visas or permanent residence may be perceived by students as inaccessible and complex this complexity was evident in our study through the high level of uncertainty expressed by international students about their ability to stay in canada moreover since migration in many countries including canada is tied to the local economic needs which position applicants with certain skills and qualifications as more desirable and is also shaped by cultural and political ideologies some students may have easier access to immigration and postgraduation work than others evidently while canada has a global reputation for cultural tolerance in our study the voices of students who selfidentified as visible minorities highlighted the instances of racism and discrimination they experienced in canada which made some of them to seriously consider returning back home our findings demonstrate the contributions of symbolic interactionist perspective to the analysis of migrationrelated decisions made by international students we showed that the meaning students attach to the notion of staying is complex which may be missed in crosssectional surveys examining international students plans to stay in the host country or come back home upon graduation while traditional migration literature explored the process of international movement as unidirectional more recent scholarship highlights the complexity of the global movement of human capital and transnational mobilities our findings showed that the decisionmaking process employed by international students is tied to the experiences they acquire in canada and is based on a variety of push and pull factors that work in complex tandem to shape students migration choices for instance students may be pulled by familial obligation to stay in canada and at the same time to go back home similarly the prospect of employment opportunities may attract students to stay in canada return back home or move to another country consistent with findings from other studies we demonstrated that international students migrationrelated plans may change with time we also showed that students experiences in canada may be instrumental in shaping their decisionmaking processes our study has some limitations our participants came from 23 different countries with different social and cultural understandings about education family obligations or migration different laws regarding dual citizenship and ease of movement to and from the home country might have their own influences on students decision to stay in canada the diversity of our sample enabled us to identify some of the common factors shaping students decisionmaking process but striving to summarize commonalities in the views of our participants we did not delve into cultural differences that shaped students perceptions about their transition to canada we also did not explore how students level of studyundergraduate or graduate degreeshaped their decisionmaking processes about staying in canada and how their duration of staying in canada may have shaped their choices finally we did not explore the role gender plays in shaping the decision to stay in canada or going back home given the traditional gender roles assigned to familial responsibilities and the role culture plays in establishing these gender roles it is possible that such nuanced analysis would have allowed us to explore the intersection between gender culture and migration which is something that we aim to do in our future work he qualitative nature of our study mandates that the findings from this study would not be considered generalizable to the general population of international students in canada rather summarizing the results from our study we aimed to highlight the subjective experiences of those students who took part in our study while the conclusions drawn from our study cannot be considered representative of all international students in canada we believe that they nonetheless shed some light on how the decisionmaking process regarding migration can be experienced by some international students conclusion in this study we explored how international students make decisions about staying in canada or going back home upon graduation and what factors shape their decisionmaking process we showed that students assign various meanings to staying in canada ranging from remaining in canada for a few additional months to moving to canada permanently we also showed that only a handful of students remained firm in their decision to stay or go back home with the vast majority altering their decisionmaking process based on their experiences of studying in canada overall our findings suggest that the considerable range of students views on staying in canada may be a reflection of how education and immigration are understood by these studentsthey see themselves as a part of a globalized and mobile workforce where the boundaries between countries can bend with the right education professional qualifications and employment experiences and it is possible that countries competing for international human capital might need to consider what temporary and permanent migration opportunities should be developed to attract the best and the brightest who are constantly on the move 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 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

recent decades have seen an increase in the popularity of international education approximately 500000 international students were in canada in 2018 and this number is projected to grow while we know that many international students decide to stay in canada we do not fully understand the decisionmaking process employed by international students regarding staying in canada or going back home after completing their education the purpose of this study was to explore how international students make decisions about their postgraduation destination and what factors they see as pivotal in shaping their decisionmaking process we utilized a symbolic interactionist approach to analyze qualitative semistructured interviews with 60 international students enrolled in postsecondary programs in canada our findings suggest that the meaning students attach to staying in canada varies from obtaining permanent residency to working for a few months upon graduation we also demonstrate that for most students the decision to stay in canada is formed gradually and is shaped by familial obligations cultural climate they experience in canada employment opportunities available to them upon graduation and the possibility of obtaining permanent residency

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human rights and democracy in southeast asia continue to attract the attention of scholars from the region for in depth research and discussion a centralized and methodical style of authoritarianism such as that used by suhartos new order in indonesia restricted public dialogue of human rights and democracy and is unlikely to attract the public of southeast asia today according to social scientists researchers and islamic scholars the people of southeast asia are tireless champions of human rights social justice and democracy to this day the editors of this book al khanif and khoo ying hooi have put together a book that in its own way succinctly analyzes marginalization and human rights in southeast asia and provides a range of perspectives on the subject this book covers a wide range of topics including the success of asean cooperation in ending statelessness human rights violations committed against migrant workers the protection of disabled peoples rights on a regional scale the rohingya refugee crisis the moros plight religious and ethnic minorities rights academic freedom in authoritarian regimes child abuse and security concerns in southeast asia human rights breaches in southeast asia share many commonalities but they also vary widely from country to country due to the wide range in the use and abuse of political power this book examines the connection between discrimination and the erosion of human rights for marginalized populations particular attention is paid to disadvantaged groups such as children indigenous peoples transient workers and refugees this book also draws attention to the unequal access to resources and opportunities for minority and disadvantaged communities in southeast asia it looks at marginalization from different perspectives including regional and national ones human rights provide in depth examinations of the efforts made and the ways in which larger socioeconomic and political structures affect the access to or denial of basic freedoms for various groups of people around the world the contributors of this book claim that protecting citizens from human rights abuses is still a big challenge for many southeast asian nations in the indonesian context it is worth noting that under president joko widodo both al khanif and herlambang wiratraman have written extensively on the issues of religious minorities and academic freedom human rights are seen as issues of state power by most indonesians particularly those who grew up during the soeharto new order era and experiences during the joko widodo era the concentration of authority shapes how human rights are understood and implemented1 a nondialoguefostering discourse emerges when citizens are taught to keep their personal lives separate from public issues which are those that fall under the purview of the state writers in the book observe that the mainstreaming of governmental interests cannot be substituted for individual wants and that this fact frames the confrontation between public and private in the development programs of countries in southeast asia furthermore the state has positioned itself in a place that is outside the reach of criticism and dissent in both indonesia under suharto and the philippines under ferdinand marcos as a result the state as representatives and leaders continues to manage and regulate public debate despite democratization following the overthrow of dictators like soeharto in indonesia and marcos in the philippines human rights press freedom and other fundamental liberties continue to be threatened in both nations 2 herlambang p wiratraman in chapter 12 stresses that academic freedom is still being repressed and silenced in the indonesian setting its not complete repression though in legal parlance this is called a derogable right meaning a right or freedom that can be waived or restricted however in order to foster moral development in society constraints on freedom must highlight freedoms role in the advancement of human civilization academic freedom is not only addressed expressly in the law on higher education and is translated in the university statutes but it is also the subject of efforts to assert such a stance on campus which serves as an academic community atmosphere however its conceptual significance is murky and therefore cant be used as a legal reference to safeguard those liberties the truth of the situation on campuses is that academic freedom is under siege and this is not surprising given the absence of a clear or stringent legal definition including the wording of the constraints utilizing anticommunist backlash religious intolerance and corporate influence on campuses the last five years have seen a dramatic increase in documented cases of pressure on academic freedom herlambang p wiratraman stated that since 2014 many colleges including those in yogyakarta malang and surabaya have banned the screening of silent directed by joshua oppenheimer take for instance the defamation report filed by south jakarta district court judge sarpin rizaldi against professor komariah emong of padjadjaran university and professors charles simabura and feri amsari of andalas university for criticizing judge sarpins judgment when dr case rosnida sari brought her students to church to hear priests explain gender relations in christianity she was accused of imparting wild teachings and reprimanded by her university even now her situation has a lasting effect on her because in addition to the threats he faced she was denied an equal share of teaching duties at the university this book reveals that indonesia malaysia thailand and the philippines are all examples of countries in southeast asia where the educated elite has formed structures that are not always able to have a critical stance towards the state stateconditioned speech permeates the public consciousness by reading al khanif s views in this book we can imagine that under the new order in indonesia for example the media itself served as a spokesperson for the government hence official pronouncements were made to the public in the third person however some of the current situation and conditions are still unchanged because of the ongoing repression and confinement of press freedom the current reform regime in indonesia has aspirations to realize democracy and human rights in all aspects of life uphold the rule of law and respect for human rights without discrimination however instead of the long coveted democratic life rule of law and human rights being upheld what happens on the contrary freedom gives rise to acts of violence and discrimination that are no less haphazard than the despotic rulers of the old regime in my opinion al khanif in his writings in this book protecting indonesias religious minorities a challenging task opens the eyes of the readers hearts that religious minorities in indonesia still experience violence pressure persecution and discrimination the difference is that violence and discrimination in this regime are no longer perpetrated by the state authorities alone but by a handful of community groups with certain identities the presence of this group seems to present oligarchic power in the midst of legitimate republican administration violence and discriminatory treatment in indonesia today seem to have strengthened in shaping social institutions which are institutionalized a series of bitter incidents in the recent reform era grazed matters that intersect with religion which attacked the existence of religious minorities and claimed many victims these various acts of violence and discrimination can be witnessed by the rampant incidents of murder torture rape kidnapping and acts of anarchism in the form of destroying educational institutions and places of worship as well as various forms of discriminatory acts and coercion from the powerful against the powerless borrowing azyumardi azras view3 religious and sociopolitical sectarianism has seen an increase in indonesia since liberal democracy after soehartos new order was implemented in 1999 the history of indonesia proves that the government has failed to protect religious minorities like ahmadiyah and shia from intolerance and persecution lack of political will and democratic spirit on the side of public authorities and state elites is reflected in the states failure to protect religious freedom for its minority citizens the procontra stances of ahmadiyya and shia for example polarized the ummah in brutal ways leading to the current crisis this book argues that in the current era of reformation indonesia should approach minority issues rationally and avoid resorting to violence public leaders should be aware that a focus on political ideas that support justice will also strengthen the law and the constitution as explored in this book indonesia malaysia thailand and the philippines are all examples of countries in southeast asia where the educated elite has formed structures that are not always able to have a critical stance towards the state 4 stateconditioned speech permeates the public consciousness under the new order in indonesia the media itself served as a spokesperson for the government hence official pronouncements were made to the public in the third person according to al khanifs assessment of indonesias current trajectory its apparent that the government is unable to guarantee the safety of religious minorities like the ahmadiyah and the shia lack of political will and democratic spirit on the side of public authorities and state elites is reflected in the states failure to protect religious freedom for its minority citizens ahmadiyya and shia circles of communities have split the ummah with their procontra stances this book argues that in the current era of reformation indonesia should approach minority issues rationally and avoid resorting to violence public leaders should be aware that a focus on political ideas that support justice will also strengthen the law and the constitution this book is sure to be wellreceived in the domains of asian law and human rights in asia particularly southeast asia because it offers a new perspective on marginalization and human rights in the region

human rights and democracy in southeast asia continue to attract the attention of scientists in this region to study and examine them in depth in this context a centralized and methodical style of authoritarianism such as that used by suhartos new order in indonesia has restricted public dialogue of human rights and democracy and is unlikely to attract the public of southeast asia today according to social scientists researchers and islamic scholars ulemas the people of southeast asia are tireless champions of human rights social justice and democracy to this day the editors of this book namely al khanif and khoo ying hooi have put together a book that in its own way succinctly and forcefully analyzes marginalization and human rights in southeast asia and provides a range of perspectives on the subject this book covers a wide range of topics including the success of asean cooperation in ending statelessness human rights violations committed against migrant workers the protection of disabled peoples rights on a regional scale the rohingya refugee crisis the moros plight religious and ethnic minorities rights academic freedom in authoritarian regimes child abuse and security concerns in southeast asia

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introduction electronic cigarettes vaporize a solution of glycerin propylene glycol additives and sometimes nicotine 1 2 3 4 5 while early models mimic conventional cigarettes the design characteristics of newer models and eliquid flavors available are elaborate and attractive to both cigarette smokers and nonusers 3 6 7 8 9 10 11 12 in 2018 31 of the dutch population ever used an ecigarette in addition 231 of the dutch population were smokers of which onethird were between twenty and twentyfour years old 13 ecigarettes have the potential to reduce the harm of cigarette smoking on smokers health 10 recent studies have argued thatwhile quitting the use of tobacco and related products yields the most health benefitsthe health effects associated with exclusive ecigarette use are less harmful than those related to cigarette smoking 11 14 15 16 17 18 19 still ecigarette use is not harmless and consequently the initiation of ecigarette use among nonusers needs to be prevented 1011 20 21 22 to aid tobacco control that yields the most public health benefits for cigarette smokers and nonusers insight into differences in the decisionmaking process of ecigarette users smokers and nonusers is needed about ecigarette use initiation in particular it is important to know whether the decision made by former cigarette smokers to switch to ecigarettes or by nonusers to refrain from ecigarette use is consciously deliberated previous research among different types of users and different age groups has described differences in reasons why initiating ecigarette use is attractive 23 24 25 for example cigarette smokers have argued that the expected health benefits of ecigarette use compared to cigarette smoking and design similarities with cigarettes are reasons to initiate ecigarette use 25 26 27 nonusing youth have stated curiosity as a reason to initiate ecigarette use 25 despite previous research into reasons for initiating ecigarette use 2527 insight into the process of making a choice about ecigarette use initiation lacks this information is crucial to facilitate a conscious decision among cigarette smokers about switching to ecigarettes and among nonusers about refraining from experimenting with ecigarettes a conscious decisionmaking process is defined by deliberating available and relevant information about the options and by weighing advantages and disadvantages of the choice in the context of the decisionmakers attitudes 28 29 30 previous research found that smokers have not made a conscious and informed decision to initiate cigarette smoking but that this decision is rather passive 2829 31 32 33 34 our study explores the deliberation process of successful switching among current ecigarette users and the deliberation process of refraining from ecigarette use among cigarette smokers and nonusers to the best of our knowledge this is the first study to examine the decisionmaking process of ecigarette use among cigarette smokers and nonusers we explored whether ecigarette users cigarette smokers and nonusers have similar knowledge and attitudes regarding ecigarettes and if they used this knowledge to consider pros and cons of switching to or refraining from ecigarette use by comparing differences in this process of ecigarette use initiation between ecigarette users cigarette smokers and nonusers we offer new information on the views and experiences of ecigarette users who switched from cigarettes to ecigarettes materials and methods to explore the decisionmaking process about ecigarette use we conducted focus groups with three homogeneous groups consisting of adult ecigarette users adult cigarette smokers and adolescent nonusers who used neither cigarettes nor ecigarettes for each of these types of users four focus groups were conducted the study was approved by the medical ethics committee of zuyderlandzuyd recruitment in june 2016 participants were recruited in the netherlands through an advertisement on facebook© instagram© twitter© and scholierencom inclusion criteria were awareness of ecigarettes being a current smoker ecigarette user or nonuser and fluency in dutch adolescent nonusers were selected because previous research showed differences in reasons for ecigarette initiation among adult ecigarette users adult cigarette smokers and adolescent nonusers 25 supplementary file table s1 shows the characteristics of included participants procedure the group discussions were based on a semistructured protocol with openended questions and minimal steering to allow participants to freely discuss ecigarettes 35 the topic list of this protocol was developed to investigate decisionmaking according to the definition of van den berg timmermans ten kate van vugt and van der wal 29 and previous qualitative research conducted by gray hoek and edwards 31 this topic list was tested in a pilot focus group and subsequently revised while the same moderator led all group discussions the observers varied all focus groups were audio recorded and flipcharts were used for participants to visualize the topics that had been discussed the focus groups were conducted between june and july 2016 and lasted approximately 2 h informed consent was obtained before the start of the focus group and after participation the participants received an incentive of 30 euros the focus group started with a general introduction the discussion proceeded in four steps exploring participants knowledge regarding ecigarettes their attitude towards ecigarettes their deliberation regarding ecigarette use initiation and their information needs qualitative coding and analysis all group discussions were transcribed verbatim qualitative data analysis comprised of three phases 36 in the first phase the first author applied descriptive level coding to a randomly selected focus group transcript to deduce relevant themes and subthemes the first author and the second coder then developed a descriptive thematic analysis the second coder identified little additional text fragments to be relevant in the second phase the first and the second coder resolved minor differences in coding themes and subthemes to create a final coding taxonomy a third coder who did not participate in the first phase of the coding process reviewed the final coding taxonomy with the first author and minor adjustments were made in the final and third phase the first author and third coder coded all the transcribed focus groups results we conducted four focus groups with adult ecigarette users four focus groups with adult cigarette smokers and four focus groups adolescent nonusers all ecigarette users reported to be former smokers overall the sample was 47 female and 53 male the average age of adult participants was 293 years and adolescents 153 and the sample was highly educated table 1 summarizes the demographic variables for ecigarette users cigarette smokers and nonusers the following section describes themes which were considered important in the overall decisionmaking process of ecigarette users smokers and nonusers with illustrative quotes because of the explorative and qualitative nature of this study the results are not meant to convey generalizability beyond the studied population to describe themes and patterns in the data we distinguish between rarely and commonly mentioned aspects 37 note demographic information is displayed for each user group knowledge when participants were asked to talk about what they knew about ecigarettes many participants were able to mention some facts about ecigarettes for example many participants stated the variety of eliquid flavors available the rechargeable batteries of ecigarettes the lack of a burning process and tar the variety of devices and the ability to avoid smoking bans you use an eliquid there are a lot of flavors you can choose whether you want with or without nicotine and there are many different types compared to cigarette smokers and nonusers ecigarette users described more detailed information about ecigarettes ecigarette users reported to have acquired much information in order to make a decision about ecigarette use initiation for example about product characteristics ingredients of eliquids and legislation regarding ecigarettes knowledge reported by ecigarette users was mainly based on user experiences when asked how informed they felt cigarette smokers and nonusers stated that they did not search for information about ecigarettes and expressed they did not know much about ecigarettes ecigarette users felt very informed attitude participants shared experiences both positive and negative with ecigarettes and cigarettes cigarette smokers and nonusers were negative towards ecigarette use in general mentioning it was weird i think its ecigarettes really weird and pathetic everybody will be laughing at you all groups mentioned that using ecigarettes has the advantage of avoiding smoking restrictions compared to ecigarette users and nonusers many cigarette smokers were positive towards cigarette smoking regardless of the negative health effects associated with cigarette smoking smokers expressed they really enjoy smoking several of the ecigarette users reported a positive attitude about ecigarettes and negative attitude towards smoking based on knowledge acquired beforehand in general ecigarette users emphasized the positive aspects of ecigarette devices and positive experiences such as the variety of flavors and the adjustability of nicotine levels deliberation many ecigarette users consciously deliberated initiation of ecigarette use versus continuation of cigarette smoking by using knowledge acquired and weighing up the benefits of ecigarette use and disadvantages of cigarette smoking for example the personal health benefits of ecigarette use and the negative health issues for their social environment associated with secondhand smoking they described this decision process of switching from cigarette smoking to ecigarette use as a deliberation of benefits and disadvantages switching from cigarettes to ecigarettes it was a deliberate choice i had an ecigarette laying around and i tried it a few times i liked the flavor and the satisfaction it gave me throat hit from nicotine in the end i ordered a really nice one because i decided i was going to quit smoking so yeah it was a really deliberate choice many cigarette smokers and nonusers reported that they had not contemplated using ecigarettes deliberation was often limited to brief passive moments when they were confronted with an ecigarette in their environment one of my friends had one ecigarette and i thought that might be a way to quit smoking when asked to compare ecigarette use initiation with cigarette smoking initiation ecigarette users and cigarette smokers agreed that cigarette smoking initiation was not a conscious or deliberate choice many cigarette smokers expressed they passively discovered themselves to be smokers months or years after they initiated smoking everybody smoked so i started too there wasnt a point where i thought ok from now on im a smoker all of a sudden you just are one smoking is not a deliberate choice you make something you really think about in general nonusers did not show an interest in ecigarettes or cigarettes pros and cons were not actively deliberated among nonusers but sometimes curiosity was reason enough to passively experiment with ecigarettes or cigarettes information need of ecigarettes when asked about their information need all three groups stated they had several unanswered questions such as are ecigarettes harmful what are the benefits of ecigarette use compared to cigarette smoking and what are the negative longterm health effects of ecigarette use ecigarette users compared to smokers and nonusers had more questions about product characteristics such as are there results of quality tests of eliquids available cigarette smokers and nonusers wanted to know more about the successful quit attempts with ecigarettes they wanted to see a riskbenefit analysis of ecigarette use versus smoking and they wanted to know what the average duration of use was for ecigarette use as a smoking cessation tool all groups agreed that this information should be communicated to the public to facilitate smoking cessation for cigarette smokers many participants explained that there is a large body of information available but that it is difficult to filter useful and correct information from the internet additional aspects this section describes additional aspects participants mentioned that played a role in their decision about ecigarette use risk perception the risks of ecigarettes versus cigarettes were discussed ecigarette users did not perceive any health risks of ecigarette use so i thought its just vape that cant be really harmful for you or your lungs so if i just vape and i dont do it every day that wont be so wrong cigarette smokers stated that although they knew about the common risks of cigarettes the specifics of how cigarettes causes smoking related diseases were not clear they also perceived the health risks of cigarettes as a problem for the distant future something to worry about later when they were older ecigarette users tended to deliberate the risks and severity of cigarette smoking related diseases and acknowledged that the risks applied to them as former longtime cigarette smokers my grandfather smoked like me and you can see his health is getting worse and worse he suffers from emphysema i dont want that so i wanted to quit while nonusers were aware of the risks of cigarette smoking the risks of ecigarettes were unclear to them similar to ecigarette users they mentioned that if it is just vape it did not seem harmful ecigarette users perceived ecigarette use compared to cigarette smoking not as a risk but as a lifestyle i often say that besides a hobby its ecigarette use also a lifestyle similar to ecigarette users cigarette smokers perceived cigarette smoking as an addiction and they described triggers for the desire to smoke such as alcohol consumption nonusers perceived both ecigarette use and cigarette smoking as addictive behaviors social environment all groups described the importance of their social environment with regard to ecigarette use and cigarette smoking in the initiation of ecigarette use the social environment was an important factor for many ecigarette users my mother had one ecigarette so i tried it too several ecigarette users further noted that social support for ecigarette use from their social environment grew after initiation of use which they described as a sense of belonging to an ecigarette community its a community very similar to bikers you know how they all greet each other on the road the vaping community is the same in general participants expressed it was more acceptable to smoke than to use ecigarettes while cigarette smokers and nonusers categorized ecigarette use as weird cigarette smoking was still considered as acceptable by the several of participants and their social environment when asked about the role of their social environment in their decision to initiate cigarette smoking compared to switching to ecigarette use cigarette smokers expressed that friends who smoked often influenced their decision one of my friends told me try a cigarette so i did and i liked it and i continued smoking cigarette smokers did not describe the influence of friends as pressure but they did describe the disappointment their parents expressed in response to finding out about their smoking behavior as embarrassing i was really afraid to tell my parents that i smoke they were so disappointed nonusers viewed ecigarette use and cigarette smoking not as a social activity but as peer pressure and addiction not a choice nonusers felt strongly about parental disappointment related to cigarette smoking and noted this as a specific reason why they would not start smoking cigarettes or start using ecigarettes trust in information due to the large body of information available about ecigarettes it was difficult for participants to make sure the available information is correct ecigarette users and cigarette smokers mistrusted evidencebased information and relied on anecdotal user experiences researchers often dont know what they are doing yes we need to know about the experiences of ecigarette users unlike ecigarette users and cigarette smokers nonusers explained they rather receive scientific information because they trust this information to be true discussion we explored the decisionmaking process of ecigarette use initiation among adult ecigarette users adult cigarette smokers and adolescent nonusers compared to ecigarette users cigarette smokers and nonusers did not make a conscious decision to refrain from ecigarette use they have acquired different information and have different attitudes several of ecigarette users perceived the risks of cigarette smoking as personally relevant they acquired information and formed an attitude about ecigarettes finally their knowledge attitudes pros and cons were deliberated and a conscious decision was made to initiate ecigarette use additionally lack of information seeking perception of risk of smoking related diseases perception of risks and benefits of ecigarette use compared to cigarette smoking support to switch to ecigarettes a sense of belonging to ecigarette users and trust in information offered about ecigarettes showed to be important factors for a participant in a decisionmaking process about ecigarette use a possible barrier in the decisionmaking process is the large body of contradicting information available and lack of trust in scientific evidence although ecigarettes users appear knowledgeable their reported knowledge did not match scientific consensus we categorized this type of knowledge as beliefs and these beliefs were primarily based on anecdotal user experiences found online this finding matches research that shows that experienced ecigarette users are eager to share their advice and experiences about switching with cigarette smokers 38 due to these beliefs ecigarette users perceived ecigarettes as harmless research has showed that confirmation bias and online information may lead to misperceptions about the safety of ecigarettes 39 40 41 42 these beliefs and misperceptions about the harmfulness of ecigarettes may hinder the process of making a conscious and informed decision about ecigarette use initiation thus there is a clear need for further research on targeted communication strategies to facilitate the conscious deliberation of relevant and evidencebased information about ecigarette use these strategies need to highlight advantages and disadvantages of switching to or refraining from ecigarette use and correcting misperceptions about perceived risks and benefits of ecigarettes 43 this will emphasize the public and individual health benefits of ecigarette use initiation for cigarette smokers and the disadvantages for nonusers cigarette smokers did not contemplate to switch to ecigarettes or consciously decide to continue smoking our results indicate that though cigarette smokers are aware of the health risks of cigarette smoking they do not perceive the longterm health risks of smoking as personally relevant additionally they perceive ecigarettes as weird smoking as a normal social behavior 44 and possibly due to their young age display an optimism bias about their ability to quit in time before serious health effects occur 3045 this optimism bias greatly diminishes cigarette smokers interest to acquire knowledge about the benefits and disadvantages of switching to exclusive ecigarette use and deliberate these pros and cons of ecigarette use compared to smoking 304546 low perceived susceptibility and severity of risks associated with cigarette smoking a lack of knowledge and a social environment in which ecigarette use is considered weird and smoking is considered normal or encouraged hinders smokers to deliberate the pros and cons of switching to ecigarettes or smoking cessation similar to cigarette smokers nonusers did not actively deliberate ecigarette use initiation adolescent nonusers mentioned that if they were to start ecigarette use it would be out of curiosity the risks of ecigarette use were unclear to nonusers but because it was just vape ecigarette use was perceived as harmless this lack of perceived personal risks of ecigarette use may diminish the interest to acquire knowledge about the disadvantages of ecigarette use without information seeking and information about advantages and disadvantages of ecigarette use for nonusers no deliberation can take place 29 a lack of deliberation of the risks associated with ecigarette use and curiosity about ecigarette use may result in a tendency to initiate experimenting with ecigarettes among some adolescents low perceived risk of ecigarettes and a lack of knowledge hinder nonusers to make a deliberate decision to refrain from ecigarette use this qualitative study shows that cigarette smokers and nonusers did not consciously deliberate information about the risks and benefits of ecigarettes use to make a decision to refrain from ecigarette use initiation the differences and similarities in the decisionmaking process of ecigarette use among the different user groups raise a question namely can insights into the conscious decisionmaking process of ecigarettes users who switched from cigarette to ecigarettes be used to stimulate cigarette smokers to consciously deliberate something they consider weird further research is necessary to investigate how cigarette smokers can be stimulated to consciously deliberate a switch to ecigarettes because of the explorative nature of this study the results are not meant to convey generalizability beyond the study population and thus these findings are limited to a specific geographic context and time respondents were asked to participate in a twohour discussion which may have attracted individuals more inclined to talk about cigarette smoking and ecigarette use additionally we asked ecigarette users cigarette smokers and nonusers to consider their decisions about initiation in retrospect knowledge and attitudes may be different when first faced with the decision participants knowledge attitudes and deliberation process might be influenced by their level of education and living in different areas of the netherlands further research is necessary to explore the impact of education on a decision about ecigarettes conclusions to conclude our exploration of the decisionmaking process of ecigarette initiation identifies distinct differences between the decisionmaking process of current cigarette smokers ecigarette users and nonusers current ecigarette users in this study made a conscious decision to switch from cigarettes to ecigarettes but current cigarette smokers and nonusers did not contemplate or deliberate ecigarette use initiation ecigarettes have a potential public and individual health benefit for cigarette smokers as switching to exclusive ecigarette use is less harmful than cigarette smoking ecigarette use is not harmless initiation of ecigarette use and cigarette smoking should thus be prevented among nonusers several of the ecigarette users deliberated personally relevant risks of cigarette smoking which made them interested in switching to a less harmful alternative these findings underline the importance to explore the possibility to learn from the decisionmaking process of ecigarette users in order to support cigarettes smokers with their decision about switching to ecigarettes and nonusers with their decision to refrain from ecigarette use supplementary materials the following are available online at table s1 participant characteristics and alias table s2 topic guide author contributions conceptualization kagjr and rt methodology kagjr and lvo data collection kagjr formal analysis kagjr writingoriginal draft preparation kagjr writingreview and editing kagjr lvo hvd and rt supervision lvo hvd and rt

ecigarettes are increasingly popular among both cigarette smokers and nonusers although smoking cessation yields the most individual and population health benefits switching to exclusive ecigarette use offers some individual health benefits for cigarette smokers however ecigarette use is not harmless and its use among noncigarette smokers should be prevented our study aims to explore the decisionmaking process about ecigarettes among an ecigarette users cigarette smokers and nonusers we conducted 12 semistructured focus group interviews with ecigarette users cigarette smokers and nonusers we performed a thematic analysis of the interview transcripts first knowledge reported by ecigarette users was mainly based on other users experiences second cigarette smokers and nonusers were more negative towards ecigarettes than ecigarette users third ecigarette users considered switching from cigarette smoking to ecigarette use by deliberating relevant information and weighing up the benefits and disadvantages of ecigarette use versus smoking additionally important factors in the decisionmaking process were a perception of risks and benefits of ecigarettes compared to cigarettes a supportive social environment about ecigarette use and trust in information offered about the risks and benefits of ecigarettes our findings provide insight into what we can learn from the conscious decisionmaking process of ecigarette users who switched from cigarettes to ecigarettes this information can be considered to develop targeted communications strategies to stimulate a conscious decisionmaking process these may highlight benefits of switching to ecigarettes for cigarette smokers discussing the risks of smoking and correcting misperceptions about the perceived risks and benefits of ecigarette use

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introduction the novel coronavirus disease 2019 is a deadly respiratory and systemic disease caused by the severe acute respiratory syndrome coronavirus 2 which has infected over 210 million people and unfortunately killed over 4 million globally as of august 18th 2021 about two thirds of people with covid19 are asymptomatic but other individuals may become severely ill and require hospitalization with respiratory support humantohuman transmission of covid19 occurs through respiratory droplets contaminated objects direct physical contact with infected people and potentially aerosols at the early onset of the pandemic the world health organization strongly recommended countries to implement interventions to curb the rapid spread of covid19 through minimizing contact between infected and uninfected persons so far these measures have included lockdowns closure of educational institutions and public places banning of large gatherings selfisolationquarantine shielding of the individuals most vulnerable to the infection use of personal protection equipment and stringent personal methods of hand hygiene and physical distancing these measures were necessary at the onset of this novel pandemic to help health systems and policymakers adopt strategies to tackle the virus adequately the covid19 pandemic is arguably the biggest global health crisis of the twentyfirst century it continues to impose enormous strain on healthcare systems and plunges nations to a standstill with an unprecedented social and economic impact worldwide considering that vaccine development is the most effective strategy to prevent and eliminate infectious diseases the global health community began work in earnest with regards to covid19 vaccines recently the pfizerbiontech reached a critical milestone in the vaccine development programme at a time when the infection rates continue to rise and stretch hospitals beyond their capacities amidst prolonged lockdowns and economies struggling to reopen with the recent breakthrough development of covid19 vaccines by several manufacturers governments across the globe are in a race against time to acquire and rollout largescale vaccinations of its population however this will require strategies and frameworks that promote peoples trust in and the acceptance of the vaccine despite the availability of covid19 vaccines generally vaccination has continued to be a subject of many different controversies and vaccination scares these controversies have affected vaccine acceptance to varying degrees and led to rising incidence of vaccine hesitancy worldwide particularly among minority groups vaccine hesitancy ranked among the 2019 top ten global health threats and is often characterized by a delay or refusal of vaccines despite the availability of vaccination services though the reasons for vaccine hesitancy are multifaceted a prominent factor may be the proliferation of conspiracy theories and misinformation arising from several sources particularly antivaccination activists until this is addressed it poses an enormous threat to achieving coverage and community immunity therefore there is the need for more research to address this hesitancy and identify potential factors that could build public trust to accept the vaccination programmes the covid19 pandemic has further illustrated that vaccine research development and rollout is crucial for combating emerging infectious disease outbreaks but has also revealed many unanticipated side effects ethical behavioral and inequality questions we hypothesize that vaccine hesitancy is prevalent among minority ethnic populations and might vary from the ghanaiandutch afro and hindustani surinamesedutch communities in amsterdam available evidence from the most successful countries in terms of covid19 vaccines rollout and percentage of population vaccinated against covid19 indicates that the uptake of the vaccination programmes is lower among people from minority ethnic groups scientists have been attempting to understand contemporary vaccine hesitancy leading to refusal particularly by focusing on the influences around how people make decisions sobo has demonstrated how vaccine refusers in schools in the united states are not homogenous showing how hesitancy can lead to selective refusal of vaccines or doses and hesitancy can be traced along nuanced roots of efficacy adverse reactions as well as the broader political and economic culture of vaccine products processing and procurement this present study attempted to identify and understand public perceptions and decision making among the ghanaiandutch afro and hindustani surinamesedutch people resident in amsterdam regarding covid19 vaccine this is because vaccine hesitancy might partly be fuelled by inadequate knowledge about the prevalence and actual burden of the disease unaddressed concerns about the safety of a vaccine could contribute to vaccine hesitancy it could also be influenced by the lack of confidence of the vaccines and complacency regarding the need for vaccination and the perception of how conveniently it can be obtained in this study therefore we plan to investigate the driving factors and causes of vaccine hesitancy with reference to the uptake of covid19 vaccines and develop a framework to mitigate vaccine hesitancy in these communities this is because mass vaccination programmes and its acceptability are shaped by context in addition to individual and vaccinespecific factors we attempt to evaluate the potential vaccination compliance rates among the minority ethnic populations in amsterdam vaccine hesitancy remains a complex public health issue referring to concerns about the safety efficacy or need for vaccination relatively little is known about vaccine hesitancy among these minority ethnic groups we aim to assess the sociocultural determinants of vaccine hesitancy regarding covid19 vaccines among the three communities in amsterdam our aim is to provide a detailed characterization of vaccine hesitancy and the sociocultural factors to assist policy developers in designing an intervention tailored to improve covid19 vaccination among people from minority ethnic groups in amsterdam it is against this background that we explore some issues relating to peoples acceptance refusal or delay regarding the covid19 vaccines materials and methods study design this was a pilot study that applied a mixture of quantitative and qualitative methods to investigate the spectrumfactors responsible for vaccine hesitancy and develop a framework aimed at improving vaccine uptake in the ghanaiandutch afro and hindustani surinamesedutch communities in amsterdam the application of these mixed methods allowed for the triangulation of the data to increase its accurateness this was a communitybased crosssectional survey study and indepth interviews conducted from january 30th to april 30th 2021 study area and population the study was conducted in the city of amsterdam the capital and most populous city of the netherlands the metropolitan region of amsterdam has an estimated population of 2480393 and home to many nondutch immigrants who either settled for economic reasons or as asylum seekers and undocumented migrants available statistics show that native dutch residents constitute about 466 while the remaining trace their routes through immigration among these minority ethnic groups in amsterdam are people with surinamese and ghanaian backgrounds according to current figures as published by the statistics netherlands there are 356402 people of surinamese origin making up nearly 21 of the dutch population out of this surinamese population 176963 belong to the first generation while 179439 representing more than half of them were born in the netherlands surinamese with an african background are mainly the descendants of west africans and those with a southasian background have their roots in north india it is also estimated that there are about 12184 persons who trace their route from ghana and live within the municipality of amsterdam available records showed that about half of the officially registered people with ghanaian and surinamese background reside in the bijlmermeer a suburb of zuid oost municipality the zuid oost municipality is ethnically highly diverse and it is often referred as amsterdam citys black neighborhood due to the presence of many african migrants numerous shops sell foods articles and fabrics from ghana and suriname it is also an area where several beauticians and hairdressers with diverse background are located the ghanaiandutch as well as the surinamesedutch residents form a closelyknit community and are predominantly religious ethics considerations sampling for this study was part of a bigger research project sexual wellbeing and relationships among migrants from subsahara africa in the netherlands this study was approved by amsterdam institute for social science research the ethics advisory board of the university of amsterdam the netherlands respondents were informed about the purpose nature and procedures of the survey and the indepth interviews no respondent was coerced to participate in this survey and all those who responded did so willingly likewise all respondents who took part in the indepth interviews willingly consented to be part of this study there were no personal identifications requested as part of this survey all names used in this report are pseudonyms selection and recruitment of study respondents the target populations for this study were people with a ghanaian or surinamese background residing in amsterdam it included all persons aged 18 years and above respondents were recruited through personal invitations on the streets from churches online social media platforms community parks and snowballing most of the respondents were recruited at hairdressing saloonsshops marketplaces and workplaces study procedure and data collection quantitative procedures sample size justification sample size for this study was estimated using g power © statistical software the input assumptions for the sample size calculation were an a priori f test with a 5 margin of error at 95 confidence level following this the minimum sample size required to sufficiently power the study assuming a 100 response rate and no dropout is approximately 70 per community making a total of 210 participants however assuming a 20 nonresponse rate the number of participants per community is 84 this will make a total effective sample size of about 250 participants for the study administration of survey questionnaire using a standard questionnaire sociodemographic data including sex age ethnicity level of education occupation and household composition of respondents were collected respondents were asked about their previous history of vaccination against other flulike diseases such as influenza and whether they intend to accept the covid19 vaccination respondents who accepted or declined the acceptance of covid19 vaccine were asked further questions to determine the push and pull factors toward covid19 vaccination data collection was done through face to face interview and digitally using an online survey tool determination of vaccine hesitancy the most widely used model in explaining and developing strategies to overcome vaccine hesitancy is the 3cs model developed by the sage working group on vaccine hesitancy from the world health organization the three concerns that influence vaccine acceptance hesitancy delayal or refusal are as follows • confidence • complacency • convenience as part of the survey questionnaire this study sought to measure the confidence of respondents from these communities in the covid19 vaccines or vaccination programme in amsterdam the netherlands the level of trust was answered using a 10choice scale ranging from a very low level to a very high level the study also sought to measure the level of complacency by asking respondents if they thought it was important for everyone to take vaccine and whether they perceived covid19 as a risk to their health or wellbeing in terms of convenience respondents were asked if they were aware about the availability of covid19 vaccines in amsterdam and whether they were planning to take the vaccine qualitative procedures indepth interviews respondents who agreed were invited for additional indepth interviews to determine the sociocultural factors driving their decisonmaking toward the covid19 vaccine acceptance or hesitancy indepth interviews were conducted simultaneously alongside the collection of the survey data with the respondents during the idis the questions that generated further elaborations from the respondents were probed to investigate reasons for any discrepancies between data from the survey and what people do or say in addition this study explored further to understand the choices people made and the motivations behind those choices this was a mechanism to ensure accurate data on the sociocultural beliefs and provide an understanding of the factors behind the choices people made the idis were also used to discuss immediate past practices of the survey respondents that informed their current behavior decisions knowledge and opinions this allowed for the researchers to link the choices of the respondents participant observation participant observation was a continuous element throughout the data collection procedure during data collection a considerable time was spent in places that amsterdam residents of ghanaian or surinamese background pointed out as the most popular public places they visited for diverse reasons the average number of people going there each day was also observed the research team also visited some churches on different sundays to observe the interaction between congregants present besides generating important contextual information participant observation enabled the building of rapport with respondents but also generated conversations on prevention methods that were difficult andor easy to adhere to most of the data were completed through facetoface or use of video call interviews and that enabled the respondents to seek further clarification on some questions they did not completely understand at all times both the respondent and interviewer had their facenose mask on and maintained a physical distance of 15 m from each other collection of ethnographic data and its validation through a systematic inquiry attempts were made by the researchers to consider all matters sensitive to the ghanaiandutch and surinamesedutch communities regarding the objective of this survey study to assure the quality of the collected data the questions were prepared first in english and then translated into the dutch or twi languages by the researcher for respondents who could not adequately understand or express themselves in english appropriate modifications such as wording changing terms rephrasing for better understanding deleting and adding some information for clarity were made on the tool accordingly the researchers closely observed and monitored data collection data analysis the data collected through paper questionnaires and google forms were entered into excel and exported for analysis using spss software the descriptive proportions of participants who used each common source to obtain information about covid19 were presented in terms of number and percentage the survey aimed to collect 50 responses from the ghanaiandutch and each of the surinamesedutch communities putting together a representative sample of the ghanaiandutch and surinamesedutch residents in amsterdam was not possible within the limited time and budget for this study however as previous research works have shown and this present study shows efforts directed at specific groups and focus on their unique concerns were more effective than broad messages directed to the whole population due to the method of sampling some results and analysis are generalizable to the various age occupational and ethnic groups who make up the sample but this is not a representative crosssample of the three communities in amsterdam results demographic characteristics of study respondents the demographic characteristics of the study respondents are presented in table 1 at the end of the survey a total of 160 responses for the survey and 36 idi were collected through facetoface telephone and online interviews there were more male respondents 86 compared to females 74 in both the afro and hindustani surinamesedutch groups there were more male respondents than the female respondents however among the respondents from the ghanaiandutch community there were more females 30 compared to the males respondents belonging to the 1825 years constituted the lowest proportion 25 while those in the 3645 years had the highest proportion 37 with a median age range of all the respondents between 36 and 45 years all but one of the respondents had some level of formal education ranging from primary school to doctoral degrees had accepted previous vaccines to other flulike diseases among the hindustanidutch respondents 40 out of 49 had also previously been vaccinated against other flulike diseases factors that promoted compliance to previous vaccination programmes against other flulike diseases among the 44 afro surinamesedutch respondents who took previous vaccine against other flulike diseases 20 reported that they took the vaccine because they considered it was safe and effective meanwhile 19 took the vaccine because it was mandatory and part of a nationwide vaccination programme however beyond mandatory and perceived safety or efficacy some respondents 11 also felt convinced that the vaccine provided protection against a deadly disease among the ghanaiandutch respondents the main driving factors for accepting previous vaccine against other flulike diseases were based on the proven safety and effectiveness of the vaccines and because it was mandatory or government policy similarly for the hindustanidutch community most of the respondents also accepted previous vaccines against other flulike diseases because of the proven safety and effectiveness of the vaccines and because it was mandatory or government policy as shown in table 3 no respondent reported from the three ethnic groups indicated that religious or ideological belief influenced them toward or against taking the other flulike vaccines determining factors for uptake of covid19 vaccine all the respondents who took part in this study were asked if they had already taken the covid19 vaccine only 2 representing 36 out of the 55 respondents from the ghanaiandutch community had taken at least one dose of the vaccine among the afro surinamesedutch respondents only 7 had also taken at least one dose of the vaccine while a further 7 out of the 49 hindustanidutch respondents had taken the vaccine furthermore respondents in this study were asked if they were planning to take the covid19 vaccine the results showed that the number and percentage of respondents who were likely to take the vaccine among the ghanaiandutch afro surinamesedutch and hindustanidutch were 26 26 and 23 respectively there were 16 11 and 13 respondents from the ghanaiandutch afro surinamesedutch and hindustanidutch respectively that indicated they would not take the covid19 vaccines a further 13 17 and 13 of respondents from the ghanaiandutch afro surinamesedutch and hindustanidutch were undecided about taking the vaccine in summary the willingness to take the covid19 vaccine was relatively similar among respondents from the ghanaiandutch and afro surinamesedutch respondents however the highest proportion of respondents who are undecided about taking the vaccines are from the afro surinamesedutch community the data collection for the ghanaiandutch respondents were completed on 14th february 2021 and at this time the total number of people who had received at least one dose of covid19 vaccine in the netherlands was 694075 representing 40 of the population generally the willingness to take the covid19 vaccine appeared to be dependent on age groups and gender the dependence on occupational status was not clearly determined in this study the level of education was evenly distributed among the groups and showed no effect in specific terms with regards to age although older respondents were more likely to say they would be vaccinated younger respondents age 2635 were also more likely than those younger than them or immediately older than them in the 3645 age group in terms of gender males were significantly more likely to agree to be vaccinated than the females the relationship between level of education and willingness to be vaccinated was not linear however respondents with a highvocational school education formed a large proportion of those who were more willing to be vaccinated in terms of occupation those who showed willingness to be vaccinated include students unemployed selfemployed and retired personnel for most students the willingness to get vaccinated was largely dependent on their eagerness to focus on their education with limited interruptions while the selfemployed people who traveled for their businesses favored getting vaccinated interestingly healthcare workers were the least willing to be vaccinated among the various occupations perceptions and assessment of vaccine hesitancy the result on perception and assessment of vaccine hesitancy is presented under complacency confidence and convenience complacency all respondents were asked the question do you perceive covid19 crisis as a threat to your personal health or wellbeing out of a total of 55 respondents from the ghanaiandutch 40 representing 727 perceived covid19 as a threat to their personal health or wellbeing out of 52 respondents from the afro surinamesedutch community 37 representing 712 answered yes indicating that covid19 had negatively affected their wellbeing from the hindustanidutch community 42 out of 49 respondents also perceived covid19 as a threat to their personal health or wellbeing many of the people affected by the pandemic explained their choice was based on the distressing effects of the covid19 on people in their families and communities health or even loss of family friends and neighbors others talked about it mainly because of the financial hardships that accompanied because they lost their jobs or were unable to pay for bills for some their businesses did not run fully and led to accumulated debts all of these had resulted in a psychological toll on their lives of many respondents talking to 53yearold anish he explained that the hindustani community in amsterdam is perhaps the worst hit with covid19 fatalities saying due to the lockdown many of us were not seeing each other we socialize less but after that i heard people telling me other people i knew had died from corona you ask of people you used to play cards with and then you are told they died so very sad i even read an article that said that a lot of hindoestaanse have died from covid it is very serious and most of us apart from age have some other sicknesses i have diabetes when age and these heart conditions come together plus corona then we are heading toward a lot of death among the ghanaiandutch respondents 27 indicated that it is important for everyone to take the vaccine among the afro surinamesedutch respondents majority of them 26 responded that i think it is important for everyone to take it a high proportion of respondents from the hindustanidutch community 22 think that it is important for everyone to take the vaccine compared to the other two groups the hindustanidutch community had a slightly higher proportion of respondents who think the vaccine is not important 4 none of the respondents from the ghanaiandutch or the afro surinamesedutch indicated that it is not important confidence to gauge the perception toward the current covid19 vaccines respondents were asked what do you think about the covid19 vaccine the responses received across the different ethnic communities are presented below in table 4 the majority of respondents 25 from the ghanaiandutch community reported that they do not trust the effectiveness and safety of the covid19 vaccine and only 10 of the respondents believed that the vaccines are effective and safe only 1 respondent indicated it was a conspiracy by the government to control the people among the afro surinamesedutch respondents 18 also answered that i dont trust the effectiveness and safety while 7 indicated that i think it is effective and safe there were 2 respondents who considered the introduction of the covid19 vaccines was a conspiracy by the government to control us the largest proportion of respondents of the hindustanidutch community 25 indicated that they do not trust the effective and safety of the vaccine a further 13 think that the vaccines are effective and safe a few of the respondents 5 from the hindustanidutch community also considered the vaccine as a government policy to control the citizens in general the proportion of respondents who indicated that they do not trust the effectiveness and safety of the vaccine were highest among the hindustanidutch followed by the ghanaiandutch and lastly the afro surinamesedutch communities scaling of confidence level in the covid19 vaccines the results presented in table 4 above shows that trust in the safety and effectiveness of the covid19 vaccines was a major concern for most of the respondents in this survey this survey therefore attempted to examine the level of confidence of the vaccines by asking the question how would you rate your level of trust in the covid19 vaccine to offer protection against severe disease a 10grade scale was used to assess the level of trust by choosing from very low to very high figure 2 shows the illustration of the level of trust as reported by all the 160 respondents from the various communities the peak level of trust in the covid19 vaccines as expressed by respondents for the ghanaian community was 7 out of 10 among the afro surinamesedutch community 16 out of the 54 respondents scored their level of trust in the covid19 vaccines as 810 for respondents from the hindustanidutch the peak level of trust was 7 thus there was a general skewness above the midpoint level of confidence an indication of a high level of trust in the effectiveness of the vaccines to protect them convenience this survey considered the level of awareness and concerns of the respondents of the ongoing covid19 vaccination a total of 53 out of the 55 respondents from the ghanaiandutch community were aware of the availability or that covid19 vaccination has started in amsterdam and across the netherlands among the afro surinamesedutch respondents nearly all of the 52 respondents indicated they were aware about the availability or that covid19 vaccination had started in amsterdam out of a total of 49 responses received from the hindustanidutch community 45 representing 92 respondents indicated their awareness about the covid19 vaccination programmes being implemented across the metropolitan region in amsterdam and across the netherlands those who said they did not know were of the view that it was the trial period and perhaps the largescale vaccination would start later a total of 35 out of the 55 respondents from the ghanaiandutch community answered yes to the question do you have any concerns about taking the covid19 vaccine in addition 32 of the 52 respondents from the afro surinamesedutch community to the question do you have any concerns about taking the covid19 vaccine answered yes among the hindustanidutch 32 out of 48 respondents indicated that they also had concerns about the covid19 vaccines a significant proportion of the respondents indicated they fear that the covid19 vaccine may either be harmful or have severe side effects some respondents were simply concerned that the vaccine was discovered too quickly these were followed by concerns such as the vaccine is government policy to useintroduce vaccine passport to control us lack of trust in the science behind the vaccine development and lack of trust in the sourcemanufacturer of the covid19 vaccine taking urgency and cautiousness together participants views and interest in the covid19 vaccination were mixed a close observation revealed that people were carefully engaging with the experiences and stories of others regarding the covid19 vaccination as noted by sahoed a 57 years old afro surinamesedutch man it would be an understatement to say i rushed to my huisart to get my prick two days ago rolling down my sleeve after my prick i felt as if i had been fully protected and can start hugging and visiting friends again but my joy was not for long when i realized many of my friends and family did not want to get the prick or when they wanted they could hardly get it because it was not their time yet the decision is a hard one to think of but i am happy i am out of the dangerous zones factors likely to influence acceptance of the covid19 vaccine majority of the respondents 37 from the ghanaiandutch community indicated their preparedness to take the covid19 vaccine when it is proven to be safe and effective other factors that could influence the acceptance of the covid19 vaccine are personal understandings 12 travel requirement 7 and trust in government policy 5 only a small proportion of respondents indicated their willingness to accept the covid19 vaccine when it is recommended by their family and friends 2 or by their employers 2 the study showed that 29 among the afro surinamesedutch respondents indicated that the most influential factors that can influence their willingness to take the vaccine is when there is a mandatory introduction of a vaccine passport by the government the availability of sufficient scientific data to prove a high vaccine efficacy and mandatory vaccination as a travel requirement account for 40 and 36 respectively recommendations by family and friends 8 or by respondents general practitioners 3 or by employers 2 were other factors that could influence acceptance of covid19 vaccination among the hindustanidutch community the scientific proven high vaccine effectiveness and safety could encourage about 413 of the respondents to accept the vaccine in addition this study shows that 32 of the respondents appear likely to accept the vaccine when the introduction of vaccine passports is made mandatory by the government other major factors that could drive the likelihood of accepting the covid19 vaccine include travel requirement for vaccination the probability of minor side effects and recommendation by family and friends discussion perception of the covid19 vaccination national polls conducted in the netherlands before the roll out of covid19 vaccination programmes began suggested that about 40 of the population were hesitant to receive covid19 vaccination however the public perception and response to the covid19 vaccination among some minority ethnic groups remain undetermined this present study revealed that some respondents think that the covid19 vaccine is important because of the significant effect of previous vaccinations toward other contagious diseases while others had concerns about how the covid19 vaccines will come to shape almost every area of their lives either granting them access or not to certain spaces and settings the findings from this present study show that public or individual perceptions about the covid19 are not homogenous but appear to vary widely among people from the minority ethnic communities in amsterdam more so it shows that there are wide sociocultural and demographic status variations in the perception or opinions and understandings among individuals within the same community or among the three selected minority ethnic groups showing the differences concerning their vulnerability or reluctance to engage with covid19 vaccination programmes even before the pandemic public health agencies around the world were struggling to counter increasingly sophisticated efforts to turn people against vaccines in general coronavirus vaccines seem to face additional hurdles especially the lack of a longterm safety record as well as inadequate stories of others that had received the vaccine especially at the time of data collection the frenetic pace of vaccine development has played into the concerns raised by respondents in this study as seen in other research works even those who are eager to receive their shots have been worried that the vaccine could be ineffective or have harmful side effects luptons p 7 underscores that risk perception is intersubjective produced through social relations and so through observation and interviews we can better understand the ways of making sense of situations naming responses part of the diverse cultural meaning systems that we use to try to understand the world one significant observation in this present study was the claims that one could boost their immune system or cure covid19 by taking vegetables and fruits including vitamin c and hot herbal teas when people have perceptions that taking certain medications herbs or immune boosters can protect them against the virus or even heal them it could have huge impact on their decisionmaking regarding taking vaccines the implication is also that such people may hesitate refuse or delay in taking up the covid19 vaccine besides the safety concerns others were concerned that the different vaccines may be a conspiracy by the governments all over the world to control population the notion that the disease is a conspiracy involving the governments and philanthropists has an effect on the reception of the covid19 vaccine many of our study respondents have relied on social media posts to create the psychological habits that makes them think doing nothing is safer than taking action the health belief model and its conceptual framework have been very instrumental for evaluating some of these psychological habits beliefs and attitude toward some major vaccines including those against influenza swine flu and covid19 however our present study did not examine the covid19 acceptance or hesitancy factors based on the constructs of the hbm this is because as our findings show using such models alone to evaluate health decisions by people could be inadequate as their decisions are influenced also by their current living situation advice from friends or experts past experiences and embodied routines more so in a media environment that favors speed emotion and memorable stories that can easily circulate it is essential that the accurate and reliable information on vaccine safety and effectiveness is clearly available thus it may be important for the media as well as the dutch public health agencies to focus on publishing more diverse stories with different outcomes and avoid the danger of single story that portrays doom the stories people see hear or read have an impact on how they decide on important issues that concerns their live and that of others the dutch public health service could follow some of the current initiatives have pioneered a more storybased approach such as the national human papillomavirus vaccination roundtable which promotes vaccination against the human papillomavirus a leading cause of cervical cancer through youtube videos of women who survived cervical cancer to share their story with other women determinants of covid19 vaccine among minority ethnic groups in the netherlands emerging evidence from some of the countries with most successful early roll out of covid19 vaccination for its population including israel chile united states of america and the united kingdom shows that the uptake of vaccines among minority groups is low findings from this present study shows that 4 13 and 14 of respondents from the ghanaiandutch afro surinamesedutch and the hindustani surinamesedutch communities respectively had taken at least one dose of the covid19 vaccines as of 7th february 2021 when data collection for the ghanaiandutch community was concluded only 694 075 of the dutch population had been vaccinated thus it is difficult to assume that there was a higher vaccine hesitancy rate among the ghanaiandutch community as the proportion seem to correspond with that of the general population at the time however as at 25th april 2021 when data collection for the afro surinamesedutch and hindustanidutch ended a total of 3930671 people in the netherlands had received at least one dose of the vaccine representing 227 of the countrys population this suggests that the uptake of the covid19 vaccines may be low among these two minority ethnic groups compared to the national average this finding shows the need to pay particular attention to where there are divergences among population groups in a similar study in the uk it was found that there was substantial divergence in the uptake of vaccine as the proportion of those vaccinated was lowest at 205 among the black population of bangladeshi and pakistani descent the findings from this present study and others raises great public health concern since people from these minority ethnic groups seem to have the highest covid19 hospitalization and mortality rates in the netherlands including higher rates of job loss among others in a recent study the ghanaiandutch population had a high seropositive prevalence for covid19 and was found to be associated with age and large household composition our findings also showed a high proportion of respondents across the three ethnic groups live in homes with high household sizes and that could pose a great public health threat if efforts to improve vaccination rate are not implemented to protect individuals and their households the findings from this study revealed that the percentage of respondents who were likely to take the vaccine among the ghanaiandutch afro surinamesedutch and hindustanidutch were 473 481 and 47 respectively our findings show that the male respondents were more likely to accept the vaccine than the female respondents agedependent analysis also indicated that the likelihood to accept the covid19 vaccination was linearly correlated with increasing age with the highest acceptance among respondents aged 56 years or older this finding is similar to other findings from israel which showed the highest uptake of covid19 vaccine among persons aged 50 years or older consequently there were nearly 236 315 and 265 of respondents from the ghanaiandutch afro surinamesedutch and hindustanidutch respectively who were undecided about taking the vaccine a further 291 204 and 265 of respondents from the ghanaiandutch afro surinamesedutch and hindustanidutch respectively opted not to take the covid19 vaccines as suggested by earlier studies the main factors for the low uptake of covid19 vaccines include perceived lower risk of infection socially disadvantaged groups socioeconomic status level of education inconvenience and access barriers in addition this present study show that other factors for the low uptake of covid19 vaccines is the lack or low level of confidence in the safety or efficacy of the vaccines across all ethnic demographic and occupational groups in this present study this confidence is grounded not in the reputation of any single manufacturer of vaccines but on the scientific method that is required by manufacturers to demonstrate that a vaccine works and is safe our findings revealed that respondents showed trust and confidence in the ability of the covid19 vaccine to protect them but were skeptical about the notion of good and bad covid19 vaccines this is in reference to the news in the media about certain types of vaccines causing some rare form of thrombosis in persons who took that vaccination as evident by this the fear of the covid19 vaccine causing harmful or severe side effects appears to be the major concern respondents had about the covid19 vaccines the finding from this study supports the findings by the uk scientific advisory group for emergencies ethnicity subgroup review in december 2020 that looked at the factors influencing covid19 vaccine uptake among minority ethnic groups the causes of vaccine hesitancy often correspond strongly with past research around public confidence in various vaccines this study has demonstrated that covid19 vaccine decisionmaking of some ethnic minorities in the netherlands may hinge on issues concerns and anxieties a vitriolic public message or representations that single out minority ethnic groups may only run the risk of damaging their relations with public health and other health institutions or workers and can be avoided by better understanding the processes of vaccine decisionmaking the main limitation of this study was that data collection was conducted at the period when the covid19 infection rate in the netherlands had reached its second peak the imposition of strict lockdown and other mitigation measures such as work from home and ban on mass meeting made it difficult to recruit a high number of study participants as a result participant observations were limited to participants who were willing to invite us into their homes meetings in addition to open public spaces conclusion the covid19 pandemic has created the need of developing a prioritized set of vaccine recommendations and communications as well as varying them among different communities this survey study provided a systematic evidence of factors associated with participants decision making regarding covid19 vaccination among the ghanaiandutch afro surinamesedutch and the hindustanidutch communities in amsterdam the findings show that vaccine choice and likelihood of selfreported willingness to receive a vaccine were associated with vaccine efficacies as shown in this study the scientific demonstration of high vaccine efficacy could encourage about 413 of the respondents to accept the vaccine in addition 696 of the respondents appear likely to accept the vaccine when the introduction of vaccine passports is made mandatory by the government other major factors that could drive the likelihood of accepting the covid19 vaccine include travel requirement for vaccination the probability of minor side effects and recommendation by family and friends the analyses in this study provide insights about the groups or factors that are likely to be associated with vaccine hesitancy so as to inform public health efforts to communicate effectively about the covid19 vaccine data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by aissr ethics board written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

the outbreak of the deadly novel coronavirus disease covid19 has disrupted life worldwide in an unprecedented manner over the period scientific breakthroughs have resulted in the rollout of many vaccination programmes to protect against the disease reduce the fear and ease public health restrictions for lives to return to some normalcy the aim of this study was to identify the factors responsible for covid19 vaccine acceptance or vaccine hesitancy and to develop a framework to improve vaccine uptake in the ghanaiandutch afro and hindustani surinamesedutch communities in amsterdam using a mixed method approach this communitybased crosssectional survey recruited 160 respondents consisting of 57 ghanaiandutch 54 afro surinamesedutch and 49 hindustanidutch residents in amsterdam our findings showed that the choice of a vaccine as well as the likelihood of selfreported willingness to receive a vaccine is highly dependent on vaccine efficacy and safety available evidence of high vaccine effectiveness and safety could encourage about 413 of the respondents to accept the vaccine additionally 696 of the respondents indicated their willingness to accept the vaccine when vaccine passports are made mandatory by the government other major factors that could drive the likelihood of accepting the covid19 vaccine include travel requirement for vaccination 283 the safetyprobability of only minor side effects 261 and recommendation by family and friends 152 the study therefore provides systematic evidence of factors associated with individual preferences toward covid19 vaccination it demonstrates that the needs of each community are unique and specific interventional efforts are urgently needed to address concerns likely to be associated with vaccine hesitancy

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© 2024 conscientia beam all rights reserved and socioeconomic wellbeing such as poverty and family breakdown in nigeria the most widely used and abused substances are alcohol and cannabis which are materials of minor medical importance but consumed by millions of people in the country there are cases of other substance abuse or misuse such as lysergic acid diethylamide tramadol and methamphetamines to obtain comparable and trustworthy data for addressing the threat it is critical to identify the sociodemographic characteristics and prevalence of usage of these substances tobacco smoking or the use of hard drugs are leading causes of mortality and morbidity nearly one billion people worldwide consume tobacco and smoking is a great economic burden on health systems and families of smokers especially in developing countries with limited resources in nigeria substance abuse has become a household problem and nigeria is the leading consumer of illicit drugs among african countries the prevalence rate for amphetamine use in africa was 0214 and that in nigeria was also the highest in africa drug addiction which is a broadspectrum multietiological disorder has many negative longlasting effects on individual wellbeing particularly that of young adults several studies have examined the prevalence epidemiology prevention rate trends and influence of substance use disorders some studies have found an association between personality traits and substance use while others have found that psychopathology and personality traits have an effect on substance abuse even in adolescents a comorbidity of personality disorders in individuals with substance use disorders has also been reported thus many researchers have used a comorbidity hypothesis to explain substance abuse disorders in different populations nguyen et al examined the knowledge on human immunodeficiency virus perceived risk and hiv testing among users of methadone maintenance services in some vietnamese communities and found satisfactory knowledge of the disease among users with most of them conducting safe practices towards transmission however newly admitted patients in the area clinics showed high levels of hivrisk behaviors such as drug injection smoking drinking and unprotected sexual intercourse longer duration of methadone maintenance therapy was significantly correlated with reduced illicit drug use and higher levels of psychological distress were associated with increased use of illicit drugs among patients it is important to explore the prevailing use of illicit drugs and the sociodemographic factors associated with their use in order to gain reliable and comparable data for addressing the menace however there is little research information to support a thorough understanding of the variables that predispose citizens to drug abuse or help in the formulation of effective measures for ensuring public health and safety in nigeria here we studied the sociodemographic factors as perceived by the victims that affect drug addiction in the southern senatorial district of cross river state nigeria the factors examined were sex peer influence occupational status social environment and individual level of education methodology the study was conducted in the southern senatorial district of cross river nigeria comprising calabar municipality calabar south akpabuyo akamkpa bakassi biase and odukpani local government areas together these areas have a population of about 16 million people the major languages spoken are efik efut and ejagham according to the traditional residential areas of the efiks efut and qua communities the district is well known for its tourist and business activities and is home to nigerias premier export free zone the sample size for this study comprised respondents admitted for drug abuse in the psychiatric hospital calabar and those that could be assessed from the selected local government areas in the southern senatorial district a total of 381 people were sampled from five out of the seven lgas for the study akamkpa akpabuyo calabar south calabar municipality and odukpani lgas each of these five local government areas had 7 health facilities including a general hospital in addition to the university of calabar teaching hospital and the calabar neuropsychiatric hospital these public health facilities have frequent cases of drug and substance humanities and social sciences letters 2024 12 2432 reactions in emergency care units fiftynine patients were sampled from the facilities in each of the five lgas while 35 patients were sampled from ucth and 54 from neuropsychiatric hospital for a total random sample of 384 respondents a questionnaire consisting of 48item questions subsumed into sections a b and c was used section a solicited information on the demographic background of the respondents such as sex age educational status marital status occupation religion etc section b carried structural questions measuring the opinions of respondents on the independent variables under study section c consisted of items focusing on the dependent variables views on drug addiction most of the questions posed in this study were based on the likert scale with a series of opinion statements about drug addiction to which the respondents were asked to indicate the degree to which they agreed or disagreed with the opinions expressed the questionnaire was distributed to 384 respondents of whom 381 were retrieved for analysis returns from the field were checked to ensure that all the questionnaires were collected the responses were coded and summarized using frequency distribution and simple percentages results and discussion the majority of the respondents were males while 129 were females thus male respondents dominated the study population suggesting that the males are more likely to take drugs or be addicted than the females nearly 30 of the respondents were aged 1827 years 241 were aged 2827yrs 223 were aged 3847 years and 236 were aged 48 years or older thus the youths aged 1827 were the modal group of addicted persons in the study area augustine and godiya also found a high incidence of substance use and abuse among people aged 1824 about 49 of the respondents were single 354 were married 134 were single parents and 18 respondents were divorced nearly fifteen percent of the respondents had primary education 375 had secondary education 365 had tertiary education and 113 had no formal education these data suggest that the majority of the addicts were secondary school leavers by religious affiliation 929 were christians 39 were muslims and 31 were of other religions about 93 of the respondents were not employed 31 were civil servants and 39 were farmers this suggests that unemployment predisposes people in the area to drug addiction table 3 presents results on the perception of gender differences in relation to drug addiction about 93 of the respondents agreed that men were more addicted to hard drugs than women while only 71 did not about the same ratio of respondents agreed that men use drugs more however 625 of the respondents considered that there was no difference between men and women as to who takes a greater variety of drugs compared with 375 who considered that there was a difference the response by 314 respondents also showed that both men and women take tramadol and alcoholic drinks and about 79 of them considered that addiction was more common © 2024 conscientia beam all rights reserved with males than females for the specific drug marijuana 782 of the respondents considered that it affects women more than men the responses further showed that the intake of drugs varied between the sexes the observed perception of differences between the sexes confirmed an earlier report of gender differences in predisposition to drug and substance abuse according to hser evans teruya huang and anglin there is less likelihood for women than men to abuse drugs and when this happens the abuse occurs much later in life than in men however women were greater abusers of some other substances than men and women progressed from regular use to first treatment more rapidly than men for many substances including alcohol cannabis and opioids there is no difference in drug intake between men and women 238 143 4 in my community both men and women take tramadol and alcoholic drinks 314 6 5 many reported cases of addiction involve more men than women 304 77 6 igboh or wi wi affects women more than men 298 83 table 4 presents data on the scale of pear influence on drug addiction more respondents agreed that younger people abuse substances more than older people and 832 of respondents were certain that drug abuse was more prevalent among secondary school students the majority of respondents agreed that young addicts influence children into addiction slightly over half of the respondents agreed to failure on the part of parents in checking the company their children keep which results in them becoming addicts about 80 of respondents considered that teen age is the most vulnerable age to becoming an addict and that children aged 12 years and older take tramadol less than half of the respondents were of the opinion that children think taking hard drugs makes them more recognized in their group but a slight majority did not respondents were evenly split on their views as to whether the cause of childrens involvement in illicit drug use was the polarized family structure however about 78 of them did believe that children from broken homes tend to be more addicted overall the data showed that an association with children or friends who abuse drugs could influence others to become drug addicts hsieh and hollister found that the age at which an individual starts substance abuse is significant and peer influence was a major driver of this start peers may influence individuals directly by offering drugs or indirectly through social modelling and perceived norms the high concordance between peer groups and drug use may be a result of individuals seeking out peers with similar interests and behaviours as their own there are several previous reports of young people ruining their lives through illicit drug use relative to other developing countries nigeria is among the highest users of dangerous drugs such as alcohol tobacco cannabis benzodiazepines cocaine and opioids in many higher institutions of learning in the country there have been incessant students unrests riots crimes and cultism many of which were directly or indirectly linked to drug abuse the perception of the respondents as to the effect of social environment on drug addiction showed that about 82 of them believed that social environment can influence drug addiction a majority of them understood that living in an environment where people take hard drugs may influence ones behaviour about 83 of the respondents were aware that the annual calabar carnival festival is a major cause of drug addiction in the area a further 54 of them believed that the carnival has induced a significant number of youths to be addicted to drinking and smoking environment does not influence drug addiction 351 30 also 822 of respondents agreed that residents in the suburban area of calabar south tend to take harder drugs these results showed that a social environment like the carnival calabar and the associated business environment during the christmas season as well as the riverine areas of calabar south and places where hard drugs are sold freely have a significant impact on peoples vulnerability to drugs and could eventually lead to addiction according to benavides and bibb the social environment in which people live could be a stimulant to drug use or addiction as individuals residing in environments notorious for the sale of nicotine or other substances are likely to become addicts among illicit drug users in vietnam le et al found that family income history of drug rejections concurrence in drug usage and distance from clinics affected methadone maintenance treatment scholars have considered close contact and the availability of drugs as risk factors for the use of drugs themselves thus people can be put at risk because of their proximity and close contact with drugs and drinks table 6 presents the perceptions of respondents as to whether unemployed youths tend to be more vulnerable to drug addiction ninety percent of them agreed about 85 agreed that unemployment had no influence on people becoming drugaddicted and 60 did not agree that military personnel abused drugs more than civilians the majority of the respondents opined that gainful employment would minimize the abuse of drugs but 83 were of the opinion that there are unemployed people who do not abuse drugs or are not addicted to them nearly 60 of respondents agreed that addiction is genetic and not caused by occupational status while slightly more than half concurred that a situation of low employability can cause addiction the overall results showed that the nature of an individuals occupation or occupational status can be a factor in drug addiction in the study area thompson found a strong correlation between unemployment and drugtaking habits whether in developed or developing countries and that the lifetime prevalence of drug abuse among the unemployed exceeded that among the employed by 60 employers can make significant contributions to the prevention of drug abuse helping themselves and the community in the process effective workplace initiatives to prevent drug abuse should begin in the community and be directed at young people who are potential workers table 7 shows the perceptions of respondents on the level of education in connection with drug addiction about 76 of the respondents considered that uneducated people abuse drugs more while 59 of them agreed that the number of uneducated addicts exceeded that of educated addicts about 87 of respondents considered that a lack of education leads people to mix all kinds of drugs at once to stay active nearly 67 of them agreed that illiteracy predisposes young adults to taking hard drugs to enhance sexual performance however 69 of them understood that there is no health benefit to being high on drugs while 74 of them agreed that using hard drugs could be harmful to the body the result showed that an individuals level of education as well as knowledge of the effects of hard substances could moderate his use of those substances previous reports by augustine and godiya ebirim and morakinyo okoza pacula ringel and ross and owoaje and bello showed that level of education most especially tertiary education was a consistent predictor of substance abuse although there is global concern and education about psychoactive substances many adolescents have little awareness of their adverse consequences in nigeria a reasonable percentage of the national budget is used for the treatment and rehabilitation of people with substance abuse problems however validated information on the overall effectiveness and costbenefit analysis of various approaches is not usually available drug use and academic failure have some common measurable antecedents at the individual level such as misbehavior and lack of interest in school attention deficits hyperactivity and depression deviant peer groups and early antisocial behaviour the prevalence of these many measurable common risk factors may suggest that unobserved risk factors tend to suppress the negative association between drug use and educational attainment thus a strong correlation between drug use and low educational attainment may not reflect a causal relationship most people using hard drugs do not know that they are harmful to the body 282 99 table 8 presents the level of agreement with widely held views on drug addiction the majority agreed that addiction is harmful to health also the majority agreed or strongly agreed that the use of tramadol beyond practitioners prescription kills and that addiction can cause an individual to indulge in crime the majority of reported cases of rape are due to addiction according to about 53 of respondents and 152 strongly agreed a simple majority agreed that taking hard drugs to enhance sexual performance could be harmful however less than half agreed that addiction causes severe economic damage also nearly half agreed and 228 strongly agreed that addiction can result in poverty two hundred and thirtyfour respondents agreed and about 20 strongly agreed that many youths have lost their lives through the use of hard drugs thus the educational level of the individual social environment occupational status or nature of occupation peer pressure and sex difference have significant influences on drug addiction in the study area conclusion and recommendations in this study we investigated the sociodemographic factors underscoring drug addiction based on the opinions of addicts in the southern senatorial district of cross river state nigeria using a standard questionnaire the factors studied were sex variation occupational status of individuals social environment peer influence and level of education the results showed that the occupational status or nature of the individuals job had a considerable impact on drug addiction this portends significant problems in the workplace respondents also perceived low levels of education high unemployment and general poverty as direct triggers of drug addiction as found during a supplementary interview session many of the addicts who were chronic drugdependent people suffer the double stigma of abject poverty and drug dependency it seems that the social and psychological effects of drug addiction are severe and growing rapidly in the study area public authorities should therefore focus attention on addressing the main causes of addiction by reducing poverty and unemployment providing goodquality childcare implementing labor market programmes and providing effective early intervention programmes such as parental support in the first few years of a childs life parents should monitor the kinds of friends and associations their children belong to eliminate negative peer influence as early as possible the present study is limited to only one state in southern nigeria future research should expand to more states in the region and also explore the effectiveness of government interventions in minimizing cases of drug addiction and abuse in the region

drug addiction has become a serious public health challenge in nigeria today and there is an urgent need to address this problem in this study we investigated the impact of some sociodemographic factors on drug addiction in the southern district of cross river state nigeria during the study a questionnaire survey with 381 respondents who were sampled from the study region was conducted the results showed that sex peer influence occupational status social environment and individual level of education strongly influenced drug addiction about 93 354 of the respondents agreed that men were more addicted to hard drugs than women but 625 of them considered that there was no difference between men and women as to who took more variety of drugs three hundred and seventeen respondents agreed that younger people abuse drugs more than older ones and 832 of them were certain that drug abuse was more prevalent among secondary school students 614 responded that young addicts influence children into addiction the majority of the surveyed population specifically 90 identified unemployment as a significant factor contributing to drug addiction additionally 76 of the respondents said that illiteracy is associated with an increase in drug misuse as the number of addicts without education surpassed those with education many of the addicts suffered from the double stigma of low socioeconomic status and drug dependency it was determined that a reduction in poverty and unemployment the provision of goodquality childcare support for social capital and effective early intervention programs such as parental support in the early years of a childs life would greatly minimize addictionthe study addresses the menace of drug addiction in cross river state nigeria by evaluating the underlining factors of sex peer influence level of education and the social environment addiction can be minimized by reducing poverty and unemployment providing quality child care and introducing an effective social support programglobally people have used drugs and related substances as pain relief and providers of pleasurable sensations the oldest are those derived from the cannabis plant the opium poppy and the coca bush the search for beneficial drugs to treat human illnesses has been the focus of modern medicine however drug use disorder has since been and still remains one of the most serious public health challenges worldwide the number of global deaths from drug misuse increased by more than 60 between 2000 and 2015 drug misuse is a threat to both personal health

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introduction nongovernmental organizations have traditionally performed a range of roles and activities in the situation of developed and developing countries primarily they are wellknown for their vital service role and for leading the way in responding to urgent public requirements 1 ngos have stepped in to make available essential health education and child care services running homes for the destitute and distressed providing training opportunities as well and implementing various rural development activities 2 persons with disabilities require aid and care to attain a decent life to take part in society on an equal basis with others the role of nongovernmental organizations is the need of the hour to support and assist the welfare of disabled persons 3 deafblindness is an exceptional condition that affects around 1 million persons worldwide many children who are deafblind are yet to be recognized because of the complication of diagnosis owing to comorbidity 4 deafblindness refers to a double sensory impairment which means that it is a mutual situation of a loss of hearing and vision cooccurring in a similar person 5 the uniqueness and complexity of the requirements and characteristics of children who are deafblind make it particularly difficult to decide who they are as a result identifying and meeting their needs through proper intervention models and strategies is also difficult children with deaf and blindness have needs that further make difficult participation strategies 6 deafblind children represent the lowest occurrence yet most varied groups of learners receiving early intervention and special education services they make up a tremendously heterogeneous group whose sensory losses are observed through extra bodily or cognitive disabilities complicated clinical wishes and conduct challenges deafblind children cannot learn from their interaction with their environment as easily as their nonhandicapped peers due to their multisensory deprivation 7 persons who are deafblind may also be talented with a range of desires throughout all levels of growth this includes communication parenttoddler relationships cognition and motor and perceptual growth which causes severe educational requirements that cannot be accommodated in special education programs solely for children with deafness or blindness learning occurs through vision and hearing therefore learners who are deafblind need services that are provided by a team of skilled professionals and paraprofessionals who create suitable communication and learning opportunities for them 8 there is a desire for a couple of conversation techniques that ought to be applied in both the house and faculty environments to ease the verbal exchange demanding situations for each party deafblind persons have a very limited scope than people who are just blind or just deaf limited access to social opportunity and social feedback coupled with the communication challenges faced by deafblind children put them at risk for exceptionally late socialization 9 their world is shrunk behind what they can sense in several cases blinddeaf doesnt signify that they cannot see or hear most times it is the degree of impairment that dictates the classification many of them have extremely low visibility and extremely low hearing ability related work 2 s no focus of study outcomefindings reference vulnerability of deafblind people the vulnerability of deafblind persons is considered selfevident and not only as a vulnerable group but also as one of the most vulnerable groups 6 communication with the children who are deafblind and their social partners struggles in the use and understanding of figurative communication supply delays in children with sensory disabilities damen et al 15 7 various challenges from birth to primary education the efforts of the voluntary sector have been recognized by the state to a great extent in the support of the deafblind humphries et al 16 8 the various challenges from birth to postsecondary education attending conferences workshops training and other educational events to help practitioners and parents to reduce the distance between limited research and practice guardino et al 17 9 deafblind children are societys most vulnerable groups deafblind children are unable to learn from communication through their environment the same as their nonhandicapped peers due to their multisensory deficiency sl no focus of study outcomefindings reference 1 deafblind people and various support service providers deafblind people would like and be worthy of the same opportunities to live an active life as afforded by their family friends neighbours and coworkers however the everyday challenges limit their capacity to obtain existing communication information and transportation to attain this goal deeming et al 30 the role of ngos in integrating the differently able in general ngos can work on five stages diagnosis early incorporation schooling higher education and training and development mathew et al 31 3 setting up the minimum standard for the inclusive education of deafblind almost all parents were unable to comprehend the nature of deafblindness but they are eager to learn and be involved in the daily life of them the parents get only a very minimum opening to be involved in their childs education sebuliba et al 32 4 deaf blind persons and their communication independence and isolation deaf blind people are not just inactive beneficiaries of support from others in many ways they can support others as well hersh et al 33 5 early intervention and implementation of preschool special education the curriculum of the national preschool special education should be included as a guide or reference for teachers to accomplish early involvement in preschool special education bari et al 34 6 through the work with deafblind people help to develop a good practice approach deafblind people vary in regarding the type and onset of their sensory impairment their communication modalities orientation and mobility requirements assistive technologies and their identity roy et al 35 research methodology the study explores firsthand information based on the cases of the beneficiaries through their reallife experiences to assess the intervention and effectiveness of the sparsh project on their empowerment the researcher used an interview schedule to gather data from the parents of the beneficiaries secondary data is collected from the journal papers published and available in the google scholar platform between 2012 to 2023 objectives of the study the following study objectives are as below to study the organisational profile to understand the functioning of the sparsh project to review the interventions provided under the sparsh project to assess project outcome assessment based on the case studies to conduct swoc analysis of the sparsh project organisational profile the workers vocational instructors and the centre assistant work with a diverse group of professionals such as government officials medical professionals and other institutions in the area of our service to deliver quality service to the beneficiaries interventions under sparsh project professional clinical and functional assessment all the beneficiaries who are identified will undergo clinical assessment for the confirmation of their disability and regular followup will be continued at the request of the doctor for the monitoring of the condition of the child functional assessment 38 for every child will be completed by the special educators to analyze the skills and the capacity of the child to work on further study plans and to decide the level of support needed for the child of the beneficiaries 60 of them are under closed doors meaning a life of helplessness but the project implementation widened their life for them part of this project the medical doctor finds out the level of deafness and blindness with the support of medical equipment and special educators assess the skills of each person according to these assessments the qualified resource team formulates the support measures for each beneficiary the special file which is kept in the central office for each person shows these facts medical and nutritional support the beneficiaries are also supported to purchase the medicine as per the requirement and the availability of the budget the beneficiaries are prioritized according to the financial condition of the family and the requirements of the child these services are delivered either in a refund mode or the agency purchases the product and gives it to the beneficiaries as per the requirement 39 use of assistive devices the project supports the beneficiaries in purchasing any means of assistive devices such as hearing aids wheelchairs spectacles walkers canes etc this helped the beneficiaries to come forward and trealize what they could do for the betterment of their life 43 to train the beneficiaries with the proper use of materials and make the learning more effective and easier teachers have to come up creatively with the idea of making effective tml materials as per the needs of each beneficiary because there is no standard syllabus or curriculum to follow for all the children project outcome assessment based on case studies note these stories are written on the base of the data collected by the project team because of the uniformity of the questions few stories are similar to keep confidentiality and privacy the actual details of the beneficiaries are not mentioned here case 1 hopelessness is a condition to seek the ray of hope is a choice elevenyearold pavithra wants to become a nurse when she grows up pavithra was born to mr shivakumar who is an autodriver and mrs suja v who is a homemaker she was diagnosed with genetic profound hearing loss and low vision growing up with her two sisters in an economically backward family nobody ever identified that she was differently able and not disabled stories that stay consistent dont leave a mark but stories that take a turn bring many changes pavithras story took a turn in march 2019 when she was in first standard her parents met a cbr worker and were introduced to the projects and programs for children like pavithra which later made pavithra a beneficiary of the senses success stories at that point in life pavithra was a hyperactive girl who could communicate verbally and was good at academics but had no interest due to a lack of proper attention and response she struggled with different languages mr brind ajith was the key worker who trained pavithra and equipped her to read malayalam english hindi and sanskrit with little support she was able to write even a few words in hindi letters sparsh animators gave necessary intervention for her special health condition and according to her mother pavithra has improved a lot she is better in her studies now ever since she was involved in sense india she has been active and smart according to her trainer still weaving her success it is the relentless effort of her mother who encourages and supports her daughter to achieve all the milestones along with the team pavithra is no longer a dependent girl soon you will see how she fends off her disabilities and flies high selva a coolie and his mother nisha as a premature baby diagnosed with msi sevenyearold kichu found it difficult to communicate his needs and emotions and instead cried out loud shaking his head when he was lonely and stayed numb this was kichus condition until he was introduced to senses india through a partner organization it was his window to hope kichu who failed to hold an object properly and made loud noises instead of conveying his needs in a period of fiveyear training from his educator mr reji started improving his adl activities identifying people and using sign language for communication the greatest relief of his family was hearing him call paa amma his grandparents were his greatest support system after amma a good part of their attention and time were devoted to kichu following his needs improving his skills and instructions from his trainer isnt it evident that his family is going to be his core strength in this journey along with the sense team for communication case 3 threeyearold abel is a very smart active boy calling out his name will give you the warmest smile he was born with reflective hearing loss and short eye vision due to chromosomal abnormality he lacks social interaction due to a lack of communication techniques he makes noises and seeks attention he wont respond to anyone except his mother his parents came to know about the project through a cbr worker and yes abel took a major step in his life he was a very cooperative child throughout the training responding to his trainer very smartly he has improved his verbal communication skills and even started showing improvements in his adl activities he stays with his mother who is a housewife and she supports him with his training abel is also given physiotherapy the trainer also gives special attention to improving his capacity to hold objects which was quite poor and his hand eye coordination for better performance abel has already shown improvements in his journey one day he will finally be independent enough to bring out his needs and activities usually a great change takes time but those changes will make a signature in changing lives blessing would be sitting in a corner with his hands always in his mouth crying for anything when he was four months old he was diagnosed with msi born to a coolie and his wife this child didnt receive any attention or necessary training in the beginning until they met a cbr worker he lacked adl skills and struggled to communicate with people he barely called out for his parents whenever necessary until he joined the training under the trainer he started improving his socializing skills started pronouncing paa and amma and even got better in his adl skills his mother and grandparents were always his biggest support system no matter how small his improvement was it mattered a lot to them it was in their reaction the joy was evident in their expectation he is another hopeful story for the parents with children who are differently able case 5 born in an economically poor background anandhu was one and a half years old when he was diagnosed with deafblindness he lives with his grandmother and the primary concern of his parents when they made part of him for the project was to improve his communication skills and to make him capable enough to handle his own needs he used to make sounds to call for attention and was a little aggressive when he didnt like something since he started taking the training he started identifying and memorizing words like sit stand cry etc according to the trainer he is a very active kid and was not cooperative in the beginning his mother and grandparents are active in his training activities his mother wanted to see this tenyearold anandhu managing his daily activities without any external support as per his mothers wish someday he will play with his brother and enjoy his favorite places without any limitations one cannot redo a condition but can bring necessary changes to the existing condition for the betterment swoc analysis of the sparsh project in bringing the betterment of the life of deafblind children analysis of the sprash project with the swoc analysis provided an overall picture of the project especially the implementation strategies and its results this project is very relevant because it addresses one of the most vulnerable sessions in society the project helped many to better their quality of life and the life challenges but simultaneously there are a few drawbacks as well swoc is the base for evaluating the internal potential and boundaries and the probable opportunities and threats from the outside surroundings 44 the swoc analysis 45 46 47 48 is carried out to analyze how the project helped deafblind children to overcome their life challenges and get a better quality of their life strength of the project  the un has awarded the msss special review status with the economic and social council since 2016  it supported 121 children and adults with deafblindness and multiple disabilities  it has trained professionals special educators and cbr staff with specialized knowledge in the field  it has two resource centres that are supported by sense india and offer rehabilitative services to people who are deafblind  about 14 people with deafblindness received vocational and income generation activity support to become microentrepreneurs and start earning to support themselves  about 30 children and young adults were trained to become independent and contributing members of society based on their capacity and skills  approximately 750 anganwadi workers and school teachers were trained to identify and include children with deafblindness and multiple disabilities in anganwadis and schools  it is associated with samagra shiksha abhiyan in kerala and tamilnadu icds officers anganwadi workers asha workers medicalpara medical professionals vocational training centers and government officials to ensure the support of its target groups  it has a wonderful physiotherapy unit in our two resource centers it is providing positive results for target groups weakness of the project  the project allocated fund is not sufficient for the fruitful execution of the project deafblind children need more training and treatment but the lack of funds meant the beneficiaries received only basic support through the project many of them need proper followup training and support to keep their improved health condition  many of the beneficiaries are living in interior places so they face difficulty in traveling because of this they couldnt attend properly in physiotherapy and other training  most deafblind children and their family as well face many mental health issues so they need more support in this field at present the project provides only minimum support in this area opportunities in the project  the agency can provide different training to the project team at both national and regional levels to train deafblind children and their parents  the joint meetings of parents and trainers help a lot with the proper implementation of the project by creating a special platform to clarify the doubts of the parents and to get feedback on the training to improve the training sessions  the awareness programs help parents avoid doubts about the conditions of their children and also help the project team with various activities of the project very effectively  the supporting aids distributed to deafblind children helped to overcome their physical difficulties and helped them to become more independent and confident challenges in the project  in the field the problem of drunken parents alcohol consumption in the family alcohol consumption causes fights and other domestic disputes and violence within the family because of this the parents couldnt be actively involved in the project  many of the parents are not ready to accept the real situation of deafblind children and because of this they are not sending them to skill development training or medical treatment  communication barriers among the parents parents are not able to communicate with deaf children if they dont use sign language this affects the socialization and relationship between parents and children  lack of knowledge about sign language and the enormous shortage of sign language experts and deaf teachers  deafblindness causes severe communication and learning needs so deafblind children need to receive special needs education and associated support to deal with their requirements findings and suggestions findings the sparsh project implementing ngo malankara social service society is one of the leading ngos in kerala and its field experience highly influenced the proper implementation of the project and the result of the project msss is implementing the community based rehabilitation projects and it has trained professionals special educators and cbr staff with specialized knowledge in the field through this project implementation many came forward and realized their capacities it helped about 14 persons with deafblindness receive vocational and income generation activity support to become microentrepreneurs and start earning to support themselves 49 before the project implementation deafblind children and youngsters were isolated from society and led a lonely life in short they were inside closed doors about 30 children and young adults were trained to become independent and contributing members of society based on their capacity and skills 50 there is a shift in the approach toward to deaf and blind mainly from the part of parents siblings and teachers according to the annual report of msss from 2020 to 2022 the following outcome is derived from the sparsh project  14 people with deafblindness received vocational and income generation activity support to become microentrepreneurs and start earning to support themselves  through this project 30 children and young adults were trained to become independent and contributing members of society based on their capacity and vocational skills  approximately 2000anganwadi workers and school teachers were trained to identify and include children with deafblindness and multiple disabilities in anganwadis and schools  local networks linked with 9 agencies in trivandrum and 6 agencies in kanyakumari  assistive devices  there should be more awareness created for the parents to be actively involved in the project without the involvement and full dedication of the parents the deafblind children wont come forward  there should be proper resource mobilization and collective effort of the public and private agents of society then the deaf and blind get more opportunities and facilities to strengthen their lives the local governance bodies hospitals and other voluntary organizations support the smooth implementation of the project especially various supports after the project period  there should be more facilities at the central or regional level to develop their sensory capacities for example and sensory gardens 51 sensory pavements 52 and other types of technological equipment  there should be a more effective plan after the implementation period of the project otherwise many of them may not be able to continue their developed life situation conclusion initiatives like sparsh are crucial for the betterment of deafblind children and similar projects should be executed to ensure their promising future nongovernmental organizations take part in a significant role in supporting underprivileged individuals to combat food insecuritys root causes and consequences their primary objective is to enhance the quality of life for all distressed humans msss an ngo is actively engaged in numerous activities aimed at improving society with a special emphasis on the sparsh project this project has significantly impacted the daily lives of deafblind children living in and around the operational area of msss despite the many challenges that deafblindness poses to those affected and their caregivers mssss efforts have helped to overcome these difficulties it is admirable that many deafblind persons have achieved a high worth of life despite their challenges they share commonalities such as accepting their lack of sight and hearing as a unique life experience that gives them a meaningful viewpoint on the world these basic acceptances take place regardless of these verities of a persons exacting sensory losses or further challenges second they have had educational experiences that have helped them maximize their abilities to communicate and function productively individuals who are deafblind and have a positive outlook on their life situation tend to live amongst families communities or social businesses that welcome and accept them these individuals have friends relatives and coworkers who recognize their value and the significant contributions they bring to the world deafblindness provides opportunities for learning and joint enrichment for both those with partial sight and hearing and persons around them

study the case study aims to review the outcome of the sparsh project in getting a better quality of life for the deafblind through ngo intervention deafblind are those vulnerable children suffering from the absence of hearing and eyesight this study considers children with varying degrees of vision and hearing loss it reviews the support system offered by the external trainers and facilitators in transforming the lives of the subjects it is a case study conducted on children from the city of thiruvananthapuram based on their stories of transformation designmethodologyapproach the study explores firsthand information based on the cases of the beneficiaries through their reallife experiences to assess the intervention and effectiveness of the sparsh project on their empowerment the researcher used an interview schedule to gather data from the parents of the beneficiaries result and outcome of the study the study describes the effectiveness of the sparsh project in improving the quality of life of deafblind children it explores the various interventions used to empower the deafblind children by training them to face their physical challenges originalityvalue this paper presents a couple of case studies by exploring the reallife experiences of beneficiaries concerning the intervention carried out under the sparsh project

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background maternal and newborn mortality had been unacceptably high despite the implementation of many interventions globally there were an estimated number of 295000 maternal deaths in 2017 the vast majority of these deaths occurred in lowresource settings subsaharan africa and southern asia accounted for ∼86 of the estimated maternal deaths new on the other hand there was an estimated number of 25 million newborn deaths in 2018 in ethiopia maternal and newborn mortality was also high with a ratio of 412 and 30 maternal and newborn deaths per 1000 live respectively most maternal and newborn deaths occurred during the first week of life this was because existing evidence showed that lifethreatening maternal and newborn complications occur during this period on the other hand the postnatal period was the most neglected time for the provision of quality services especially in lowand middleincome countries postnatal care is a highimpact intervention provided for women and newborns to achieve a global plan targeted to reduce maternal and neonatal mortality to 70 and 12 deaths per 100000 live births respectively by 2030 the world health organization strongly recommends the provision of pnc service on days 1 3 and 7 and at 6 weeks to identify and treat postnatal complications and also to provide the mother with important information on how to care for herself and her child in ethiopia the pnc service is provided at the health facilities and importantly the health extension workers provide the service at the health post and hometohome to reach all mothers and newborns on days 1 3 and 7 and at 6 weeks 11 on the other hand there are health developmental armies that facilitate service delivery and support the hews in notifying the presence of delivered women and promoting and developing the healthseeking behavior toward key maternal and newborn health care services despite these opportunities pnc service utilization has been low existing evidence indicates residence religion place of delivery maternal knowledge of danger signs history of obstetric complications having antenatal care followup birth outcome educational status and household wealth as factors affecting pnc service utilization however in the context where the pnc service is provided both at the health facilities and hometohome only communitycaregiversrelated factors might not be enough to fill the knowledge gaps and needs to address the barriers related to the health facility and health care provider therefore this study aimed to explore barriers related to pnc service utilization from the perspective of the communitycaregivers health facility and health care providers methods and materials study setting period and approach a descriptive qualitative study was conducted in debre libanos district north shoa oromia regional state ethiopia from 11 march to 7 april 2019 the district is 90 km far away from addis ababa the population of the district was 45179 of whom 23351 and 21828 were men and women respectively approximately 1982 of the population was urban dwellers most inhabitants practiced ethiopian orthodox christianity the district had two health centers eleven hps and three private primary clinics there were four health officers twentytwo nurses four laboratory technicians two druggists five midwives and nineteen hews study participants and participant recruitment a purposive sampling technique was used to recruit study participants among women who gave birth within 2 months before data collection and their families pregnant women religious leaders kebele chairman hews health workers and other community members participants were recruited based on having perceived rich data on the pnc service for example community members including women who gave birth within 2 months prior to data collection were recruited based on their role as a newborn caregiver history of pnc followup for the last child history of perceived maternal and newborn illness history of newborn death within the postnatal period history of home delivery history of seeking care for maternal and newborn health problems during the postnatal period family and other community members were also involved in this study based on the social role played within the community in providing care or support to the mother and newborn with close intimacy in addition health workers including health extension workers were included as key informant interviews based on their role in providing pnc service and monitoring and supervising the service delivery data collection procedures the data were collected using a semistructured guide the guide was first developed in the english language and then translated into afan oromo and amharic languages and backtranslated into the english language by an independent translator it contained 810 questions that were customized per respondent type the guiding questions were prepared to start with the general concept and then move to specific issues to cover topics related to communitycaregiverrelated barriers health facilityrelated barriers and healthcare providerrelated barriers for pnc service utilization data were collected through indepth interviews key informant interviews and focused group discussions the indepth interviews were conducted with five women who gave birth within 2 months before data collection additionally a total of 12 key informant interviews were conducted with hews health workers kebele chairman and a religious leader four fgds were conducted with a total of forty participants for each fgd ∼712 heterogenous groups of individuals participated the participants were women who gave birth within 2 years before data collection and their families pregnant women and other community members the participants were informed 3 days before data collection all the interviews and fgds were conducted in the participants natural setting women or caregivers were interviewed at their homes kebele chairman religious leader health workers and hews were interviewed at their respective offices and the fgds were conducted within the community at a place where it was comfortable for all participants at the beginning of each interview and group discussion the purpose of the study and topics of discussions were mentioned to the study participants written informed consent was taken from the participants for their willingness to participate the principal investigator was the modulator throughout the data collection only the modulator facilitated the indepth and key informant interviews facetoface with each participant however one research assistant was involved while conducting the fgds to take a note and record the voices of the participants on average the fgds lasted from 115 to 141 and the interviews lasted from 2133 to 4351 min with the community members and from 03940 to 112 h with health workers and hews data analysis the inductive thematic analysis was used to analyze the data using the atlasti71 software package and the codes categories and themes were generated from the data data analysis commenced during the data collection process after each data collection the data were debriefed data were transcribed verbatim from audiorecorded material and translated into the english language then reading and rereading the transcriptions were done to get a whole sense of data the codebook manual was developed after a linebyline coding was conducted by the principal investigator and research assistant separately starting with transcription having relatively richest data and checking the intercoder consistency then the principal investigator precisely coded the whole data potential categories and themes were generated by clustering codes and categories respectively to answer the research question coding was repeated four times while refining the codebook manual categories and themes finally findings were presented with the major themes categories and quotations derived from the data trustworthiness different approaches were followed to ensure the trustworthiness of the study findings first a guide was pretested with three women who gave birth within 2 months and with the three hews second the data were debriefed daily together with a research assistant third major thematic areas were raised to the study participants at the end of each data collection for their clarification and verification also the transcriptions and key findings were shared with the hews and health workers to check interpretations and they provided their comments fourth a diversified number of individuals were recruited and data were collected through three techniques fifth a thick description was provided of the research methodology interpretation of results and contributions of a research assistant therefore anyone interested in applying the findings of the study should understand and consider the contextual information provided in the study furthermore the study findings might apply to a setting that is similar to the ethiopian health care system sixth the consistency and a detailed chronology of overall research activities processes and study outputs were audited by colleagues and qualitative research experts seventh researchers selfreflectivity and bracketing the researchers are public health officers and health education officer they have work experience at governmental private and nongovernmental institutions they also have experience conducting qualitative and quantitative research this preconception knowledge and skills benefited the researchers to focus on research questions additionally the researchers were not familiar with the study setting and there was no potential bias that could be introduced if the researchers were from the same location the subjectivity of the researchers was managed by balancing together with the data analytic processes and findings in such a way that the reader can confirm the adequacy of the findings additionally the researchers can speak the local language well which is used to minimize interpretation bias that could happen from language differences eight the principal investigator spent 1 month in the study setting and created rapport with study participants and verified the closure of hps during closed working hours the residence of hews and lack of regular supervision and monitoring given to the hews ninth negative case analysis the contradicting ideas or deviant cases that emerged in the data were analyzed by enquiring indepth from potential study participants ethical approval and consent to participate ethical approval was obtained from the jimma university research ethical review board ethiopia with approval number of thrpg3012019 the right of the study participants was maintained by ensuring nonmaleficence and underscoring the benefits of the study study participants were informed adequately about the purpose of the study voluntary participation and the right to participate or withdraw at any time to ensure their privacy and autonomy codes were used in place of their names in connection to the study findings or their responses to discussions or interviews enough time was given to them to reflect and provide a detailed explanation of the issue all of the participants completed the study participants sociodemographic characteristics and written informed consent were taken individually before starting the interview or discussion results a total of five indepth interviews twelve key informant interviews and four fgds were conducted a total of fiftytwo participants were involved in the study participants sociodemographics the demographic characteristics of the participants are summarized in table 1 the mean age was 376 years the majority of the participants were women all of them were ethiopian orthodox christianity followers and oromo in ethnicity barriers to pnc service utilization the study findings were organized into two major themes communitycaregivers and health facilities and health care providers the majority of the barriers were mentioned by all groups of participants however the first two barriers presented in table 2 were the majority mentioned by participants from the community a detailed description is found in table 2 study participants mentioned that the community members or caregivers had a gap of knowledge or awareness about the pnc its importance and schedules additionally it was mentioned that they did not perceive the importance of visiting health facilities or seeking care from health care providers unless the women and newborns faced severe conditions the caregivers or women also mentioned that the health care providers did not create awareness about these issues and they appointed the caregivers to visit the health facility on the sixth week to immunize the newborns and get the family planning service due to this it was mentioned that women did not visit the health facility or call the hews to their homes to get the service visiting the health facility after delivery is not practical in our community due to a lack of awareness of its importance we learned nothing about the importance of postnatal care and their schedules we only know that immunization is started on the 45 th day lack of awareness of maternal and newborn danger signs women families and other community members also indicated that they did not know about the maternal and newborn danger signs occurring during the postnatal period they replied that hews or other health workers did not tell about it which made them perceive it as it was not important to have pnc followup unless the mother andor the newborn become severely sick i do not have any information about the danger signs occurring after deliver on the mother and baby the health workers did not tell me about these issues during my antenatal followup or while we return home after delivery sociocultural and religious beliefs study participants mentioned two types of sociocultural and religious beliefs that affected pnc service utilization the first was a religious belief and among the community members who practiced ethiopian orthodox christianity study participants mentioned that it was forbidden to go out of the home for both the women and newborns before the date of baptism due to fear of evil spirit therefore they mentioned that they did not visit the health facilities to seek the pnc service before the date of baptism after i gave birth the health extension worker visited us yesterday on the fortyfifth day this is because in societys culture it is forbidden to go out of the home before the date of baptism the second belief mentioned by the study participants was hamechisa within the first 2 months of life they mentioned that community members who believe in this culture did not visit the health facilities to seek any health care service before newborns were taken and blessed by the witch they perceived that unless the newborns were taken and blessed the witch or traditional healers curse the family especially the delivered mother and newborn and harmed or died from the evil spirit at some kebeles even to take for baptism there is something called hamu at those kebeles newborns do not take vaccines any treatment or even not celebrate their date of baptism before going to hamechisa and the witch blesses them topographical di culties and transportation problems study participants mentioned that there were kebeles that have difficult hills and no transportation access there to go to the health facilities for getting the service they responded that in these settings there was no suitable condition for the hews to conduct a home visit or for the caregivers to go to the health facilities for getting the pnc service due to this issue only community members who lived around or nearby the health post benefited from the service given at the health post especially where there was only one hew our kebele is very wide and there is a topographic and transportation problem that makes us unable to take especially the newborns to the health post also there is only one health extension worker and because of this case she only visits delivered mothers who live around the health post and those who live far from the health post would not gain followup service health facilityand health care providerrelated barriers to pnc service utilization supervision and monitoring study participants mentioned that there were no regular supportive supervision and monitoring given to the hews from the district health office and health centers because of this the hews did not open the hps for service during working hours as it was mentioned by the study participants there was a weak health center and hp linkage and the health workers were not committed to supporting the hews as a result the community members could not visit the health facilities to get pnc service utilization one challenge is that the health extension workers do not conduct the activities appropriately at all there is no monitoring given to them other health posts are not always open for service due to these issues community members do not go to health posts the hews commitment study participants mentioned that the hews did not provide pnc service through hometohome visits or were not available full working hours at the hps for providing the service they replied that hews were not committed to conducting the activities as expected from them and they did not provide pnc service routinely but provided it along with the immunization campaigns if the health post is considered as a health facility why do the health extension workers live here and provide the service they hews are only available here for only two days it is expected for a woman who gave birth to get postnatal care within seven days however in our district almost all of the hews travel from here town and they only target in providing vaccines for newborns they provide postnatal service on routine vaccine program or not provide it regularly as needed residency of hews and closure of hps on working hours study participants also mentioned that the hews conduct activities traveling from the district town because of this case it was mentioned that they might not go to the hp or reach late and the hews opened the hps for a maximum of 3 days per week for example participants mentioned that the community memberscaregivers need to seek care for newborns early in the morning but hews came late due to this they faced challenges in utilizing the service given by the hps it is expected that the health extension works should provide pnc service on the first third and seventh days and at six weeks through a homehome visit however we do not conduct it as it is expected from them since they are living and work traveling from the district town the health extension workers live at town and available at the health post three days per week even on these days they came late around 3 or 4 hours morning and returned back at eight hours afternoon however our community members want to take especially their newborns to health facilities early in the morning therefore at a time when community members want to return back to home the health extension workers reach health post the functionality of health developmental army study participants mentioned that the majority of the hdas were nonfunctional it was mentioned that previously hdas had benefited the community in creating awareness promoting service and developing behavior of community members toward health care service utilization however they mentioned that the hdas became nonfunctional and it was mentioned as a barrier to pnc service utilization in my perception the health developmental army has a very essential benefit to get health care service especially to avoid maternal and newborn death but it is not available and the supervisors should also have to work together to aware of the community and reestablish it shortage of hews study participants mentioned that there were two health posts with only one hew which made it difficult to reach the delivered mothers and their newborns to provide the pnc service there are two health posts that have only one health extension worker and one health post with no health extension worker therefore with this condition it is difficult to utilize the postnatal care service lack of an organized system for notifying delivered women to hews study participants mentioned that there was a lack of organized system to notify the presence of delivered women to the hews from both the health centers and community members it was mentioned that the hews traced the women from the delivery register every week or every 2 weeks and during immunization campaigns due to such cases study participants mentioned that the caregivers visited the health facilities or hews visited them after 6 weeks we provide pnc when we heard the presence of delivered women we traced women who gave birth from the delivery register every 15 days or we heard from the community members during immunization campaigns they did not visit us until our 45 th day but she visited us on this day to provide a vaccine for the baby nonfunctionality of hp study participants mentioned that there was one hp with no hews and became closed due to this women and newborns did not get pnc service either through a home visit or at the hp discussion the study found communitycaregiverand health facilityand health care providerrelated barriers to pnc service utilization the explored barriers were lack of awareness about pnc its importance and schedules lack of awareness of the maternal and newborn danger signs sociocultural and religious beliefs lack of an organized system to notify delivery to hews topographical difficulties and transportation problems nonfunctionality of the hdas lack of commitment among hews shortage of hews the residence of hews and closure of hps on working hours poor supportive supervision and monitoring given to hews and nonfunctionality of hps this study found that there was a lack of awareness about pnc its importance and schedules among community memberscaregivers to utilize the pnc service the finding is similar to other study findings conducted in ethiopia additionally the study found that women were appointed to visit health facilities on the 45th day to take family planning and immunize the newborn therefore the community members had no awareness of the importance of pnc and its schedules this implies that the health workers did not consistently follow or adhere to the pnc guidelines and principles this might indicate that there is a need to provide an update to the health workers including hews through refreshment inservice or onjob training about the importance of pnc and its schedules furthermore this underscores the importance of developing strategies and taking actions to create awareness about pnc its importance and schedules for community members this finding is consistent with other study findings reported elsewhere this study also found that community members including women had an awareness gap about maternal and newborn danger signs as a result it affected pnc service utilization this made the community members or caregivers perceive that it was not important to visit the health facilities unless there is a severe maternal and newborn health problem this might indicate that there is a poor quality of counseling or services provided to the women in the continuum of care starting from pregnancy during labor and delivery and postnatal period similarly this underscores that there is a need to provide refreshment inservice or onjob training to the health workers including hews on appropriate communication skills and knowledge on the continuum of care moreover health workers including hews need to be committed to providing quality counseling to pregnant women and family members about danger signs that would appear during these periods this was similar to study findings gained from different settings the study found religion and hamechisa as barriers to pnc service utilization among the ethiopian orthodox christianity followers it was found that community members did not allow the delivered mothers or newborns out of the home until the date of baptism on the other hand there were community members who believed in a culture called hamechisa among these community members women and newborns were first taken within the first 2 months and blessed by the traditional healer therefore in both beliefs the community members did not seek care from the health facilities or health care providers before christianization and were blessed by the traditional healer respectively due to this problem they did not utilize the pnc service from the health facilities this was similar to the study findings conducted in different settings this underscores the importance of conducting social and behavioral change communication to change the perception of community members or caregivers and develop their healthseeking behavior to utilize the pnc service this study also found a lack of regular supervision and monitoring given to hews as a barrier to pnc service utilization even if it was expected that they should have to be supervised and monitored every week because of this the hews were not committed to providing the pnc service similarly lack of commitment among hew was mentioned as a barrier to pnc service utilization the lack of an organized system that notifies the presence of delivered women timely to hews was a barrier to pnc service utilization the hews traced women and newborns from the delivery register every week or every 2 weeks or during the immunization campaigns which means that pnc was not provided on critical days however health care providers and hdas are expected to notify the presence of delivered women at the health center and home respectively to the hews to provide the pnc service at home or the hps therefore there is a need to develop a strong system that facilitates the notification of delivered women to hews to enhance pnc service utilization the study also found topographical difficulties and lack of transportation access as barriers to pnc service utilization some kebeles had difficulty topographically and no means of modern transportations to go to the health facilities or suitable to the hews to conduct a home visit for providing the service this was similar to different study findings the study also found that the nonfunctionality of hdas is a barrier to pnc service utilization as it was mentioned by the study participants the hdas provide pnc service notified delivery to hews identified and referred sick newborns and carried out social mobilization to increase knowledge develop the attitude and healthseeking behavior toward maternal and newborn health and support the hews in delivering mnch services however this study found that the hdas were not functioning well as what is expected from them importantly appropriate strategies need to be developed and action needs to be taken to reorganize strong hdas that play a substantial role in enhancing pnc service utilization moreover the provision of close supervision and monitoring is required to make them organized and fully functional the shortage of hews and the nonfunctionality of hps were also explored as barriers to the pnc service provision there were two health posts with one hew and one health post with no hew however the health extension program acknowledges the availability of at least two hews and all hps should have to be functional additionally the residence of hews and closure of hps during working hours were also identified as barriers to pnc service utilization almost all of the hews work traveling from the district town and for this reason hps were mostly closed during working hours affecting the service delivery in contrast other studies have shown that the majority of hews open hps for five working hours this might happen due to geographical differences or the availability of constructed residences in the previous studies conclusion from this study it was understood that pnc service utilization was affected by the barriers related to communitycaregivers health facility and health care providers this underscores the need to develop different strategies and take actions to address them first women need to get important knowledge and appropriately seek care during pregnancy labor and delivery and postnatal period given that it is a continuum of care second the community members including families need to provide social support and encourage her to get adequate knowledge and service during these continuous periods of care third the health centers and district health office should have to assign the required number of hews at each hps provide regular supportive supervision and monitoring of hews and develop an organized system that facilitates early notification of delivery from both at home and the health facility to the hews on the other hand the hews should have to live in nearby hps reorganize the hdas create awareness of the maternal and newborn danger signs conduct social and behavioral change communication to change the perception of the community members or caregivers and develop their healthseeking behavior to utilize the pnc service data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement the studies involving human participants were reviewed and approved by jimma university research ethical committee 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 supplementary material the supplementary material for this article can be found online at fgwh2022986662full supplementarymaterial

background in ethiopia postnatal care pnc service utilization was low although many interventions had been implemented previous studies showed communitycaregiverrelated barriers to pnc service utilization but limited evidence was available on the health facilities and health care providerrelated barriers therefore the study was aimed at exploring both community and health care providerrelated barriers to pnc service utilization methods a descriptive qualitative study was conducted at debre libanos district ethiopia from march to april a purposive sampling technique was used to recruit study participants among recently delivered women months health care providers and community members a total of five indepth interviews key informant interviews and four fgds were conducted data were audiorecorded transcribed verbatim and translated and inductive thematic analysis was used to analyze the data using the atlas ti software results a total of participants were involved in the study the findings were organized into two major themes communitycaregiverrelated barriers to pnc service utilization lack of awareness about pnc its importance and schedules lack of awareness about postnatal danger signs sociocultural and religious beliefs topographical and transportation problems nonfunctionality of the health developmental armies hda health facility and health care providerrelated barriers to pnc service utilization poor supportive supervision and monitoring lack of health extension workers hew commitment lack of an organized system to notify delivery to hew shortage of hews the residence of the hews closure of health posts hp on working hours and nonfunctionality of hpsthe study findings underscore the need to develop di erent strategies and take actions therefore the health centers and district health o ces should have to assign the required number of hews at hps regularly supervise and monitor hews and develop an organized system to facilitate early notification of delivery to hews the hews should have to live near the hp reorganize hdas create awareness of maternal and newborn danger frontiers in global womens health frontiersinorg girma tareke et al fgwh signs and conduct social and behavioral change communications to increase the healthseeking behavior of community members for utilizing pnc services

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background and context of zerotolerance in 2018 the trump administrations zerotolerance policy was created with the intention to curtail and control illegal border crossings on april 6 2018 attorney general jeff sessions stated that the situation at our southwest border is unacceptable congress has failed to pass effective legislation that serves the national interestthat closes dangerous loopholes and fully funds a wall along our southern border to those who wish to challenge the trump administrations commitment to public safety national security and the rule of law i warn you illegally entering this country will not be rewarded but will instead be met with the full prosecutorial powers of the department of justice to the departments prosecutors i urge you promoting and enforcing the rule of law is vital to protecting a nation its borders and its citizens thenattorney general jeff sessions suggested that immigration from the usmexico border is an urgent national security issue threatening the safety and wellbeing of us citizens and legal permanent residents sessions with the support of other trump administration officials made it clear that detainment and criminal prosecution were to be the primary approaches to addressing migration from central and south america the sociopolitical context is important to the trump administrations enacting of zerotolerance the trump administration operated under a decidedly antiimmigrant platform that fueled stigmas around the country of origin and skin color zero tolerance aligns with other legislative decisions of the trump administration which the supreme court upheld that were specifically focused on issues of immigration such as what was understood as the muslim ban where travel bans from seven countries five of which were understood as majority muslim was a legislative priority similarly the trump administrations preoccupation with the construction of a border wall along the usmexico border to keep migrants and immigrants out of the usa is consistent with this administrations approach to immigration migration and border control racist rhetoric about black and brown immigrants was employed by the trump administration to justify enacting zero tolerance in the years leading up to the implementation of zero tolerance there was an increase of migrants specifically migrant families seeking asylum andor crossing the usmexico border in decades past the majority of migrants were people traveling alone often men and a shift had occurred with more children and youth trying to reach the us in the years leading up to the implementation of zerotolerance some of these youths have traveled alone and many have traveled with parents and caretakers as stated by attorney general jeff sessions above improved border enforcement at the usmexico border was an issue of national security and as part of the trump administration all were committed to increasing criminal immigration enforcement however the distinct difference to trumps zerotolerance approach to addressing unauthorized border crossing is that all people crossing the border without declaring themselves at a formal port of entry were now in criminal violation of us law which includes children and pregnant people this is a stark contrast to previous approaches to immigration enforcement that excluded pregnant people and family units from mandatory detention the trump administration is not the first us presidential administration to implement antiimmigrant legislation the obama administration for example is responsible for deporting an unprecedented number of immigrants and asylum seekers although deportations reached a record high during the obama administration criminal and federal detention of migrants was low as they were not considered enforcement priorities the trump administration implemented a 100 prosecution policy under the belief that a zerotolerance approach was necessary to discourage migrants from coming to the united states and submitting fraudulent asylum requests the family separation that ensued because of zero tolerance was justified by the trump administration with the logic that when parents are placed in jail they are naturally separated from their children anyway crossing the border without formally presenting oneself at an official port of entry or overstaying a visa was considered a criminal offence that would be addressed by the us immigration and customs enforcement carceral system at the usmexico border immigration and customs enforcement operates a health service corps with the mission of working hard to be the best health care delivery system in detention and correctional care currently ice has around 200 facilities where migrants are currently detained in the us under zero tolerance policy every migrantincluding asylum seekerswere automatically detained and placed in the custody of ice if entering other than at an official port of entry or overstaying a visa and criminally prosecuted given what we know about the stringent nature of zero tolerance policy any latinx person seeking asylum at the usmexico border likely faced federal criminalization separation and detention into federal custody once in custody migrants were sent to ice detention facilities that operated at various sites along the usmexico border these facilities were operated by the us department of homeland security these facilities experienced considerable growth in detained persons accompanied by the rise in use of private prisons for detention and they operate with inadequate numbers of support staff and medical staff men women and children were all detained and often separated from one another and held in different facilities since children cannot be imprisoned with parents or family members children were separated from parents and caregivers and separately placed into the federal custody of the us department of health and human services 2022 this resulted in over 3000 children being separated from their families and often placed hundreds of miles away in detention centers also known as office of refugee resettlement centers many children experienced trauma because of this experience including reported incidents of violence and sexual assault and severe psychological harm 2019 the trump administration was aware that enforcement of this policy would separate children from parents and caregivers ice health service corps since all prisoners within the usa have a constitutional right to healthcare all people detained under this policy were technically provided healthcare through the ice health service corps this care was part of the federally mandated screening process for detained children and adults inclusive of pregnant women the ice health service corps has several accrediting bodies including the american correctional association the national commission on correctional health care the national practitioner data bank ice family residential standards and ice performance based national detention standards the aca is the entity responsible for setting the standards of human dignity and treatment in custody while the ncchc writes the actual policy both dictate laws and applications of the ice health service corps and these standards are known as ice performancebased national detention standards change to ice health service corps directives under zero tolerance there are three major immigration practices that have commenced since immigration law at the usmexico border was amended under the trump administration in 2017 through executive order 13768 enhancing public safety in the interior of the united states these are family separation removing the exemption of detention for pregnant migrant women and the federal criminalization of any migrant latinx person seeking to cross the usmexico border in this paper we focus on pregnant latinax women who have been impacted by the removal of the exemption of detention under ice health service policy 110323 identification and monitoring of pregnant detainees this policy is largely informed by the performancebased national detention standard 44 medical care on december 14 2017 the trump administration with the effort led by thenattorney general jeff sessions issued ice directive 110323 identification and monitoring of pregnant detainees according to ice directive 110323s purpose was to ensure that pregnant detainees are identified monitored tracked and housed in an appropriate facility to manage their care the policy dictates that the field office director and field medical coordinator are to be contacted upon detaining a person identified as pregnant the policy also outlines individual responsibilities of executive field officers such as a 72hour window to notify facilities that they are housing a detainee who is pregnant ensuring that detention facilities are aware of their obligations ensuring that detainees receive appropriate care and that the facility can provide appropriate medical care monitoring and knowledge regarding use of restraints neither this policy nor the pbnds provides specific information beyond the types of services offered regarding what medical care for pregnant detained migrants should look like there is a very strong emphasis on surveillance and tracking of the individual in custody along with a statement of compliance with standards of care set by the national commission on correctional healthcare the procedures and requirements outlined in eo 110323 largely encompass provision of care determining needs for care and ensuring that if the needs of a person who is pregnant are above and beyond what the facility can provide that they will be transferred to a facility that can meet those needs and there is no definition of what above and beyond might mean according to directive 110323 ice detention facilities will continue to provide onsite prenatal care and education as well as remote access to specialists who remain in custody additionally ice ensures access to comprehensive counseling and assistance postpartum followup and in certain cases abortion services per the policy services are available yet there is an absence of details related to the implementation expectation or quality of care of services provided due to the removal of this exemption that previously allowed for pregnant migrant women and asylum seekers to not be held in detention as it is a threat to their health and wellbeing pregnant latinax migrants and asylumseekers were disproportionately impacted by being detained by ice and forced to carry out their pregnancies and for some births while being detained in federal custody pregnant migrants lacked proper and timely access to abortion many pregnant women in detention received subpar prenatal care this is due to several factors that highlight both systemic challenges and systemic racism within the ice carceral system according to the department of homeland security regardless of how medical care is provided facilities face challenges recruiting hiring and retaining medical staff specifically remote locations competing opportunities difficulty offering competitive pay rates and cumbersome hiring processes adversely affect ices ability to attract qualified staff however it is difficult to measure medical vacancy rates facility requirements are fluid and strategies for ensuring adequate coverage vary widely in addition ice has limited options to impose consequences if contractors do not meet staffing contract terms challenges ice faces in recruiting medical staff require resourceintensive mitigation 2021 while the 2021 report did correlate lack of providers low quality of care and negative medical outcomes it does suggest that a lack of providers may increase the risk of inadequate medical care but at the time of this evaluation covid19 limited a full assessment and determination of outcomes contrary to these findings the american public health association argues that the rapid growth of privately contracted detention facilities has led to numerous human right concerns including but not limited to inadequate medical care mistreatment unsanitary conditions and reports of reproductive violence against women even if there is not a direct correlation between adequate staffing and quality of care there is a correlation between quality of care and systemic racism in the form of reproductive violence committed against migrants and asylum seekers who are detained by ice prior to the 2017 amendment ice policy dictated that pregnant women were generally not detained unless their detention was mandatory under the law or when extraordinary circumstance warranted detention therefore understanding the zero tolerance policy and its subsequent implications helps to understand and to frame the farreaching impacts of the types of reproductive rights violations for latinaox migrants living in the borderlands diaspora and beyond we use a reproductive justice lens to analyze the impact on the reproductive healthcare that latinax migrants and asylum seekers were provided while detained in ice custody through this lens we can explore the human right abuses that occur during this strategy of reproductive control the american civil liberties union womens refugee commission and the washington office on latin america have identified how these policies have obstructed the reproductive and human rights of migrants and asylum seekers in the usa in particular the center for american progress notes numerous reports of miscarriages due to shackling the hindering of access to abortion solitary confinement sexual abuse and nonconsensual gynecological services reproductive justice using a rjinformed lens issues of reproduction that impact any person containing the components of a reproductive system would indicate the binary labeling of female assigned at birth we acknowledge that not all pregnant and birthing persons identify as their gender assigned at birth there is other existing research that addresses the ways in which border policies impact people who identify as nonbinary gender nonconforming transgender andor queer in similar and complicated ways however the case studies used in this policy analysis represent pregnant and birthing persons who are identified as female therefore a policy analysis that addresses the impact on pregnant and birthing persons who do not identify as female is beyond the scope of this paper we acknowledge that a policy analysis with a specific focus on migrant latinx pregnant and birthing persons who identify as nonbinary transgender and or queer is an area of study to consider for further research and policy assessment reproductive justice at its core is a movement that was started and continues to be led by women of color activists the movement is a response to a mostly white womens movement that often excluded the unique needs of people of color and queer and trans identifying people rj engages with intersection of immigration citizenship status and reproductive justice and has been concerned with these issues since the emergence of rj focused activism an rjfocused critique embraces an intersectionality framework that critiques gender class race and power simultaneously rj is an inclusive and rightfocused framework that centers the right to have children the right not to have children and the right to parent children in safe and healthy environments in addition reproductive justice demands sexual autonomy and gender freedom for every human being central to this definition of rj is that any person who desires to reproduce andor who does become a parent through whichever means they choose requires a safe and dignified context for this experience which extends beyond the perinatal period rj acknowledges that choice and having options around reproduction are not often available to marginalized groups which is where rj and the more traditional abortion frameworks that center choice diverge as isolating abortion from other issues of social justice fail to recognize the environments in which people make reproductive decisions rj values the many ways in which people can become parents and that ideally people can have choice in this process however one becomes a parent an rj framework highlights that all people have the right to parent in safe and healthy environments detention centers and federal custody are not considered safe dignified or healthy environments rj helps to highlight how policy 110323 identification and monitoring of pregnant detainees denies pregnant latinx migrants basic human rights and reproductive rights the basic human and reproductive rights that were rescinded under zero tolerance reflect the history and systems of policies and practices that rely on discrimination and racism to promote white nationalism within the usa socially and politically although zero tolerance was rescinded by the biden administration in january of 2021 these human right violations have not suddenly disappeared in fact zero tolerance policies were heavily supported by many people in the usa and continue to be especially within republican and conservative circles given the recent decision by the supreme court to overturn roe v wade on june 24 2022 we must now consider the ways in which the denial of protections to access reproductive healthcare such as abortion is now justified on a federal level in more than half of states within the usa therefore consequences of such policies are compounded by the reversal of legislation that has historically protected rights to reproductive healthcare such as abortion we must consider how the reversal of roe v wade will disproportionately impact and cause harm to pregnant latina migrants and asylum seekers who are still being detained by ice at the usmexico border an rjfocused lens demands the acknowledgement of an accurate historical account that informs the present and the future as such an rjfocused application also recognizes that the us political and social structures were created to protect and serve white individuals and communities and always have had at its core antiimmigrant sentiments at its inception rj activists have always conceptualized immigration as a central rj issue which undoubtedly concerns family separation detention of pregnant women and access to reproductive health care while detained 2017 as social workers we do not believe that migration and immigration are crimes in fact the usa became a settler colonial nation because white europeans migrated and immigrated the disparate application of migration as a crime for black and brown bodies but not so for whites is discriminatory and harmful this paper analyzes the ways in which zerotolerance policy criminalizes migration when it concerns the movement of black and brown bodies as well as how health policy was weaponized to exert power and control over those bodies we are particularly concerned about the impact of stereotypical tropes about latinax sex and sexuality related to fertility and reproduction and the impact on the reproductive health and wellbeing of latinasxs and their families we assert that an rjfocused framework helps to highlight the ways in which policy 110323 is shaped by and tied to the xenophobic fear that latinx people over reproduce and threaten the demographic standing of the usa statistics on migration in 2018 evidently we see an increase in the numbers of pregnant migrants in custody because removing the exemption of detention did not deter women children and families from migrating to the usa as many were fleeing violence in their home countries and were seeking financial opportunities by august of 2018 a mere 4 months after the implementation of zero tolerance apprehension totals showed a 38 increase from the previous month with 457 of all migrants who were apprehended reported to be children or family members therefore removing the exemption not only increased the number of migrants who were pregnant and detained but it also increased risk for an already incredibly vulnerable population with an insufficiently staffed carceral system under zero tolerance ice detained pregnant people 2098 times in 2018 a 52 increase relative to 2016 the length of detention also increased with 13 of detentions of pregnant people lasting more than 30 days case studies concerning pregnant migrants when analyzing the policy and standards that impact pregnant migrants who have been detained in ice custody there is a necessity to understand the current social problems of racism xenophobia and mass incarceration in the usa it is imperative to understand the ways in which the violation of human rights of pregnant latina migrants is a direct reflection and outcome of that problem for this reason this analysis is grounded in three case studies all from 2018 which report on the experiences of pregnant latina migrants who were detained at the us border because of the zero tolerance policy after the removal of the exemption of detention for pregnant women these cases are evidence of reproductive abuses and human right violations that occurred under the zero tolerance policy even though longterm impacts remain to be well understood in conducting this analysis an rj lens will operate to locate critically analyze and scrutinize the broader realm of ice practices within the us health service corps that violate human and reproductive rights two of the case studies presented here come directly from the american civil liberties union aclu and the third is from the washington post all three demonstrate that pregnant migrant latina detainees were provided with suboptimal and inadequate healthcare while in custody and we assert their reproductive rights were violated it is important to ground this topic in the framework of human rights international human right bodies such as the international covenant on economic social and cultural rights and convention on the elimination of all forms of discrimination against women have played a substantial role in codifying womens sexual and reproductive health as a matter that intersects in multiple ways with the right to life the right to be free from torture the right to health the right to privacy the right to education and the prohibition of discrimination the united nations also outlines the obligations of and examples by which states have obligations to respect protect and fulfill rights related to womens sexual and reproductive health we frame these case studies in the context of data on reproductive healthcare services that was reported by ice to the united states government accountability office in 2018 according to this report services such as ordering consultation pregnant patient seen by an obgyn within 30 days prescribed prenatal vitamins ordering of proper diet screenings for sexually transmitted infections and offering hepatitis b vaccination all went unreportedgao regarded that any data left blank was unreported and considered to be noncompliant services such as scheduling of obgyn appointments documentation of consultation in a timely manner documentation of prenatal education medical record reviews and ordering appropriate labs ranged between 75 and 80 compliance in 2018 this data points to some of these issues faced by pregnant migrant latinas concerning reproductive rights while in the custody of ice in specific casebycase findings from 2015 to 2019 the inspection found compliance deficiencies in the areas of at least one detained person not receiving health appraisal within 48 h of arrival and therefore was also not afforded access to specialized care and obstetric evaluation lack of access to a mental health assessment after miscarriage while in custody lack of documentation regarding outcome of and completion of pregnancy tests and lack of documentation regarding miscarriage at a previous facility and the useofforce policy did not include pregnant detainees nor did it address special precautions regarding use of restraints furthermore the gao reports that many of these instances of compliance violation occurred at private immigration detention facilities that were not staffed with ice health service corps members this again raises the issue of the problematic use of privatized carceral systems to housedetained migrants and the ways in which it leaves migrants vulnerable to obstruction of their reproductive rights case study 1 jane doe vs trump administration in september 2017 a young migrant woman crossed into the united states and discovered that she was pregnant soon after while in ice custody this woman expressed that she wanted to access an abortion but the trump administration did not approve this that panel included judge brett kavanaugh jane doe a pregnant 17yearold unaccompanied immigrant minor was effectively held hostage by the government to stop her from accessing abortion the trump administration ordered the private shelter where she was staying to prevent her from going to any abortionrelated appointments while the court battle raged the governments obstructionism pushed doe further along in her pregnancy against her will she always remained resolute in her decision to terminate her pregnancy yet day after day she was forced to sit in the shelter waiting to hear whether she would be able to have an abortion or whether she would be forced to carry the pregnancy to term an emergency order from a lower court allowing doe to have the abortion was secured but the government appealed over a vigorous dissent by judge patricia millett judge kavanaugh wrote a decision that allowed the government to further obstruct janes abortion by the time of judge kavanaughs ruling the trump administration had already delayed does abortion by almost a month the decision allowed the government to continue to obstruct her abortion while the government looked for a sponsor for jane which they had been unsuccessful in finding for the prior month and a half as judge millett put it there was no reason to think that a sponsor could be found in short order as a result judge kavanaughs order would force doe to delay her abortion for multiple more weeks because further delay was clearly unacceptable the full court of appeals was asked to review the case it did so and reversed judge kavanaughs decision ordering the government to allow doe to have an abortion without further delay under policy 110323 medical care for women falls to the 2008 pbnds 44 medical care according to the purpose and scope of this pbnds the detention standard ensures that female detainees in us immigration and customs enforcement custody have access to appropriate and necessary medical health care additionally when policy 110323 was enacted it was stated in the pbnds that a pregnant detainee in custody shall have access to pregnancy services including routine or specialized prenatal care pregnancy testing comprehensive counseling and assistance postpartum followup lactation services and in some cases abortion services rj illuminates how in practice this standard was not enacted and in fact healthcare was denied because timely access to abortion would be seen as a procedure that was both appropriate and necessary for this woman for the case jane doe v trump administration jane doe was nearly denied an abortion and held up in a monthlong process of fighting for an abortion for so long that she nearly missed the window for which it would have been safe for her body and legal for her to access an abortion which means she was forced to endure an unwanted pregnancy for a certain amount of time this case study is a direct example of reproductive violence in that prior to 2020 it was standard practice for ice to deny abortions to minors who are in custody even after a prohibition was placed on preventing access to abortion care state laws often restricted access in the form of mandatory waiting periods and gestational age limits in 2022 with the reversal of roe v wade pregnant migrants and asylum seekers will face even greater limitations on timely access to abortion considering that much of the us border with mexico coincides with states such as arizona and texas that have already or will soon place severe restrictions on abortion if not eliminating access completely there was no indication in this story that this person was being held in ice custody for other than that she was seeking asylum in the usa and fleeing violent family members under the policy that superseded 110323 also known as 110322 identification and monitoring of pregnant detainees jane doe as a pregnant woman would not have necessarily been detained in ice custody for arriving at the border and seeking asylum under previous policy the detention of a pregnant migrant was mandatory under the law only when extraordinary circumstance warranted detention not only was jane doe criminalized and detained at the border but jane doe was also held hostage by the trump administration when she sought out an abortion this administrative decision and migrant experience ultimately highlight what ross and solinger have already stated as a means for imperial power and control no matter what kinds of regulations the government the church the family or other authorities created girls and women have always done what they could do to shape their own reproductive lives these assertions have particular meaning for the lived experiences of women of color whose reproductive capacity has constituted both a key engine for white power and wealth historically and a touchstone for those who want to distinguish the value of womens reproductive bodies by race these perspectives make clear that women of color have been targeted in distinctive brutal ways across us history it becomes clear that the ice health service corps did not have the sole autonomy to help this woman in her decision to get an abortion instead the trump administration with the support of the us supreme court detained this woman and withheld necessary medical care until an appeal emergency order by the aclu allowed for an appeal that ordered the government to allow jane doe to access abortion the trump administration was in direct violation of the sexual and reproductive rights of jane doe in two ways the first being when the supreme court was accessed as a third party to delay the authorization of jane does access to services the second was an attempt to deny access to abortion as a service that only women require the third was a direct violation of cedaw by obstructing her rights to freely and reasonably make decisions about her pregnancy these violations specifically reflect the failure of pbnds 44 to protect a detained migrants right to determine and consent to their reproductive healthcare as well as failure to prevent the psychological harm that would accompany carrying an unwanted pregnancy within the rj framework these failures are a direct confirmation of how systemic racism and inequality shapes power dynamics in terms of decisionmaking access and dignity around all aspects of reproductive rights and freedoms and access to healthcare the failure of ice hsc to protect migrants with healthcare policy and performance standards is evidence that showcases how this impacts those who are most vulnerable to systems of oppression and state violence case study 2 23yearold asylum seeker requires prenatal care a 23yearold asylum seeker was detained at a us port of entry when she was 12 weeks pregnant she was held in ice custody for three months and transferred between facilities six times one transfer between new mexico and texas took 23 hours and landed her in the hospital for exhaustion and dehydration she experienced nausea vomiting weakness headaches and abdominal pain during her detention and did not receive sufficient prenatal vitamins or adequate medical attention this case study highlights several violations of human and reproductive rights under policy 110323 and pbnds 44 this woman was transferred to different facilities in different states six times according to the report there is a correlation between these transfers and the hospitalization for dehydration and exhaustion reifying the argument that immigration detention is dangerous for maternal health while in ice custody this woman did not receive routine age appropriate gynecological and obstetrical health care did not receive ageappropriate assessments and preventative womens health services as medically appropriate and did not have access to pregnancy services including routine or specialized prenatal care all of which are standards of care within pbnds 44 from a human right perspective if the us government is making the claim that it is necessary to take thousands of latinaox migrants into custody it should also be held responsible for assuming the responsibility of providing adequate healthcare to those individuals the committee on economic social and cultural rights affirms health as a fundamental human right and entitlement to the highest attainable standard of health that reflects a life with dignity nd regarding maternal health cescr affirms the health of pregnant and parenting persons to be a core obligation of which the state has immediate obligation to take deliberate concrete and targeted steps towards fulfilling the right to health in the context of pregnancy and childbirth the right to maternal and reproductive health also includes access to prenatal care which this person was denied and thus was not provided with a safe and dignified context in which to be fertile reproduce or become a parent case study 3 pregnancy ends in stillbirth a 24yearold woman went into premature labor and delivered a stillborn baby while she was in custody at an immigration and customs enforcement detention center in south texas last week officials said the woman a migrant from honduras whose identity the agency withheld was arrested near hidalgo tex on feb 18 2018 she was six months pregnant at the time four days later she went into labor and delivered a premature and unresponsive baby boy local doctors pronounced the newborn dead soon after in a statement officials said the department of homeland security which oversees ice and us customs and border protection doesnt count stillbirths as incustody deaths rather theyre recorded in their own category along with miscarriages an ice spokesman said stillbirths are very rare but the announcement drew swift public condemnation from advocates and migrant rights groups had this woman been transferred to a hospital with prenatal and perinatal services this woman and her premature infant may have received the immediate medical attention they required instead of being forced to give birth within the confines of an ice health facility that was likely understaffed and not equipped to medically intervene in the instance of premature birth it is possible that the outcome of this case was related to the conditions that this woman experienced while in ice custody and the care received through the ice health services corps media reporting confirmed that the woman gave birth prematurely premature birth ended in a stillbirth and the government denied responsibility of this outcome as demonstrated within the previous case study adequate prenatal care and a birth environment where women have access to medical intervention are not only appropriate but also a codified human right despite this it appears unlikely that there is a routine practice of preventive health services provided while in ice custody and therefore demonstrates a failure to provide adequate reproductive healthcare to a migrant person in ice custody each case study demonstrates several violent themes such as delayed care and treatment the denial of care and treatment the violation of the right to healthcare and the lack of protections for migrants requiring healthcare access while detained hrw identify the following as violations to the human right to reproductive healthcare inaccurate information about available services barriers to clinic access lack of interpreters invasion of privacy and violations of consent for medications and procedures in framing the failures of ice hsc throughout each case study it is essential to understand that these human right violations are commonplace and point to a larger systemic failure which can be attributed to a culture of white supremacy that functions to justify and facilitate statesanctioned violence against pregnant migrant latinas and latinx migrants in general furthermore the ice medical context does not provide a safe emotional space to process through these distinctly migrant latinaox brown and blackembodied experiences which points to more avoidable emotional harm and physical trauma in the form of structural violence implications for social work implications for social work practice and policy advocacy with immigrants and their families alongside the human and reproductive right abuses of this policy it did not actually meet its intended goals of curtailing immigration or keeping americans safe zero tolerance and the removal policy was extremely expensive especially compared with alternative options such as communitybased detention programs congress in fact did not allot special funding for zero tolerance and one major critique is that it diverted funds away from monitoring actual criminal activity which ultimately left the usmexico border more unsafe that previously so from a financial analysis alone this policy was unsuccessful and it has done little to nothing to curb migration at the usmexico border which was stated by jeff sessions as the intended goal as social workers although we feel strongly against any criminalization of migrants this is a much more human right alternative to automatic federal detention and can increase the likelihood that people can seek healthcare interdisciplinary and interprofessional collaboration should be emphasized in practice based on the premise that human beings are global citizens and there should be freedom of movement for all people those fleeing economic hardships climate change violence and war social workers are well positioned to partner with other professionals to provide support to immigrants migrants refugees and asylum seekers many social work academics and practitioners carry much expertise already in a human rightbased approaches to practice with migrant communities the declaration of human rights clearly states that every human being has the right to choose autonomy dignity and community and to access basic needs required to live to support efforts that in many places have already been underway for some time is to advocate for policies that support healthcare for all people especially the most vulnerable as we are currently living in a time where access to safe and legal abortions is being criminalized and banned in many states within the usa it has become illegal and extremely challenging for many people to access abortion in states that are largely conservative prior to the overturn of roe v wade it is evident that the administration took advantage of the opportunity to deny this right to migrants and asylum seekers as some of the most vulnerable and disenfranchised people even with our own national association of social workers moving to denounce the trump administrations policies formally pregnant migrants and asylumseekers will continue to disproportionately face the denial of essential reproductive healthcare and services when they are detained in federal custody unfortunately what is being reported demonstrates that thousands of women are forced to go without essential reproductive healthcare and services while in ice custody therefore not only is policy 110323 in violation of the reproductive rights of pregnant latina migrants but executive order 1378 is in violation of the reproductive rights of all detained latinx migrants these policies have major implications for migrant and immigrant healthcare this is especially the case in a world where climate change will force migration and in considering the numerous humanitarian crises occurring globally and on nearly every continent we also hope that this analysis underscores the utility of a specific rjinformed praxis in social work rj offers social workers a digestible framework through which to address intersectionalityinformed rj approaches in their practice with children youth and families social workers in any setting should actively support efforts for families to remain intact whenever possible especially in the context of trauma work and utilizing traumainformed approaches because rj emphasizes and acknowledges trauma work from systems perspectives that underscore the interconnectedness and relational aspect of supporting healing and resilience against reproductive injustice and human right violations pregnant and parenting black and brown bodies are not disposable they matter and reflect resilience resistance and healing which is an inherent component of the latina experience that often goes overlooked social work is a values and ethicsbased profession that aspires for social justice for all people and supports the health and wellbeing of communities and families reproductiverelated policies and healthcare access are central to supporting families and communities it is likely that those directly impacted by zero tolerance directly will have to manage mental health challenges and social workers are currently and will continue to provide services to this population and an analysis could inform mental health promotion efforts for refugees migrants immigrants asylum seekers and new americans considering also that many latinx migrants like other groups who are forced to migrate are 2slgbtqia individuals who are feeling genderbased violence a central concern for the rj movement many social workers are likely to support the many people harmed by zero tolerance in the usa and other discriminatory policies in other countries and localities implications for social work education this policy analysis is useful and important for teaching content related to immigration policy migrant and immigrant healthcare as well as human right violations it is important to frame for social work students that these policies represent and perpetuate a violent legacy of the white colonial regimewherein the activity and in this case migration and reproduction of latinaox bodies are of concern to the american government the trump administrations removal of the exemption of detention under ice health service policy 1130323 functioned to violate the reproductive rights and bodies of womenand did so in ways that arguably supported the administrations agenda and concerns regarding migration into the usa via the usmexico border it is the onus of social work students and practitioners to question examine and critique any way in which modern legislation functions as a mechanism to impose imperial power and control onto racialized and migrating bodies it is a matter of social work pedagogy to call attention to this matter as well as to frame it historically in the social work classroom the three case studies offered in this paper are important examples of the nuanced and complex issue that is the detention of pregnant migrants and asylum seekers for doing nothing other than simply migrating this policy analysis also has potential to reach social work students who might be interested in these specific policy issues concerning latinoax migration and reproductive justice but may be geographically located far away from the usmexico border it also functions to call attention to a matter that one may not know much about depending on their location more broadly this policy analysis in conjunction with others like it may be used to think critically about and address past present and future policies that are written to exert power control and violence via human right violations over other racialized and migrating bodies finally the reproductive and racial justice issues noted here in this analysis hold implications for all populations that social workers work with with migration increasingly occurring throughout the world due to everpresent conflict and persecution climate change and poverty social workers must consider and understand that similar policies have been written and will continue to be implemented by regimes and are situated in colonialism power and control of those in power if we as social workers assert that migration is a basic human freedom we must also be aware of the modernday policies that criminalize migration and jeopardize the health and wellbeing of vulnerable marginalized and displaced persons and families conclusions alongside a broad range of human right violations listed here criminalization and detention of migrants from central and south america did not yield the results that the trump administration hoped for and did little to deter migration this is because this inhumane policy never once addressed the structural issues that create situations where adults children youth and families must seek asylum in usa the enforcement of zero tolerance and the subsequent human right violations that accompanied it only reinforced a climate of discrimination and xenophobia and questions whether the us is abiding by human rights and refugee related international protocols lastly we end by acknowledging and appreciating the extremely hard work of frontline social work practitioners activists and educators who have been sounding the alarm about reproductive injustices and latinaox communities for what feels like forever a policy such as zero tolerance is inconsistent with the social work code of ethics and we acknowledge the distress and secondary trauma that comes from engaging in this work and bearing witness to human right abuses such as the ones mentioned here more women are in federal custody than ever before and the number of girls and women seeking asylum is growing the criminalization of migration is a means to justify the implementation of racist and xenophobic legislation that criminalizes migration and violates basic human rights understanding the impact of zero tolerance informs how social work moves forward in supporting migrants and immigrants especially black and brown immigrants who are challenged with racist and xenophobic policies often times from wealthy and developed nations like the usa

during the trump administration the immigration and customs enforcement ice directive 110323 revoked the automatic release of pregnant women detained by ice this paper presents a policy analysis of the impact of this directive on pregnant latina migrants the directive is contextualized as part of the trump administrations zerotolerance immigration policy that directed us attorneys offices along the southwest border in april of 2018 to criminally prosecute all cases involving illegal entry with no exceptions under this policy latin american migrants seeking asylum in the usa faced criminalization family separation and detention reproductive justice rj is the guiding conceptual framework for analyzing this policys impact three case studies demonstrate the reproductive and human rights violations impacting pregnant migrant latinas seeking to enter the us under zerotolerance this policy did not deter migration from central and south america and created avoidable harm although zerotolerance was rescinded in 2021 the longterm impacts remain unknown implications and recommendations for social work practice policy advocacy and social work education are providedthis policy analysis focuses on pregnant latinas seeking to migrate to the us who were impacted by the removal of the exemption of detention under ice health service directive 1130323 identification and monitoring of pregnant detainees one of the directives under the trump administrations zero tolerance immigration policies we use reproductive justice rj as a framework and lens through which to analyze this policy as it relates specifically to the rights and healthcare needs of pregnant migrant latinas an rj framework helps to illuminate the ways in which this policy was harmful to the physical and mental wellbeing of latinas and how this policy violated human and reproductive rights three case examples are presented to that highlight the harmful impact of automatic detention of migrants and asylum seekers our analysis concludes that this policy failed in achieving its stated goals we also assert that zero tolerance policy was xenophobic and discriminatory it harmed pregnant latina migrants and asylum seekers and violated their human and reproductive rights we share the implications of such policies for social work specifically social work practice with children and families and social work education we contend that these policies of forced detention and criminalization of pregnant latina migrants caused undo harm in a myriad of ways the structural inequities criminalizing migration in the usa are discussed

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culturally specific diet and health education programmes have been implemented locally however levels of cultural competency among health professionals working with south asians require further improvement the present qualitative study conducted by a secondgeneration pakistani and two nonpakistani researchers aimed to assist this process by 1 exploring health perceptions and diet that may contribute to the increased incidence of dietrelated diseases and to cultural body image perceptions of obesity 2 exploring the understanding of perceived health risks and the social construction of obesity 3 elucidating the relevant barriers and motivations for dietary and lifestyle choices and 4 developing a framework to better understand the factors underlying the womens health behaviours and how this relates to the initiation and maintenance of a healthier diet methods focus groups and individual interviews initially the study used both ethnographic and phenomenological approaches ethnography uses unobtrusive crosscultural observations and informal discussions as a means of interpreting social reality phenomenology aims to uncover meanings without explanation of a reality that is socially constructed through lived experiences this allows for the description of realities as perceived by individuals within their community and the host community the researchers gathered data from participants during small focus groups lasting approximately 1 to 2 h or onetoone interviews lasting from 15 to 60 min they were conducted in community centres or participants homes in english and urdu and were led by either a caucasian or a pakistani researcher experienced in qualitative methods along with a trained female pakistani translator a pilot focus group session was conducted among seven bangladeshi muslim women all sessions involved using fictional vignettes as previously used in health studies among south asians interspersed with openended questions a vignette is a short description or character sketch of a person or story the researchers drafted fictional vignettes involving a character named farah a 38yearold married overweight pakistani mother of four living in manchester this technique was used to explore issues such as obesity food health fatalism faith age and family dynamics according to the method of progressive focusing where new and emerging issues are explored the vignette was adapted as the need for new data became apparent in total five versions were used subtle references were made within the vignette to t2d while later versions focused on her as a mother and wife comparing responses allows for further theories to emerge the participants were also shown a series of seven female silhouettes ranging from an underweight figure to an obese figure ie representing an unstated bmi of 17 kgm 2 to 35 kgm 2 these were used to explore the womens perceptions of body shape as applied to farah all interviews were recorded and transcribed verbatim for all sessions selected secondgeneration women who read english were sent copies of their transcripts for memberchecking amending as necessary the translator clarified nuances within the transcripts of the nonenglish speaking firstgeneration women according to recommendations for qualitative research sampling ceased when no new themes emerged from the data collected demographic data were collected using a questionnaire these data included age marital status number of children birthplace and how much education they had received the women were asked to estimate how frequently they ate pakistani v english meals or ate away from home each week analysis the transcripts were initially analysed using theme identification and coding the phenomenological analysis aimed to intensify the researchers understanding of the text in its constituent parts using the method of van manen the text was broken down and categorised manually into domains of time space body and human relations with the added domains of foodways and health beliefs the data were placed within each theme and then coded to identify subthemes following the initial analysis additional interpretation and analysis of the emerging themes was then provided by a sociologist according to researcher triangulation this process aims to reduce bias and is designed to enhance validity the sociological analysis allowed the researchers to see the participants from a new perspective taking into account the influences involved this perspective formed the social construction of obesity beyond its biomedical definitions the researchers sought to elucidate the participants understanding of health risks knowledge prevention barriers and motivators for diet and lifestyle results phenomenological analysis diabetes symptoms the participants did not recognise farahs symptoms of thirst and frequent tiredness as being suggestive of t2d some believed that farah was not well and suggested tuberculosis cancer or being overweight and that she was not eating or drinking properly a 50yearold mother stated shes farah not eating properly so her health is suffering she probably cant work in the house any more she could have some illness y she is too fat reasons for overweight reasons cited for farahs weight gain included childbirth her age and inactivity health action overall the women did not express a preference for a source of sound health advice some stated that they would consult a doctor nurse health visitor or social worker however others sought advice from elders i think professional doctors and nurses we can find out from them y but mostly y we follow the tradition we learn from our parents motivation to change a lack of motivation to address weight problems was expressed as women tend to not think about themselves and dont like seeing their bodies barriers evident among firstgeneration women included the influence of the men in the family on home cooking weight gain as being natural and unavoidable and there appeared to be a lack of concern for preventing illness the prevailing attitude seemed to be that health and weight gain were not things the women often thought about as they were too busy however some women described themselves as lazy in terms of taking exercise or changing their cooking habits a principal motivating factor was the need to look after their children and home and they sensed that they should do something about their weight when it caused pain sociological analysis identity deconstruction muslim pakistani british separating dimensions of ethnicity was difficult as reported by previous researchers the muslim identity described as being 100 complex seemed to be the strongest identity as it dictated food habits it has been suggested that muslims are likely to learn about health from their mosque and the koran however the koran was not a constant source of food information except for halal and haram foods and alcohol avoidance the pakistani cultural and spiritual identity was the second strongest influence among secondgeneration pakistani women the british identity may have been as strong as their pakistani identity family family life is essential and sacred within islamic society women are assigned the duty of looking after the household and act as culturebearers indeed the interests of family often took precedence over those of the individual woman as has been previously reported this is likely to diminish motivation and opportunities to address weight gain conversely it could also provide motivation to change as the participants acknowledged that weight gain and illness could interfere with family duties emergent themes risk awareness the participants did not always connect obesity with diabetes one mother of eight perceived that diabetes was caused by stress as previously reported among south asians another woman from rawlpindi understood a connection between obesity and diabetes but believed that the former resulted from the latter urban v rural background the womens region of origin may affect beliefs and practices including education level english literacy empowerment and activity levels for example participants stated that urban women may have access to an english education and be more empowered within their marriages however some women suggested that the rural life might be beneficial in terms of the climate fresh air and the level of activity climate participants often blamed the colder british climate for weight gain because it caused them to sweat less and to engage in less outdoor activity such associations have been reported previously among south asians some women also linked the appropriateness of the traditional diets with climate ie eating clarified butter was acceptable in pakistan where women were more active food traditionsexpectations typically food was prepared from scratch every day using recipes passed down by word of mouth and was described as being healthier most of the participants reported eating such food at least once a day often in the evening with the family breakfast was sometimes described as an english meal at which south asian food was rarely eaten as has been reported in other studies there was a strong influence of family expectations on food preparation and consumption generally younger pakistani women received advice from their elders pakistani men also have a responsibility for maintaining traditional cultural practices the social importance of cooking for guests and of celebratory meals was described hence it may be difficult for the pakistani woman to change food practices some women described eating their family meals while sitting on the floor rather than around a table one secondgeneration woman explained this as a traditional means of controlling the amount eaten legs closer to the stomach was said to reduce the amount eaten english v pakistani food some perceived that english food is processed fast foods and breakfasttype foods the women had mixed perceptions of pakistani food as it was perceived to have many healthy ingredients but also could be unhealthy such as common use of fat and frying other ingredients were considered to have specific benefits eg karela black onion seeds and honey certain food combinations were considered inadvisable according to questionnaire data firstgeneration women consumed more traditional meals than english meals secondgeneration women ate slightly fewer traditional meals and reported eating slightly more meals away from home each week chips and beans seemed to be a favourite english meal some were aware that eating takeaway meals could be unhealthy obesity and health perceptions of a healthy and overweight womens body size varied when asked what the overweight farah looked like the participants responses ranged from silhouettes 4 to 7 corresponding to a bmi of 225 kgm 2 up to 35 kgm 2 silhouette 3 corresponding to a bmi of 20 kgm 2 was generally considered the healthiest increased weight may not always be perceived as unhealthy and may be viewed as indicating good health wealth or status body shape perceptions may also be affected by modesty traditions and some pointed out that a woman dressed in traditional clothing was not always aware of her shape table 3 summarises other potential differences in the viewpoints between british pakistani women and health professionals health action transition model to our knowledge existing health models do not take account of the information obtained in the present study accordingly a new health action transition model of health improvement in firstgeneration pakistani women in north west england is proposed the model allows the multidirectional dimensions underlying the construction of health and its impact on dietary change to be addressed the model is in three parts section a is entitled structural factors and cultural knowledge section b is preventive health knowledge and section c is agency section a represents the uncontrollable aspects in the womans life and section b represents the controllable aspects via increased health knowledge the boxes on the far left of section a represent the woman not yet taking responsibility for her health or possibly being unmotivated to act moving to the right the circles then delineate concepts related to her understanding of health obesity foodways and cooking patterns section b suggests that the pakistani woman will ideally be influenced by various health professionals and not just by her peers and elders rather than considering weight gain as inevitable this woman takes control of her health section c is the stage which healthcare professionals would ideally wish her to reach the model should help health professionals understand that certain influences are uncontrollable and that she might have a strong sense of predestination respecting these issues health professionals can promote preventive measures that can help the woman take some responsibility for protecting her longterm health for example in making informed decisions about weight loss by taking these complexities into consideration health professionals can encourage healthier behaviours in the pakistani woman who will then extend these to her family and community discussion the present qualitative study aimed to provide insight into the social and cultural constructs underlying perceptions of diet weight gain and health risks among british pakistani woman in north west england and how these relate to westernised biomedical models in order to facilitate efforts to promote good eating practices and address health inequalities qualitative research methods are valuable in allowing the exploration of complex behaviours attitudes and interactions and have previously been used to explore diet and health in south asians various sociocultural factors can hamper research among south asian groups especially women accessing women who are mostly housebound can be difficult if perhaps unused to giving their opinion such women may be concerned about giving the right answer some may be reluctant to discuss health and weight issues the current research reached a crosssection of pakistani women including nonenglish speaking and the hardtoreach it employed a south asian researcher and translator in order to aid access and communication and to apply both insider and outsider perspectives the analysis was also enhanced by rigorous qualitative research methods and a sociological perspective strengths and limitations common limitations in qualitative and transcultural research include the use of relatively small samples and the need to translate and interpret interviews it could be argued that a study limitation was the use of a nonpakistani moderator and the broader applicability of these findings needs to be tested data concerning the socioeconomic status of the women and length of uk residency were not collected the usefulness of bmi silhouettes was limited because they represented weight gain in caucasian women characterised by hip adiposity rather than in south asian women who tend to accumulate fat centrally furthermore bmi thresholds for diabetes risk are lower in south asian women than in caucasian women pakistani women food and health the present study supports evidence of a lack of understanding about t2d and its relationship with weight gain among south asians and demonstrates that preventive measures are still required the participants expressed concerns about weight gain including the contributory roles of stress climate age and childbirth many of which have been reported previously importantly the women expressed a strong sense of fatalism with regard to health risks and weight gain but desired more health knowledge multiple dimensions of identity were exhibited including being muslim pakistani british female and mothers for the secondgeneration women islam is considered in relation to halal and haram food when shopping in a nonasian food store the women were strongly influenced by cultural traditions and family expectations with regard to food preparation and consumption and these represent important barriers to change the study supported other evidence that south asian groups prefer traditional food over english food the women adhered to traditional pakistani food habits important to them socially and culturally radical changes to these habits would be neither possible nor desirable for them other researchers have identified these influences on diet and food shopping together with factors such as age lack of time language barriers climate and access to foods cultural barriers may outweigh personal motivation for weight loss such as personal appearance the prioritisation of the familys expectations and needs concurs with other evidence that exercise beyond housework is considered selfish by some south asian women these perceptions may be at odds with individualistic motivations in commercialised healthy living and with individualistic models of behaviour change that involve concepts such as selfefficacy or empowerment however family concerns could be a motivator where weight gain compromises the womans role as family carer also the health of the children or husband may also be an important motivator towards dietary change this familial collectivism suggests that conventional health models that place emphasis on individuals and their selfefficacy may not be readily applicable to south asian women health promotion and education many of the aforementioned barriers to research in south asian groups also hamper nutrition and health intervention programmes experience from a health project among south asians in manchester has illustrated the difficulties in engaging communities and the importance of addressing wider social determinants of health beyond ethnicity the food and health practices of the participants in the present study were strongly influenced by their peers and elders this reinforces that familybased educational interventions are useful in these communities the participants did appear to recognise the important role of healthcare professionals however other recent evidence also suggests that south asian women may be strongly though passively influenced by their doctors recommendations and that word of mouth may have an important role in promoting programmes other evidence suggests that pakistaniborn people with diabetes expect empathy and care from health workers rather than an authoritarian style positive aspects of traditional food practices should be reinforced including cooking from scratch using a variety of fresh and healthy ingredients and family meals the importance of breakfast and lunch should also be emphasised only recently have validated tools been developed to assess diets in this group and capturing the complexity of these diets remains a challenge health action transition model various models have been developed to describe and facilitate behaviour change with regard to health and ideally should be culturally and socially sensitive designed in response to the findings a new conceptual model was developed to consider public health nutrition and health promotion planning within a sociological context to our knowledge it is the first model to describe the cultural and sociological influences among pakistani women with regard to diet weight gain and health it is designed to demonstrate the complexity of the interwoven influences on the pakistani woman and to help the health professional engage with her using concepts beyond bmi or waist circumference measurements the model implies a continuous progression from awareness through to initiation and maintenance of action it also demonstrates a sustained educational process in which many controllable influences and motivators may contribute some forces may be uncontrollable according to this model the woman maintains her traditional ways of cooking and eating patterns but understands the risks associated with overweightobesity and becomes more aware of healthier habits step by step she will take responsibility by taking control of her health applying this knowledge to her family and community the model may be used to tailor preventive health information that integrates cultural beliefs with biomedical knowledge moreover it may be used to improve cultural awareness among health professionals working with and counselling pakistani women about weight management and as an educational tool in the training of these professionals conclusions health education programmes that aim to address obesity and its associated risks in south asian communities must take into account the complex beliefs and practices and the multiple religious ethnic and social identities that interact within this population the present study provides further insight into these factors and proposes a health action transition conceptual model for use in designing and implementing education interventions for british pakistani women

objective the present qualitative study explored health perceptions diet and the social construction of obesity and how this relates to the initiation and maintenance of a healthier diet in uk pakistani women design pakistani women in greater manchester participated in focus group and onetoone discussions semistructured interviews employing fictional vignettes and body shape images were used to explore the participants beliefs and practices regarding diet overweightobesity and the risk of type 2 diabetes transcripts were analysed using phenomenological and sociological approaches setting interviews took place either in local community and pakistani resource centres or in private homes subjects firstand secondgeneration women who were both active in the community and housebound the women spoke english andor urdu results the fiftyfive participants lacked the motivation to address weight gain and were unsure how to do so there was a limited awareness of the link between weight gain and type 2 diabetes other barriers included the influence of islam culture and familial expectations on home cooking perceptions that weight gain is inevitable owing to ageing childbirth or divine predestination and the prioritisation of family concerns over individual lifestyle changes as the findings of the present research did not correspond to existing educational and behaviour change models a new health action transition conceptual model is proposed conclusions health education programmes that aim to address obesity and its associated risks in the south asian community must take into account the complex beliefs and practices and the multiple dimensions of religion ethnic and social identity within this population the present study provides further insight into these factors and proposes a novel model for use in designing and implementing education interventions for british pakistani women

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introduction intervention plans form the backbone of offender supervision and describe the goals and interventions that should help offenders stop reoffending an intervention plan may also be called a supervision plan case management plan risk management 1 jacqueline bosker correspondence concerning this article should be addressed to jacqueline bosker research centre for social innovation university of applied sciences heidelberglaan 7 3584 cs utrecht the netherlands email cilia witteman jo hermanns plan or sentence plan in this article we use the term intervention plan to refer to a plan that consists of all the conditions interventions restrictions control instruments and other activities by probation other organizations and the offender in order to reduce the risks of recidivism and harm interventions can entail behavioural training psychological treatment practical aid and support in general intervention plans focus on managing safety modifying behaviour and improving basic needs probation services use intervention plans to advise the court via a presentence report or to describe a sentence plan for prisoners or offenders who are under community supervision research regarding effective practice has demonstrated clearly that intervention plans should be based on structured risk and needs assessment first the reliability and validity of assessments can be improved with the use of a structured assessment instrument second the use of structured risk and needs assessment should lead to intervention plans that meet the criteria of effective practice however evidence suggests that in practice the coherence between the risk and needs assessment and the intervention plan is not a straightforward matter in a study of offender supervision for example bonta and colleagues found that much of the information obtained from the assessment was not used in the intervention plan vieirra and colleagues investigated the match between the assessed needs and the services received through probation in a sample of 122 cases of young offenders the general needsprobation match turned out to be only 35 the authors found a moderate correlation between needsprobation match and recidivism having only a few needs met young offenders were more likely to reoffend both earlier and more frequently these results confirm that a good match between the assessment the intervention plan and the interventions that are delivered is important in contrast to the extensive body of research regarding structured risk and needs assessment studies of intervention plans in the field of offender rehabilitation are scarce to fill this gap the aim of the current study was to evaluate the extent to which intervention plans that are based on an instrument for structured risk assessment actually meet the criteria of effective practice in probation the seven criteria that were formulated to evaluate the quality of the intervention plans are described in the next paragraph the dutch instrument for risk and needs assessment is described in the methods section the results are presented in a subparagraph per criterion limitations and future directions are discussed criteria for effective intervention plans both research on what works to reduce recidivism and research on desistance from crime afford general knowledge about what a good intervention plan should look like stable support has been found for the so called risk needs responsivity model this model consists of three principles that when used together are expected to have substantial impact on the reduction of recidivism the risk principle states that the level of supervision and intensity of the interventions should match the risk of recidivism the higher the risk of recidivism the more intensive the intervention plan should be the needs principle states that interventions should focus on the needs and problems that are related to the criminal behaviour an extensive body of research has revealed criminogenic needs such as antisocial personality antisocial attitudes antisocial relations a history of antisocial behaviour poor quality of the relations with partner and family lack of education and work and drugand alcohol abuse the responsivity principle states that in general social learning and cognitive behavioural strategies have proven to be the most effective in reducing recidivism on an individual level the responsivity principle states that interventions should match the learning styles abilities motivation and limitations of offenders the growing body of research about desistance from crime has led to additional insights about effective offender supervision this research focuses on the lifecourses of offenders and on the question why and how some offenders persist and others desist from criminal behaviour research on desistance from crime has shown that improving the socalled social capital of offenders can be an essential part of an effective rehabilitation process the concept of social capital was introduced by coleman and refers to characteristics of social relationships between individuals that generate obligations and expectations information and norms obligations and expectations refer to social structures with mutual support social relations can provide all sorts of information that can be helpful in achieving ones interests finally social structures can have strong norms that lead to rewards for positive behaviour and sanctions for negative behaviour besides family and friends social capital can be found in relations in the neighbourhood at work or in church changes in situational and structural life circumstances of offenderseg a good marriage or a stable jobcan increase social capital and thus support desistance and improve motivation for change therefore intervention plans should not only focus on improving the skills and knowledge of an individual socalled human capital but should also pay attention to the social context that offenders are in and the way this context influences their behaviour helping offenders to create a supportive network and to let go of an antisocial network can be an effective strategy to reduce recidivism the concept of social capital for effective offender rehabilitation is not included in but does not contradict the rnr model some of the criminogenic needs in the rnr model refer to social capital for example the relationship with friends and work in intervention plans it is important to include goals that can be achieved in different theories and methods for behavioural change it is found that working with goals appears to be effective in a change process goals can help people focus they energize and affect persistence in order to have this effect goals must be specific both for the offender and the probation officer it must be clear what to work on moreover goals can effectively support a change process if they are formulated as something to be approached instead of as something to be avoided approach goals are formulated in terms of what must be achieved whereas avoidance goals are formulated as situations that must be avoided or behaviour that must be unlearned both in research about addiction treatment and relapse prevention of sexual offenders it was found that people who work on approach goals relapse less frequently and are more engaged in treatment than people who work on avoidance goals in a probation context goals are often formulated by the probation officer based on the risk and needs assessment the probation officer decides which needs should be addressed and subsequently what goals should be reached regarding the assessed needs however in literature about desistance from crime the importance of working on the offenders goals is emphasized because it helps motivate the offenders for change and to commit themselves to the intervention plan agreement on goals is also considered to be an important characteristic of an effective working alliance and therefore of an effective change process therefore making offender goals and probation goals explicit and integrating offender goals in the intervention plan may be expected to have a positive impact on the effectiveness of probation services based on the research we summarised here seven criteria for an effective intervention plan were formulated to be used in our study of the intervention plans of course these criteria do not cover all there is to say about effective practice there are some principles of effective offender supervision that we have not mentioned here such as building a good working alliance the use of evidencebased interventions and strengthening protective factors table 1 criteria for an effective intervention plan used in this study 1 the intervention plan targets the dynamic criminogenic needs 2 goals match the dynamic criminogenic needs 3 interventions match the dynamic criminogenic needs 4 the intensity of the intervention plan matches the risk of recidivism 5 the intervention plan contains specific goals 6 the goals are formulated as approach goals not as avoidance goals 7 the intervention plan contains goals that are important for the offender methods risk and needs assessment the dutch probation service uses an instrument for structured risk assessment called the recidive inschattings schalen risc is based on the english and welsh offender assessment system risc contains items about the following 12 criminogenic needs offending history current offence accommodation education and employment income and financial management relationships with partner family and relatives relationships with friends and acquaintances drug abuse alcohol abuse emotional wellbeing thinking and behaviour and attitudes each criminogenic need is assessed on a scale that contains a number of risk items which are scored as 0 1 or 2 table 2 shows the number of items in each scale and some examples of items criminogenic needs can be either static meaning that they cannot change or change in only one direction or dynamic meaning they can change scales 3 through 12 represent dynamic criminogenic needs some of the risc scales that represent a dynamic criminogenic need also contain one or two static items describing problems of the past the total score of the items in a risc scale represents the severity of that criminogenic need for every scale cutoff scores are used to indicate whether the specific criminogenic need is considered to be relevant in an individual case or not taking into account the varying strengths of the correlation between the criminogenic needs and recidivism the raw total score of the scales are converted into weighted scores the weights are based on the weights of oasys and on a review of studies about the predictive value of risk factors the sum of the weighted scale scores represents the risk of recidivism and is grouped into the following four categories low risk moderatelow risk moderatehigh risk and high risk the internal consistency of the scales was found to be moderate to good for most scales the interrater agreement of the risk scales and total score was found to be moderate to substantial the predictive validity for general recidivism of risc is sufficient for both men and women the items in risc are scored by the probation officer in addition the offender performs a selfassessment to provide his or her opinion of the actual problems and to emphasize priorities based on the risk assessment the probation officer formulates an intervention plan in this study we focused on the following three domains of the intervention plan a description of the criminogenic needs that are perceived as relevant and therefore must be influenced were coded by hand from the files using a coding manual the researcher and her assistants declared confidentiality and file information was processed anonymously four research assistants helped to make an overview of the goals and interventions in the intervention plans the researcher coded the files sample the sampling pool consisted of a cohort of risk assessments that had preceded supervision in the framework of a suspended prison sentence first all supervisions with a suspended prison sentence for unique offenders that started in the period between january 1 2010 and march 31 2010 were selected subsequently to these cases risk assessments were matched that represented the situation of the offender at the start of the supervision we decided to include assessments that were completed between six months before the start of the supervision and three months after the start of the supervision this resulted in a sampling pool of 821 cases another 85 cases were removed from the sampling pool because the offender denied the offence during the assessment and when an offender denies the offence and has not been sentenced yet probation officers often do not formulate an intervention plan the final sampling pool consisted of 736 cases from this pool a sample of 300 cases was selected at random we tested whether these 300 cases were representative for the total population of offenders under supervision in connection with a suspended prison sentence in that period the offenders in the sample did not differ from the total population with respect to the number of men and women the average age and the risk of recidivism small differences were found between the sample and all offenders regarding their ethnic background in the sample 90 was male and 10 female the average age of the offenders was 34 years a majority of the offenders had committed a violent offence 24 a property offence 8 a drug offence 3 a sexual offence and 2 other offences3 based on the sum score of risc the offenders are divided over the risk categories as follows 17 low risk 31 moderatelow risk 26 moderatehigh risk 25 high risk the number of dynamic criminogenic needs varies from 0 to 9 with an average of 5 variable construction most of the items were recoded to be suitable for analysis as follows  dynamic criminogenic needs considered present risc contains 10 dynamic criminogic needs to determine whether a dynamic criminogenic need is present or absent in an individual case the risc cutoff scores are used some criminogenic needs can score above the cutoff point based only on the scores of items concerning problems in the  past for example two of the six items in the section on drug abuse regard drug misuse in the past high scores on these items can lead to a summed score above the cutoff score of this section however if there is no actual problem no intervention is expected therefore in this study a dynamic criminogenic need is considered present if it scores above the cutoff score and if there is an actual problem  emotional wellbeing the risc cutoff score for the criminogenic need emotional wellbeing is so high that some offenders with psychological problems do not reach this score therefore the cutoff score was adjusted in such a way that emotional wellbeing is considered present if offenders have actually diagnosed psychiatric problems or a combination of actual problems on this scale  addiction some probation officers do not distinguish drug and alcohol abuse in the intervention plans yet formulate goals on addiction therefore the criminogenic needs for drug abuse and alcohol abuse were combined into one criminogenic need drugalcohol abuse resulting in 9 dynamic criminogenic needs in this study  goal clusters to examine the relation between the dynamic criminogenic needs and the goals in the intervention plan the goals were recoded into clusters that match the dynamic criminogenic needs some of the goals could not be clustered into a category that matches a dynamic criminogenic need and are not included in the analysis these goals were not related to a specific need were too vague or described an intervention instead of a desired change on a criminogenic need  interventions the interventions were recoded into clusters that match the criminogenic needs and the clustered goals some interventions may influence a criminogenic need but the match is not obvious for example clinical psychological treatment is obviously related to emotional wellbeing and thinking and behaviour but during treatment problems with relations might also be addressed the files do not specifically describe what is or what should be done during treatment therefore the match between interventions and dynamic criminogenic needs is scored on a scale from 0 to 2 the intervention does not address may address or does address a specific criminogenic need  goals offender the selfassessment is used as an indicator of the goals of the offender in the selfassessment information is gathered regarding the problems that are important for the offender and regarding his or her priorities the issues that are a problem or a priority for the offender are considered to be goals of the offender these issues were clustered in the same categories as the dynamic criminogenic needs goals and interventions in 230 of the 300 cases a selfassessment was available reasons that probation officers describe for the absence of the selfassessment are too difficult for the offender no time language problems offender not necessary forgotten other reasons no reason described clustering the goals and interventions was done with the help of three experienced officers of the probation service as a first step they clustered the goals and interventions independently differences were discussed and a final clustering was based on consensus analyses the aim of this study was to describe whether intervention plans that are based on an instrument for structured risk assessment meet the seven criteria of effective practice in probation to describe the extent to which the intervention plans target the criminogenic needs goals match the criminogenic needs interventions match the criminogenic needs and intervention plans contain goals that are important for the offender descriptive analyses are used subsequently regarding criterion 1 the match is described as the proportion of offenders with a present criminogenic need that is indicated as a need that should be targeted the same is done for criterion 2 3 and 7 using the goals and interventions in the intervention plan to measure the extent to which the intensity of the intervention plan matches the risk of recidivism spearman correlation is used whether the goals are concrete and formulated as approach goals is analysed by measuring the mean scores of the goals of the 300 intervention plans per goal cluster results intervention plan targets dynamic criminogenic needs the extent to which intervention plans target dynamic criminogenic needs is shown in table 3 when assessed as present the dynamic criminogenic needs are perceived by the probation officers as being relevant to be targeted in a majority of the plans this match differs between criminogenic needs when present probation officers decide to target problems with cognitive skills addiction attitude and emotional wellbeing in 75 88 of the cases the match is relatively low for practical and contextual needs such as accommodation friends education and work and finance for none of the assessed dynamic criminogenic needs the match is 100 describing that a specific criminogenic need should be targeted does not mean that the need actually is targeted to get a clearer picture about the actual needs that are targeted in the intervention plans we must look at the goals and interventions the following paragraphs describe the match between the assessed criminogenic needs and the goals and interventions in the intervention plans goals match the dynamic criminogenic needs the second criterion is whether the goals in the intervention plan match the dynamic criminogenic needs table 4 shows whether a goal was formulated with regard to the assessed criminogenic needs the match between the goals and dynamic criminogenic needs was relatively low the goals target the assessed criminogenic needs in more than 50 of the cases only for addiction and cognitive skills with respect to basic needs social relationships attitude and emotional wellbeing no goal is formulated in a majority of the cases in which the criminogenic need was assessed as being present a comparison of tables 3 and4 shows that the perceived relevance of the criminogenic needs has a better match with the assessed criminogenic needs than the goals apparently probation officers often define a criminogenic need as relevant but they do not formulate a goal with respect to this specific need interventions match the dynamic criminogenic needs the third criterion for determining the quality of an intervention plan is whether the interventions in the plan match the dynamic criminogenic needs as described in the methods this match is coded in the following three categories no match possible match and good match the match between the assessed criminogenic needs and the interventions differs per criminogenic need a relatively good match is found for cognitive skills when a lack of cognitive skills were assessed as a dynamic criminogenic need in 72 of the cases the intervention plan contained an intervention that addresses this need with respect to emotional wellbeing attitude addiction and relationship with partner or family 57 63 of the intervention plans contained an intervention that addresses these needs when assessed as being present with respect to basic needs in a large majority of cases no good match was found between the assessed criminogenic needs and the interventions the percentage of cases in which no match was found between the assessed criminogenic needs and the interventions is small most of the intervention plans contain interventions that can influence the assessed criminogenic needs the highest percentage of no match was found for the criminogenic needs emotional wellbeing education and work finance and friends intensity intervention plan matches risk of recidivism based on studies regarding effective practice lowrisk cases should have low intensity intervention plans and highrisk cases should have high intensity intervention plans table 6 shows the match between the intensity of the intervention plans and the risk of recidivism in this study half of the plans have a low intensity meaning that only one behavioural program or low intensive treatment is delivered lowrisk cases often have low intensity intervention plans in cases with a moderatelow moderatehigh or high risk of recidivism the intensity of the intervention plans diverges from very low to very high in these three risk levels most intervention plans are either lowor highintensity and in all three risk levels lowintensity intervention plans are overrepresented in highrisk cases most intervention plans are lowintensity although a moderate to very high intensity is found in a substantial number of highrisk cases overall there is a low but significant correlation between the risk of recidivism and the intensity of the intervention plans meaning that the risk principle is employed rather poorly goal are specific and formulated as approach goals criteria 5 and 6 refer to goal formulation goals should be both specific and formulated as an approach goal table 7 shows the mean score in a range from 0 to 1 of all the goals that are formulated in the intervention plans with respect to a specific goal cluster in general goals are formulated rather specifically goals regarding addiction education and work finance and friends are found to be the most specific examples of specific goals include the offender is abstinent from drugs and the offender has a job goals regarding attitude emotional wellbeing and cognitive skills are the least specific examples of goals that are not specific include the offender must understand his problems and the offender must develop his emotions and identity in general probation officers use more approach goals than avoidance goals a mean score of 1 would mean that all goals are formulated as approach goals and a mean score of 0 would mean all goals are formulated as avoidance goals the mean score for approach goals is 063 meaning that a majority of the goals is formulated as approach goals goals regarding education and work accommodation and attitude often are approach goals avoidance goals are often found with the criminogenic need addiction examples of oftenused goals on this need are client uses no drugs or client controls the number of glasses he drinks in a week intervention plan contains goals that are important for the offender the final criterion for an effective intervention plan was whether offender goals are included in the intervention plan that is whether in the intervention plan goals are formulated about the problems that are defined by the offenders as important or as a priority in the selfassessment the first two columns of table 8 show how often offenders mention goals of a specific cluster as being important education and work finance relation with partner and family and cognitive skills are most mentioned as important by the offenders it might be surprising that cognitive skills is in this list but offenders often mention solve my own problems or lose my patience as an important problem from the 230 offenders who filled in the selfassessment 18 did not mention any problem or priority in the self assessment in the right column table 8 shows the match between offender goals and the goals in the intervention plan the proportion of goals mentioned as important by the offenders that match goals in the intervention plan this match is made on the level of goal clusters and not of the specific goals that are formulated by the offender and the probation officer therefore the actual match between the specific goals of the offender and the goals in the intervention plan may be less good than this analyses implies the results in table 8 indicate that offender goals often are not included in the intervention plan above all and again offender goals regarding basic needs and social relations only match goal clusters in the intervention plan in a minority of the cases offender goals about addiction and cognitive skills are best addressed in the intervention plans offenders do not often formulate goals about attitude but when they do in most cases there are no goals on attitudes in the intervention plan differences between high and low risk cases probation officers often say that in high risk cases with many criminogenic needs they may choose to focus only on part of the assessed criminogenic needs as addressing all of the offenders needs would ask too much of the offender if so with regard to the first three criteria in this study the match in low risk cases should be better than in high risk cases because low risk offenders have fewer criminogenic needs this was however not the case the match between the assessed criminogenic needs and the perceived relevance of the criminogenic needs to be targeted did not differ between the two groups except for the needs partner and family and attitude larger differences were found in the match between the assessed criminogenic needs and the goals however a substantially better match for the criminogenic needs accommodation education and work and finance was found for high risk offenders and a substantially better match for low risk offenders was found for the criminogenic need friends the match between the assessed criminogenic needs and the interventions is better for low risk offenders with regard to the criminogenic needs partner and family emotional wellbeing cognitive skills and attitude for high risk offenders the match was substantially better for the criminogenic need addiction overall it can not be said that the match between the assessed criminogenic needs and the intervention plans is substantially better for low risk offenders discussion the aim of this study was to evaluate the extent to which probation officers intervention plans for offenders that are based on an instrument for structured risk assessment actually meet the criteria for effective practice in probation seven criteria that can be used to evaluate intervention plans were formulated it was found that probation officers do not systematically apply evidencebased knowledge about how to reduce recidivism and support desistance in their intervention plans although they often describe in their intervention plans that they want to target the assessed criminogenic needs often the match between the assessed criminogenic needs and the goals on the one hand and interventions in the intervention plan on the other hand is fairly low also the correlation between the assessed level of the risk of recidivism and the intensity of interventions proposed in the plan is weak thus two principles of the rnr model are applied insufficiently in the dutch probation practice contrary to what might be expected the use of a structured instrument for risk and needs assessment often does not result in intervention plans that have a good match to the assessed risk and needs it is not possible to draw general conclusions from this study about how the responsivity principle is used in intervention plans because information about responsivity factors is often missing in the files however conclusions can be formulated regarding one aspect of responsivity namely motivating the offender and committing the offender to the intervention plan by formulating specific approach goals and by including the offenders goals in the plan based on this study we conclude that the formulation of goals is fairly adequate a majority of the goals is specific and more approach goals than avoidance goals were found in the plans however offender goals are often neglected particularly with respect to basic needs and social relationships while improving these basic needs and social relationships were the most important goals for the offenders the content of intervention plan seems to be determined by professional conclusions about the causes of the offending behaviour and the best way to prevent recidivism in an individual case more than thirty years ago bottoms and mcwilliams already criticised a treatment approach in which clients become objects of intervention rather than persons seeking help bottoms and mcwilliams argued that one of the aims of the probation service is providing help meaning that ultimately the offender defines what help is needed fifteen years later based on the positive effects of cognitive behavioural programs on recidivism raynor and vanstone proposed a combined approach in which the intervention plan is a result of dialogue and negotiation between the offender and the probation officer recently the importance of involving offenders in developing intervention plans is underlined in literature about desistance working with an offenders goals is an important driver of change as it can help offenders learn to govern their own lives in a prosocial way and thereby discover agency integrating offenders goals as an essential part of the intervention plan can therefore be an important improvement for the effectiveness of probation an important finding of this study is that intervention plans have the tendency to focus on only some criminogenic needs the results revealed a strong emphasis on intervention plans for cognitive skills and addiction these criminogenic needs are most commonly mentioned as relevant to being targeted and these needs have the highest match with the goals and interventions in the intervention plans varying results are found regarding social relationships with a partner and family emotional wellbeing and attitude when assessed as present these criminogenic needs are often perceived as relevant and in a majority of the cases an intervention is matched but often no goals are formulated that describe the desired change friends and basic needs such as education and work finance and accommodation are often not included in the intervention plan even when they are assessed to be a dynamic criminogenic need taken together the focus seems to be on improving human capital and the improvement of social capital and basic needs is relatively neglected this is remarkable because as described in the paragraph where we defined the criteria for effective intervention plans studies regarding desistance from crime confirm that social capital is important in helping people to cease offending having prosocial relationships having a stable job and living in a prosocial neighbourhood can be essential for offenders to desist from crime although the improvement of human capital is important and although having sufficient skills may even be a condition for handling social situations adequately helping offenders improve their social capital is an important task for the probation service in its own right and must not be forgotten the findings of this study confirm conclusions that have been asserted before and that still seem valid today namely that probation practice has a strong psychological orientation leading to a focus on individual skills and a neglect of the social context the socalled what works approach certainly has influenced this focus in the second half of the 20 th century helping offenders was the main focus of the dutch probation service and the character of the work was determined by a sociological orientation since the beginning of the 21 st century the what works agenda was introduced in the netherlands with a psychological orientation and emphasis on improving cognitive skills traditional social work methods and vocabulary disappeared to be reintroduced again to some degree only very recently limitations and future directions in this study we examined the intervention plans that were developed based on structured risk and needs assessment of course there may be differences between the intervention plan and the interventions that are actually delivered it is possible that the practical aid or interventions that address the assessed criminogenic needs were not described in the plans but were delivered during supervision moreover even a perfect intervention plan can fail due to poor execution of the plan for example the intervention plan might match perfectly with the assessed risks and criminogenic needs but if the plan is not delivered the intervention will likely not be effective which can complicate the evaluation of intervention plans in terms of goal attainment or recidivism studying the interventions that are actually delivered and matching them to the intervention plan might shed some light on this issue however probation records often lack the information that is needed for such a detailed study in the present study it was difficult to match the assessed criminogenic needs with the interventions in the plan due to a frequent lack of detailed information regarding what was actually delivered in the interventions therefore we chose to include the category possible match in our analyses as a consequence in some cases we may have either undervalued or overvalued the match between assessed criminogenic needs and interventions this study focused on the question which decisions are made by probation officers about their intervention plan having found that these decisions do not always follow the criteria for effective practice it would be interesting to investigate why probation officers make these choices on one hand knowing and understanding their reasons may yield knowledge that can be useful and relevant for decisionmaking processes in probation with respect to intervention plans on the other hand this knowledge may also reveal inaccurate views regarding effective offender supervision that can be discussed and improved through the training or coaching of probation officers deciding what interventions and practical aid should be delivered to help offenders stop reoffending is an important task for probation officers in doing this probation officers are supported by the development of instruments for structured risk and needs assessment and by a growing body of knowledge regarding effective offender supervision and program delivery it seems however that the probation officers match between the assessed risks and needs and the intervention plans must be improved providing training andor coaching to probation officers may help improve this match and this strategy has been effective in canadian practice in health care introducing a decisionbased support system has improved practitioners performance such an approach may be an attractive option for forensic professionals as well

the increased use of instruments for assessing risks and needs in probation should lead to intervention plans that meet the criteria for effective practice an analysis of 300 intervention plans from the dutch probation service showed that the match between the assessed criminogenic needs and the goals and interventions in the intervention plan is fairly low it was also found that the socalled risk principle is not fully applied by probation officers in addition personal goals that the offender values are often not taken fully into account finally the intervention plans have a strong focus on improving human capital while improving social capital and basic needs often is not part of the intervention plans even if they were assessed as dynamic criminogenic needs

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no one should have to fear victimization in their homes or their daily public life in the first situation we know that women bear the greatest burden as the primary victims of violence in the home including homicide in public life while men bear the largest burden of violence overwhelmingly at the hands of other menwomen also have much to fear this too is largely from men including street harassment workplace harassment sexual violence and in some cases homicide regardless of location the killing of women can often be described as femicide and there is ongoing research examining the definitional parameters of this phenomenon where these killings occur in the context of an intimate or familial relationship they are commonly referred to as family or intimate partner homicide while women are disproportionally affected this term also captures the killings of men in these contexts these deaths mean that in some way we as a society have failed our failure may be directly linked to actions or inactions of professionals agencies or systems on the other hand it may be indirect perhaps reflecting wider issues like lack of awareness or ongoing problematic attitudes towards women and intimate relationships or structural inequities in response to these deaths various forms of counting have emerged including domestic violence fatality reviews and femicide watches or observatories 1 although there are considerable differences between these approaches in different ways they offer an unflinching review of a homicide an opportunity to honour those who have died and to be clear about perpetrator accountability as well as reflect on our own individual community and social understandings and responses the promise is that by better understanding these deaths we can identify learning and consequently improve professional and systems responses as well as take other broader actions to bring about social and transformative change including community education and awareness to deliver that promise research initiatives must be based on data which fully captures the nuances and contextualises the events leading to the death moreover this raises questions around how such nuances and complexities can be captured in data that are largely administrative in purpose and consequently how this can shape the representation of the social identities of those affected from an intersectional perspective there is an urgent need to attend to both how and what types of data we examine to develop prevention models that are responsive to intersecting systems and structures of oppression and exclusion furthermore the emotional labour involved for researchers appears to be seldom considered both as a matter of research but also in practice yet it can have significant implications potentially on both the process and product of prevention research to address these concerns we embarked upon a shared critical reflection which draws on and synthesises our diverse experiences as researchers examining and responding to femicide andor family and intimate partner homicide in australia canada and the united kingdom our overarching aim is to individually and collectively reflect on how our work responds to the need to document the similarities of these killings while also capturing their diversity as well as the structural drivers of femicide family and intimate partner homicide we examine the limitations around data and the impacts on the construction of social identities of those affected including how intersecting forms of exclusion and structural oppression are represented in data and how intersectionality is constrained or facilitated in the processes of research we also reflect on our own experiences as researchers with respect to why we do this work and how we do it safely we conclude with some key recommendations to address the challenges and issues identified method shared critical reflection was used as the method of enquiry to explore our lived experiences as researchers examining and responding to femicide family and intimate partner homicide in canada australia and the uk shared critical reflection is appropriate for considering the impact of structural and social systems on research and practice as well as for challenging hegemonic assumptions and inequities our approach was informed by reflective practice which seeks to integrate thought and action theory and practice the academy and the everyday world but also in the spirit of a constructivist approach to the variety of ways in which we construct the reality of problematic situations we are a group of researchers with diverse experiences and interests engaging within and outside of higher education institutions and we also have relevant experiences outside this context we are reflecting on the broad scope of our research which ranges from femicide to a specific focus on family and intimate partner homicide where we use the term family and intimate partner homicide we do so to indicate fatal violence within the context of intimate familial and kinship relationships and circumstances regardless of a range of different social identities including for example age raceethnicity sex andor gender and gender identity or expression2 or sexual orientation this recognises that hegemonic white ableist heteronormative and sex andor gender binary constructs very often determine how homicides are counted and understood undertaken across three phases the reflection was aligned with iterative thematic inquiry and analysis in the first phase a problem definition was conceptualised during an initial collaborative discussion and in response a guided reflection protocol was codeveloped by all authors which consisted of five overarching points of reflection 1 context of the data iwe work with 2 who is represented or not in this data 3 representation of intersectionality in data and research 4 emotional labour and safety as researchers 5 the change iwe want to see in the second phase three authors representing each of the three countries responded to the reflection protocol in writing and shared their responses with author pc to initiate the synthesis frameworkprocess pc undertook initial charting of data according to the five predetermined points of reflection and shared this with the other authors so that they could reflect on each others responses and consider how their experiences were similar and divergent in the final phase through further collaborative discussion we undertook inductive and deductive thematic synthesis this involved considering the collective meanings of our reflections as well as questioning how this was influenced by the lens through which we interpreted the points of reflection and our experiences while this process was guided by the predetermined reflection points we continually refined these and formed new themes ultimately through iterations of health ngarruwan ngadju university of wollongong my perspective is informed by my own family and community experiences and as a public health researcher of intimate partner and family violence i am leading a review of family and intimate partner homicide from the national coronial information system to understand the trajectories of violent deaths and opportunities for health system intervention this expands my previous review of femicide that stemmed from collaborating with researchers from counting dead women australia which was my first experience of homicide research in 2016 through my research i intend to bring a better understanding to the social and structural determinants of violence as well as strengthening responses to address equity and prevent retraumatisation examining our data in the context of our objectives the data amalgamated into six overarching themes that reflected where our shared experiences illuminated broader issues of importance through the peerreview process we received valuable and constructive critiques which provided impetus for further collaborative reflection and discussion through this discussion we delved further into the ambiguities and uncertainties that are inherent in the data as well as reignited our analysis of how intersectionality is operationalised in practical terms results first we examine four themes that formed in response to our reflections on data access to data completeness of data intersectionality and invisible victims second when we consider the impact of doing this work on researchers two main themes formed around mitigating vicarious trauma and why despite the challenges we continue to do this work access to data for fatal violence against women to be considered as a national problem it requires a change of thinking which i argue includes being able to recognise the extent of the challenge in a timely fashion femicide observatories have emerged in response to this challenge to represent a death toll and focus the attention of the public onto the terrifying regularity of femicide as such they present a picture a frame which as stated by ryan and gamson organises thoughts highlights certain events and facts as important the frame helps us build a strategic dialogue intended to shape a particular group into a coherent movement but none of that can happen if the necessary information is not available in a timely fashion for femicide observatories there is dependence on publicly accessible data and the way that data are funnelled most commonly through agency reports impacts how readily it is accessible how timely this access can be and what data are available for example counting dead women australia has no official access to information about acts of fatal violence against womenbut it has a range of women with expertise in searching relentlessly we look at police media feeds news reports and coroners reports but we also receive tipoffs from the general public and heartbreakingly sometimes from family members who want their mothers sisters daughters included in our count none of this is instant and it is by no means complete access is also an issue in fatality review although as a state mandated process these tend to have formal reporting mechanisms and can be analysed as a data source yet james notes that in the uk where dhrs should usually be published there are often significant delays in doing so and some are not published at all the lack of a national repository means the capacity to routinely produce aggregate data and learning is limited completeness of data the researchers agree there are common limitations across data sources in the relevant jurisdictions there is shared frustration at both the rigour and timeliness of data collection but also at the extent to which individual relationship and contextual variables are represented at the beginning these women are bodies by the end they might have names and ages but to understand violence against women we must know more location employment place of birth ethnicity religion socioeconomic data as an example the counting dead women australia femicide census aims to count each death however this is constrained by the completeness of publicly available data in contrast fatality reviews have access to a wide variety of information drawn from the criminal justice process including the police or courts and unlike the femicide census and observatories routinely access other information from service providers family and friends thus in theory fatality reviews bring together rich sources of data to better understand the circumstances of homicides however there can be limitations for example there is considerable variation in both the style and quality of dhrs and some voices in reviews may be favoured over others consequently such reviews have been described as a partial account of a homicide furthermore as documents they are not necessarily produced with research in mind making data extraction difficult particularly when attempting to understand the context of a homicide and relationship dynamics for example one of the of most consistent and welldocumented correlates of intimate partner homicide is previous intimate partner violence however it is difficult to consistently capture this information in records kept by criminal justice organizations and often not even captured in a meaningful way by national statistical agencies for fuller discussion see dawson et al 2019 as myrna notes the situation is exacerbated in the canadian context because there is currently no specific domestic violencerelated offence in our criminal code moreover given the concern around firearmsrelated homicide particularly in rural regions we have little to no information about firearms used to kill such as whether they were handguns or long guns if they were licensed or had been previously seized from the home and so on understanding access to firearms as well as relationship dynamics and life situations are key to prevention but we seldom get this information from official data sources and they may often not be collected at least consistently by national statistical agencies or fatality reviews it is only with complete data that we can begin to understand the structural aspects of homicide given this situation collecting data on structural determinantspoverty colonization discrimination attitudes about gender normsappears far out of reach at least currently intersectionality our reflections are aligned with the original intention of intersectionality which means recognising that women of colour experience multiple competing burdens of racism and sexism in the instance of violence the physical assault is merely the most immediate manifestation of the subordination they experience writes crenshaw they are also burdened by poverty childcare responsibilities and the lack of job skills currently our administrative and national statistical systems are limited in their sophistication to capture multiple social identities and the result is that intersecting identities are not well represented particularly around sexual orientation disability mental health racialised and indigenous peoples collecting data around sex andor gender has become a particularly challenging issue on one hand traditional data collection focusing on sexbased categories only does not capture the multiplicity or changeability of gender identity and expression yet at the same time if official agencies or administrative data sources switch from collecting the category sex to gender without being able to disaggregate by sex at birth and so capture a transgender history this makes it difficult to track male violence against females or violence against transgender persons the latter of which was already difficult to collect given many instruments do not provide the space to capture gender identity or expression in practice research can contribute to this problem through aggregation of cases based upon certain characteristics and the intersections are obscured consequently certain social identities are privileged as they are more readily captured in the data than others for example despite representing the initial and primary focus of intersectionality raceethnicity remains one of the most difficult social identities to capture so systematically understanding how this identity combines with sex and or gender ableism andor other identities to compound risk of violence or impede safety is almost impossible to do reliably the outcome of this has been the relative dearth of systematic research on groups who are most often marginalized and vulnerable to violence where attempts are made to address the issue of representation it can both mitigate and exacerbate this problem decisions are made about the focus of research reflecting available data the resources or other locally determined priorities while this may render visible some identities these decisions can also obscure others to illustrate this we noted two recent examples where there has been an attempt to attend to different identities in reporting aggregate findings with different decisions being made in terms of prioritisation in canada for example recognizing the limitations of data around particular identities of marginalized andor vulnerable groups the canadian domestic homicide prevention initiative is examining risk and safety for four groups indigenous immigrantrefugee ruralremotenorthern and children killed in the context of domestic violence this includes the construction of a national domestic homicide database that seeks to capture more relevant detail although given the focus of this paper challenges are ongoing working with a similar aim a recent analysis of 84 dhrs in london england focused on the experience of homicide victims from culturally and linguistically diverse backgrounds lesbian gay bisexual trans queer communities people with mental health issues and older people moreover researchers need to approach these categorisations with care given they risk reifying specific categories and thus defeating the ambition of an intersectional perspective these issues are also pertinent in the expectation of fatality review and other research initiatives for example in the uk the language around intersectionality is not used in the statutory guidance for dhrs which instead includes a requirement to bear in mind equality and diversity issues at all times with this framed as being about protected characteristics3 in their study of 141 dhrs chantler et al found that ethnicity data were available for just over a half of victims and perpetrators but they cautioned that ethnicity may be more likely to be recorded where victims or perpetrators are not white the concept of intersectionality also draws attention to the combined effects of other social identities and so explores their compounding impact on risk and safety such as age disability rurality and so on the role of socioeconomic statusor povertyand its impacts on risk of violence in combination with sex andor gender and gender identity or expression raceethnicity and other identities also remains largely unexamined in official data sources and those regularly accessed by violence prevention researchers in practice the shortcomings in data drawn from official sources such as coronermedical examiner police and court reports creates ambiguity and uncertainty in the practice of fatality review and other femicide and homicide research initiatives such ambiguity means that researchers must make decisions and assumptions about what is implied within the text of official reports while it is often possible to tentatively conclude from the data examined that a victim was indigenous or a perpetrator was an immigrant it is not also or even often clearly stated or identified the decision then becomes what threshold must be passed for a firm conclusion to be made from the data and for a case to be categorized as involving indigenous or immigrantrefugee populations coding from official files inherently involves many such subjective decisions that impact the reliability of the data produced when analysing published dhrs researchers have to make a decision about what to code for example should social identities only be coded where they are explicitly stated or it is possible to consider implicit content moreover this data itself is dependent on the circumstances and manner of recording ranging from a disclosure by a subject through to professional interpretation together these issues raise questions of both validity and reliability invisible victims the outcome of the gaps in our data and knowledge in short is that those groups who are most marginalized and vulnerable to violence are often also the most invisible in terms of our efforts to develop prevention initiatives when we consider who the invisible victims are two groups emergethose who are not counted and those who are undervalued the deaths that are frequently not counted and are seemingly undervalued particularly as femicides and intimate partner homicides tend to be lgbtq older victims disabled victims as well as missing persons in australia and canada missing persons are disproportionately indigenous and these deaths as well as other racialized victims are particularly undervalued in white hegemonic and colonial settler nations for decades in australia and canada indigenous women and girls have been killed at significantly higher rates than nonindigenous women and girls and there is no better example of how important it is to document the structural determinantsperhaps more than individual determinantsgiven the ongoing legacy of colonisation and discrimination as drivers of their deaths in the canadian context a stark and disturbing example is the ongoing situation surrounding missing and murdered indigenous women and girls likewise in australia aboriginal women are invisible in our tolls sometimes we dont even hear of their deaths until months later maybe years the role of structural drivers including system barriers is similarly experienced by other racialized women and girls globally who face increased marginalization and vulnerability this is further reinforced by their invisibility in all forms of official data as it is not even possible to accurately document their numbers let alone collect data on other social identities the counting of homicides itself can be problematic dependent as it is on the discovery of a body cause of death and then classification decision fatality reviews may be triggered by the homicide yet not all deaths are captured and it is not clear how decisions are made to conduct reviews in the uk james notes that the decision is made at a local level with some national oversight but there is no requirement to publish information on notification and decisions so the conversion rate is unclear in other scenarios deaths may not be subject to review because of stereotypes that mean a death is not understood as occurring in a domestic abuse context mitigating vicarious trauma and generating emotional safety while robust data is essential it is just as critical to have effective researchersthis requires that we consider our own emotional safety in our experience there can be a sense of closeness to the person who is the victim of the homicide which may be via the aural or written testimony of family or friends or more indirectly via agency accounts encountering the subject of homicide can provoke a range of emotional responses including sadness and anger as i grapple with the reality of a life lost as well as frustration when reflecting on missed opportunities or failed interventions by contrast working with data can be very technical and abstract at times which can obscure the emotional impact while there are cases that stay with you and linger in your thoughts the process of selfreflection can be challenging and in our experience it can be hard to recognise if and how vicarious trauma may be manifesting i clearly remember one instance early in my new researcher life still a graduate student in which i returned home from a week spent reviewing parole board files on male homicide offenders when i walked in the door of our home my partner reached out to give me a hug and a kissa natural response on his partto which i responded dont touch me it is not only the researching of homicide and violence one way to educate and increase awareness is by speaking with the media something we are frequently called upon to do this can be extensive with multiple contacts and often little time to regenerate before the next woman or child is killed and we are asked to provide our expertise4 this means constant exposure to these stories when deaths occur and were asked for real time responsesand solutions as if we hold all the answers but just have not told anyone yet furthermore the response to publishing our work and our media commentary takes a toll particularly in the face of relentless abuse and trolling trolling is a gendered phenomenon disproportionately directed at women and as some of us have experienced even includes campaigns to discredit our work there is a massive increase in mens rights activism which are mobilised whenever feminists publish on gendered violence their attention is unrelenting and exhausting i was subject to a torrent of abuse and threats including one troll threatening to come to my house and burn me alive i couldnt write about fatal violence for weeks because i was so distraught in contrast men working in this field are not subject to the same scrutiny as a man working on domestic homicide i face challenges particularly if i am to be a reflective practitioner who is aware of my own structural privilege but trolling is rarely one of them given these challenges around vicarious trauma and the emotional labour of both the work and the response to the work we have generated strategies for accessing support and enhancing our emotional safety this involves accessing formal and informal mechanisms through debriefing with supportive colleagues and loved ones i have learnt to take my emotional safety seriously i access clinical supervision i draw on the support of my colleagues and also my family and friends where needed critically i take the opportunity to speak directly with family and friends as well as survivors of domestic violence and abuse that anchors me a reminder of lived realities is for me a reality check that is both challenging but also vitalising nonetheless this work can have an enduring impact as jenna notes there have been periods where this work has really disturbed me…for some reason i bounce back i talk about it too much i ring friends to debrief i try to protect my family but my spouse is a wonderful listener he also reminds me to get off social media when its out of control occasionally i will tell a perfect stranger about the correspondence i getthats partly because im overflowing and cant cope anymore its like runoff even if we are fortunate enough to not have experienced the extent and forms of violence and abuse that we read or hear about in the voices of the survivorsvictims that we speak with we recognize that we are impacted every time by what we read or the experiences of those whose stories we wish to know about or to tell to further prevention efforts these impacts can be cumulative and lasting and it may be particularly insidious when increasing education and awareness is a key component of our work you cannot discuss these cases over and over including details of what happened and those involved without experiencing some type of vicarious trauma especially as you continue to ask yourself what more can we do i do this work because… there are some clear tensions in why we do this work on the one hand we are driven by a clear sense of purpose in redressing the injustices of fatal violence however there is tension in understanding the magnitude of change needed which at times can feel overwhelming i do this work because i think there are actions we can take to make family violence less likely i imagine a world where family violence doesnt exist but its unlikely to be like that in my lifetime alongside this there is hope and ambition which arises from the purpose that is by telling a victims story it may be possible to memorialise them and make a difference by leading to improved understanding or systems change yet that is also tempered by a sense of repetition as we find the same learning time and time again provoking despondency and the question what does change research is seen as an important driver of change and yet there is frustration in knowing we require robust data to support those changes i do this work because it is researchers who can collect data to help increase education and awareness which is the core component of primary prevention and increasingly recognized as key to moving forward if we are to achieve progress underlying all of this there are often pivotal personal andor professional experience that have compelled us to work in this space and there is a sense of vicarious resilience that derives from the belief that the work matters and can make a difference i can still remember my first encounter with a death as a young social worker and domestic violence advocate at the time i felt desperately sad very alone and adrift there was no way to be part of an accounting of what happened and to learn if i or others could have done more or something different that may have prevented his death… i do this work because i believe it is possible to make a difference…domestic violence and abuse casts a long and devastating pall despite welcome progress it still seems sometimes to be understood as something that that is too big to end or will be always with us i dont believe that is true conclusions despite different experiences collecting data and conducting research there was considerable overlap in the issues identified that constrain the utility of data in prevention efforts particularly around completeness of data and how this flattens social identities and renders many victims invisible it is recognized that the completeness of the datain other words its reliability and validity for informing responses to and the prevention of femicide family and intimate partner homicidedepends on the research questions we ask however through our collective reflections we argue that current data sources are not sufficient for research with a focus on prevention regardless of our research questions particularly if we want to understand structural determinants of violence but equally so for individual determinants of victimization and perpetration a key reason for these data gaps stems from the underlying rationale and goals of data collection by statistical and criminal justice agencies which are not designed with researchor preventionin mind rather they are largely administrative in purpose and the types of data collected reflect administrative not research or prevention goals the exception may be fatality review initiatives whose primary focus is largely the prevention of future similar deaths therefore data collected as part of the work of these initiatives may provide the most complete information on family or intimate partner homicide related deaths and particularly those that end in the suicide of the accusedoften not investigated as fully by police given that there are no subsequent criminal justice proceedings pending however there is significant variability across review teams including how domestic abuse related homicides are defined and identified the volume and type of materials reviewed the voices heard and the stakeholders or experts represented at the table thereby data collected vary significantly impacting what can be systematically used to inform intervention and prevention one key outcome of the difficulties of collecting even basic information on homicide is that our ability to understand risk and improve safety particularly for marginalized and vulnerable populations is impacted in other words our ability to apply an intersectional lens to prevention is precluded because we cannot access the information required to examine combinations of social identities that may increase a persons risk of homicide both at the individual and structural levels consequently differential group risk remains constant for many and more worrisome is exacerbated by our inability to understand the varying challenges and obstacles that particular groups face due to oppression colonization discrimination sexism racism ableism and so on this has the longterm and negative consequence of making some groups of victims less visible than other groups of victims this is particularly pertinent in the era of the covid19 pandemic while the pandemic has in many cases exacerbated existing inequities it has also illuminated such inequities and experiences of violence on the one hand this makes issues of interpersonal and structural violence more difficult for dominant society and particularly governments to ignore yet it also underscores the critical need to have access to robust and timely data that accurately represents who is most at risk and where preventative efforts are ineffective and may be reinforcing existing structural oppression and exclusion given the above a key recommendation would be that we reconceptualize the purposes or goals of official data collection from the primarily administrative focus to prioritize or at the very least include the routine collection of data that can inform the development of effective prevention initiatives if we were to succeed in doing so however we would then have to address the issue of accessibility currently access to most official data sources are largely restricted to those working within the organizations or closely affiliated which is most often justified by issues of privacy and confidentiality privacy and confidentiality must be protected however this means that researchers who may be able to use these data for prevention rarely get to do so even though they are also concerned about privacy and confidentiality as a core part of their research ethics protocols and processes the outcome is a wealth of data albeit incomplete that is largely sitting untouched and behind closed doors often not contributing effectively to administrative goals either there is a growing recognition that much of our current data sources are often significantly flawed when it comes to identifying pathways for prevention particularly for some groups who remain invisible however we continue to rely on them nonetheless it becomes crucial then for the current and next generation of scholars to use our collective expertise and voices to call for systemic change when it comes to data collection in part it was this type of momentum and calls for change that gave rise to domestic violence death review committees such efforts need to continue to ensure that much needed data are available globally and not just in particular jurisdictions at the same time we need to raise the voices of victims survivors through a greater emphasis on qualitative research that can help us better understand what that data has failed to underscore much data relies on the official record precluding the voices of those most profoundly impacted the next generation of scholars can continue to push for the recognition of varying expertise that can inform our prevention initiatives including the expertise of victimssurvivors when we considered our own goals and the personal impact of doing this work there was a sense of vicarious resilience that comes with knowing why we do this work and the grounding that comes from working toward enacting systemic and social change however it also emerged that mitigating vicarious trauma was critical but also required us to firstly acknowledge that vicarious trauma does impact us and that we need to implement strategies that promote our emotional safety it is essential that researchers of femicide and homicide are supported to generate practices that promote emotional safety in individuals and teams yet there needs to be a better understanding of how to do this effectively there is emerging insight into the impacts of vicarious trauma on researchers in the fields of suicide and trauma research which predominately relates to researchers working in the field collecting primary data from people directly impacted by trauma however there is limited evidence andor directives in this regard for homicide and femicide researchers this perhaps reflects both reasons that compelled us to work in this space associated stoicism and a lack of appreciation for the potential traumatic impacts that comes from working with secondary data as opposed to collecting primary data however many femicide and homicide researchers are also frequently brought into contact with those who are directly impacted whether it be first responders family andor the broader community this relates to the hidden toll and burden of responsibility that comes with advocacy and media communications which is an essential component of our work and finally our own personal and family histories can be complex and at times fraught and this can change over time and may interact with our work in seen and unseen ways researchers bring their own personal experiences and histories and are often personally impacted and invested in this work yet our own experiences can seem inconsequential in the context of homicide and femicide and thus we may seek to minimise our own experiences there is much to learn about how our own lived experience intersects with our experiences as researchers as well as how this may signal vulnerability and the ways in which vicarious resilience and vicarious trauma can coexist much of what we do know about the impacts of vicarious trauma comes from research with frontline professionals who work directly with those experiencing trauma which provides important learnings and recommendations that can be considered for femicide and homicide researchers accordingly we recommend that all researchers have appropriate training and awareness of vicarious trauma as recognising the signs is critical to mitigating the impact furthermore strategies for frontline professionals and researchers can be applied to generate a culture of safety for femicide and homicide researchers particularly around engaging formal supervision debriefing with colleagues managing work load and actions to promote selfcare at a systems level research ethics committees government agencies and academic institutions which have a responsibility in regulating research safety should mandate that researchers develop and implement protocols for homicide and femicide researcher safety with appropriate monitoring and evaluation of uptake and implementation this would need to be costed into project funding and approved by institutional and funding bodies however there are substantial barriers to realising this which primarily relate to the gaps in our understanding of how this can be done effectively thus we need to invest in research to identify what works in preventing and responding to vicarious trauma therefore we strongly recommend that future research is directed toward identifying and implementing measures to better support the safety and wellbeing of femicide and homicide researchers our experiences as researchers are complex and we have found this process of shared critical reflection both cathartic and challenging this process has built on and fortified our collective agenda to work collaboratively to prevent femicide and homicide while we come from diverse personal and professional experiences we recognise the limitations of our perspectives as white privileged scholars from three global north countries which are white hegemonic nations fraught with historical and contemporary colonial manifestations we anticipate that engaging in future critical reflections will involve a greater number of voices and perspectives thus this reflective conversation among four researchers represents the start of a longer conversation and one which could be expanded across borders in conclusion understanding how to improve the situations experienced by manyand perhaps most of us to some degree requires information and the foundation of good information is good data therefore it is critical that we reconceptualize the goals of data collection it is also important to further engage in collaborative discussions between those involved in data collection and prevention initiatives so that there can be more effective use of the information being housed by organizations and institutions throughout the world in this regard it is encouraging that some agencies are beginning to understand how their data might be improved to capture key elements for prevention and are working with researchers and others to find ways to do so compliance with ethical standards conflict of interest the authors declare that they have no conflict of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

rigorous comprehensive and timely research are the cornerstone of social and transformative change for researchers responding to femicide family and intimate partner homicide there are substantial challenges around accessing robust data that is complete and fully representative of the experiences and social identities of those affected this raises questions of how certain social identities are privileged and how the lens of intersectionality may be constrained or enabled through research further there is limited insight into the emotional labour and safety for researchers and how they experience and mitigate vicarious trauma we examine these issues through a shared critical reflection and conclude with key recommendations to address the challenges and issues identified four researchers examining and responding to femicide family and intimate partner homicide in australia canada and the united kingdom shared and evaluated their critical reflection we drew on our experiences and offer insights into processes impacts and unintended consequences of fatality reviews and research initiatives there are substantial limitations in accessibility and completeness of data which has unintended consequences for the construction of social identities of those affected including how multiple forms of exclusion and structural oppression are represented our experiences as researchers are complex and have driven us to implement strategies to mitigate vicarious trauma we assert that these issues can be addressed by reconceptualizing the goals of data collection and fostering collaborative discussions among those involved in data collection and violence prevention to strengthen research prevention efforts and safety for all involved

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of european immigrant groups into us society the earliest models of assimilation proposed a slow process over generations leading to eventual erosion of economic political and social differences between immigrants and their descendants with the native population the empirical evidence shows that european immigrant groups were successfully incorporated into us society within three generations so that the third generation came to resemble the host or majority society additionally the classical assimilation model proposed that the host society characterized as white anglosaxon and protestant was static and that immigrants and their descendants would come to be like them the integration of the descendants of southern and eastern european immigrants which included large numbers of catholics and jews from the 18801920 period of mass immigration challenged the idea that the core group would remain primarily anglosaxon or protestant according to alba and nee the core evolved into a judeochristianeuropean majority or mainstream inspiring a largely revamped assimilation model 1 economic progress and political incorporation led to the dissolution of social boundaries and negligible differences in the socioeconomic outcomes by country of origin among european americans thus producing a white majority comprised of diverse ancestry and religious backgrounds segmented assimilation contemporary research has focused on the integration among children of immigrants in the post1965 era as an alternative to the classic assimilation model portes and his colleagues propose segmented assimilation theory to explain outcomes among the 15and secondgeneration young adults they argue that low human and social capital language ability dissonance in education between parents and children negative contexts of reception including treatment by the immigration system and hostility based on race account for the diverse outcomes among young adults of various immigrant origins based on extensive ethnographic and quantitative analysis of the children of contemporary immigrants portes and his colleagues found that secondgeneration mexicans southeast asians and haitians have relatively low educational and economic status while filipinos chinese and cubans are more successful with respect to education and income they argue that groups that do not follow the traditional assimilation trajectory experience downward assimilation or permanent poverty and assimilation into the underclass 2 segmented assimilation then adds a fuller explanation to the assimilation model in which race is but one factor however many of its factors particularly language ability education dissonance between immigrant parents and children treatment by the immigration system and negative contexts of reception are applicable to those with immigrant parents and not to later generations with usborn parents if there is little progress for the third generation contrary to assimilation theorys prediction of continuous generational progress then segmented assimilation theory might suggest that race becomes a major reason for explaining the outcomes of later generations neoassimilation perspective alba and nee propose a neoassimilation perspective for the contemporary period of mass immigration arguing that most of todays immigrant groups will be assimilated into a new mainstream much like the nonprotestant european immigrants of the earlier wave building on their account of an expanded mainstream for european americans from central and southern europe they expect todays nonwhite immigrants and their descendants to enter a further expanded mainstream they believe that racism is no longer a major force impeding the progress of minorities since affirmative action and civil rights reforms have raised the costs of discrimination and lowered exclusionary barriers for racial minorities the empirical evidence used to argue for the neoclassical assimilation perspective is based on the experiences of the first and second generation among contemporary immigrant groups kasinitz et al provide a prominent example of this perspective with their finding that the second generation in new york city experiences greatly improved outcomes compared to their firstgeneration parents 3 mexican americans are the only sufficiently large noneuropean group that allows for the study of three or more generations because their immigration spans the entire twentieth century like most european origin groups mexican immigrants start at the bottom of the socioeconomic ladder but unlike european origin groups they have not fully assimilated by the third generation while secondgeneration mexicans do better educationally than their modestly educated immigrant parents the third and later generations do not reach parity with whites and their educational levels are similar to those of the second generation by controlling for the socioeconomic status of parents education for thirdgeneration mexican americans is lower than the second since the parents of the second generation are loweducated immigrants this deems the achievements of their secondgeneration children as especially successful compared to their parents 4 still alba and his colleagues defend assimilation theory for the mexican case by claiming that assimilation explains the experience of some of the mexican american population for instance alba et al use internal heterogeneity to make a case for the assimilation of mexican americans they point out that a segment of mexican americans shows assimilation evinced by ethnically mixed ancestry intermarriage movement away from established mexican american areas of concentration and postsecondary education 5 however that some mexican americans are successful and that there is substantial heterogeneity within the group is not sufficient evidence of assimilation moreover this is not consistent with the major theories of assimilation that tend to consider the accomplishments of the group on average as indicative of being assimilated after all all groups show variation with some members being as successful as those in the mainstream and others doing less well for instance italians were not considered assimilated until the 1970s as the slowest group to assimilate they exhibited considerable heterogeneity yet only when the group reached parity with other european groups did assimilation scholars deem italians fully assimilated alba and islam argue that the educational outcomes of mexican americans are underestimated because more successful mexican americans stop identifying with the group they contend that their exit from the group is linked to entry into the mainstream however the segment that they consider to have exited are only 3 percent of the mexican american group while these nonhispanic mexicans have higher educational outcomes this 3 percent is not large enough to account for the overall educational disadvantages of mexican americans also duncan and trejo show that the third generation who are children of intermarriage and do not identify as hispanic are more successful compared to among those who identify as hispanic yet the education level of the two groups combined is only slightly greater than that among the hispanicidentified group suggesting that losing nonidentified mexicans does not explain the educational disadvantage of mexican americans other scholars have also been optimistic about mexican american assimilation smith constructs a lagged comparison of age cohorts of first second and thirdgeneration mexicans representing a 100year time span he argues that generations two and three do better in education and income than immigrantparent cohorts that parentchild differences decrease over time and that the gap between mexican americans and whites decreases over time despite these trends significant gaps in income and education between thirdgeneration mexican americans and whites persists zhou and lee provide another example that emphasizes assimilation they critique objective measures often used in social science research and focus on subjective measures presented by members of the second generation the latter emphasizes how the second generation perceives defines and measures mobility and success secondgeneration mexican americans feel successful because they compare themselves to their less educated immigrant parents secondgeneration chinese feel less successful because they compare themselves to highly educated and successful immigrants while selfperceptions of success are important their argument that these relative and subjective comparisons of success are indicative of assimilation is problematic these perceptions cannot substitute for objective measures of mobility and incorportation similar to what has been used in most assimilation research limitations of prior research the prior research on latergeneration mexican americans has several limitations first it relies on cohorts from earlier decades studies of adults with data collected around 1980 are based on cohorts born between 1915 and 1954 other studies with 2000 data are based on adults born between mid1940s and mid1970s 6 telles and ortiz examine a cohort born between 1947 and 1966 second the research is generally limited to education outcomes even while focusing on more recent cohorts alba et al bean brown and bachmeier focus on a cohort born between 1964 and 1984 and analyze both education and economic outcomes but is limited to los angeles lastly the only study to provide a comprehensive analysis of later generations and numerous outcomes is based on a longitudinal and intergenerational survey of mexican americans in los angeles and san antonio it is not national in scope although respondents range from first to fourth generation and the analysis models actual intergenerational change according to alba et al it is possible that mexican americans in los angeles and san antonio face greater barriers because they are part of large and distinctive communities so while the educational disadvantage is well documented we know less about how recent cohorts of latergeneration mexican americans fare socioeconomically so more research is needed on the disadvantages faced by recent cohorts of secondand thirdgeneration mexican americans on a diverse set of outcomes with national data moreover recent cohorts are imperative to study since discrimination is considered diminished in the postcivil rights era workingclass stagnation and racialization an alternative to assimilation theory is a model of workingclass stagnation in which mexican americans progress but their integration is into workingclass jobs and communities bean et al show that while educational levels for thirdgeneration mexican american men are similar to the second generation and behind those of whites they earn higher incomes compared to the second generation in contrast mexican american women do better educationally and economically according to bean et al this is consistent with the workingclass delay perspective that being able to earn more with minimal education dampens incentives to pursue costly higher education similarly terriquez shows that young thirdgeneration mexican americans are less likely to enroll in college and obtain a college degree and more likely to join the labor force a racialization framework proposes that the economic and social hierarchies are largely based on societies making racial distinctions among its members these distinctions assign undesirable characteristics to some groups and systematically exclude them from fully benefitting from societal institutions such as education racialization frameworks help us understand the processes by which groups are incorporated into society and the position to which they are relegated in society for instance scholars of race have documented how blacks were historically incorporated first as an enslaved class and later as an oppressed class in us society with consequences for their contemporary disadvantaged class and racial position based on a history of exclusion exploitation and oppression african americans have ended up at the bottom of the economic political and social hierarchy other groups have also been racialized but they ended up at different points in the racial hierarchy for instance a whitening or deracializing process for europeans in the midtwentieth century allowed them to shed their earlier racialization and fully assimilate by becoming white americans while there is considerable agreement about the racialization of blacks and whites there is considerable debate today about the experiences of nonwhites and nonblacks in us society will the us mainstream expand further to include nonwhites nonblacks or will us society incorporate nonwhites into positions in the racial hierarchy that differ from those of whites and blacks latinos and asians are at the center of debates about their position in the racial hierarchy some scholars have argued that the boundaries of whiteness will expand to include latinos and asians essentially maintaining the racial division between black versus nonblack 7 on the other hand bonillasilva proposes a triracial system in which some latinos and asians will be accepted as white called honorary white and others will be part of the collective black category at the bottom conceptualizing a racial hierarchy with just two or three categories seems inadequate given the diversity and complicated histories of latinos and asians and the racial variation within these groups rather the middle span of the racial hierarchy is more complicated with different groups in different time periods situated at different points along the continuum from white to black as the largest subgroup among latinos mexican americans figure prominently in debates about this racialization process the presence of mexican americans in the united states emerged from the colonization of the southwestern united states in the midnineteenth century and the ensuing decades of immigrating to fulfill needs for lowwage lowstatus labor they have been stigmatized as foreigners and outsiders even in later generations moreover they have been racialized by law and custom classified as a distinct racial group discriminated in public policy faced expulsion from the country and often segregated from mainstream societal institutions unlike the experiences of americans of european ancestry in recent decades mexican immigrants have disproportionately faced hostility due to undocumented status including mass deportations which has affected their immigrant and usborn children present study we revisit the debates about assimilation and racialization by studying mexican american young adults comparing to whites and blacks using a national sample and extending the analysis to include economic integration our analysis involves comparing mexican americans by generational status and to whites and blacks examining a range of outcomes including education occupation and income utilizing a nationally representative sample and focusing on a recent cohort of young adults we address the question do recent cohorts of thirdgeneration mexican americans now follow the assimilation model in that they move ahead of the second generation and reach the socioeconomic level of whites or does their progress stagnate showing a third generation disadvantage as the bulk of previous evidence has shown for older cohorts methods data in this article we use the national education longitudinal surveys a nationally representative sample of eighth graders in 1988 they were subsequently reinterviewed every two yearsin 1990 1992 and 1994and lastly in 2000 when they were about 26 years old this data set includes many background characteristics collected in the initial survey and educational experiences as they continue through school surveys were collected from teachers and parents as the respondents aged they were asked about college and work which we use as outcome variables we analyze a subset of respondents selected on race ethnicity and generational status outcomes education education outcomes are a series of dichotomous variables graduate high school attend college attend a fouryear college and obtain a degree from a fouryear college which are compared to the omitted category of less than high school graduation each education variable is coded zeroone these are obtained from the followup surveys particularly the last one in the 2000 we used the composite variables created by nels staff education school and work activity this variable captures whether respondents are actively employed andor going to school it includes the following categories the least active or those who do not have a college degree are not attending school and do not work or work parttime those who pursued work not school meaning they do not have a college degree are not attending school and work fulltime those who are delayed yet still pursuing their educational plan meaning they do not have a college degree and are attending school and those who have earned a college degree occupation occupation as collected in the last wave of nels was used in the analysis the occupational categories were recoded into four categories from low status to high status lowstatus category such as cashiers clerks and laborers lowto midstatus category such as mechanics skilled operatives and protective services midto highstatus category such as sales medical practice professionals and legal support and highstatus category such as legal professional engineers and executive managers personal income personal income was also available for 1993 when most respondents were age 19 and then again in each of the years 1997 1998 1999 and 2000 allowing us to examine change over time in a descriptive manner additionally we divide 1999 income into quartiles less than 12000 12000 21999 22000 31999 and greater than 32000 the cutoff for the lowest category is somewhat above the poverty threshold of 8300 for a single person in 2000 for the multivariate analysis we examine personal income in 2000 when respondents were generally 25 years old comparison variables raceethnicity the primary raceethnic distinction used in this article is white black and mexican american we used the composite variables created by nels staff to identify raceethnicity 8 a small number of whites and blacks are children of immigrants and we exclude them from the analysis table 1 shows that the sample sizes are 7522 whites 978 blacks and 950 mexican americans 9 generational status generational status is based on respondents place of birth as well as that of mothers and fathers place of birth generation three consists of respondents who are born in the united states and both parents are born in the united states in our sample 524 respondents are thirdand latergeneration mexican americans but for simplicitys sake we refer to this group as third generation generation two refers to persons that were born in the united states of immigrant parents some second generation have two immigrant parents and others have one immigrant parent and one usborn parent a small number of the mexican american respondents are immigrants who arrived in the united states before the age of 13 since their inclusion in the nels sample means they were attending school in the united states at age 13 ideally we would have maintained the distinctions among these more specific generational categories but as shown in table 1 these categories were relatively small 10 the combined secondgeneration group includes 426 respondents table 2 presents means for the raceethnic generation groups representing our key comparisons ten percent are latergeneration blacks 6 percent are latergeneration mexican americans and 5 percent are secondgeneration mexican americans the reference group is latergeneration whites which comprises 79 percent of the sample omitted groups we considered doing generational comparisons with other groups but no other groups are large enough or appropriate one group is secondgeneration whites of diverse origins that differ from the countries of origin among thirdgeneration whites second are secondgeneration blacks who differ in important ways from thirdgeneration african americans third are asianorigin respondents because there were too few thirdgeneration respondents and too many origins even chinese control variables socioeconomic background we examine mothers and fathers education separately as categorical variables with the following categories less than high school completed high school attended or graduated college table 2 shows that 53 percent of mothers are college graduates and 30 percent have some college 45 percent of fathers are college graduates and 32 percent have some college family income is a categorical variable comprised of less than 15000 15000 to 35000 with 25 percent 35000 to 50000 with 19 percent and 50000 or more with 20 percent gender gender is coded as one for female and zero for male more than half53 percentare women education education is used as an outcome variable in our analysis second for the analysis of occupation and income years of education is used as a continuous independent variable on average respondents have some college analysis our primary comparison is among latergeneration whites and blacks and mexican americans separately by second and third generations we present percentages for four outcomes education school work activity occupation and income since the dependent variables are categorical we use multinominal logistic regression for the multivariate analysis we present unadjusted differences from the multinominal logistic regressions as well as adjusted differences controlling for the control variablesparental education and income female and education 11 we use multiple imputation models to address the small percentage of cases that have missing values in parents education and income our sample is based on 9450 cases who have nonmissing values on race generation status our key independent variable and education times more likely to have not completed high school compared to whites and 50 percent more likely than blacks12 percent among the third generation and 13 percent among the second generation compared to 4 percent for whites and 8 percent for blacks the unadjusted differences indicate that mexican americans and blacks are statistically significantly less likely to complete high school still it is encouraging to note that high school graduation rates are relatively high including among mexican americans findings education the relative youth of the sample means that many are still in the process of completing their college education among whites 37 percent are college graduates but far fewer mexicans americans have completed college14 percent among the third generation and 15 percent among the second generation college completion rates are also several percentage points less than those of blacks again unadjusted differences are statistically significant overall the raceethnic differences are consistent in that whites have more education and mexican americans have the lowest educational outcomes the third column of table 4 shows adjusted group differences after adding the control variables with the control variables in the models we find that secondgeneration mexican americans do not differ significantly from whites since the immigrant parents of the second generation have especially low education levels the difference between secondgeneration mexican americans and whites is sharply reduced thirdgeneration mexican americans however continue to have lower rates of completing high school and completing college even after adjusting for parental characteristics the parents of the third generation are not as disadvantaged educationally as the parents of the second generation so adjusting for their status does not explain the outcomes for the third generation additionally thirdgeneration african americans have significantly lower rates of completing college compared to thirdgeneration whites but not as low as the rate among thirdgeneration mexican americans education school and work activity table 5 presents the measure of activity that combines education attending school and working few respondents are in the inactive category in which they have not completed college are not attending school and are not working fulltime still the most inactive groups are blacks and thirdgeneration mexican americans who differ significantly from whites at the other end of this categorical variable are the college graduates more of a third of white respondents are in this category as compared to 15 percent of thirdgeneration and 14 percent of secondgeneration mexican americans with blacks falling midway between whites and mexican americans all three racegeneration groups differ significantly from whites the largest percentage involves those who are working secondgeneration mexican americans are more likely to be working with 53 percent 49 percent of thirdgeneration mexican americans are working and 42 percent and 44 percent whites and blacks respectively are in this category even though they have lower levels of education we observe that secondand thirdgeneration mexican americans and african americans are pursuing school to a greater extent and the black and thirdgeneration mexican american groups differ significantly from whites in this respect overall this detailed breakdown shows that whites are in the most advantaged group in that they are more likely to be college graduates and all three of the race and generation groups differ significantly from whites mexican americans and african americans are disadvantaged in that they do not have a college degree yet many continue to pursue school the adjusted group differences are shown in table 6 once the control variables are included in the models the racialethnic groups do not differ significantly in being inactive moreover the racialethnic differences in pursuing school among those without a college degree are significant so while african americans and thirdgeneration secondgeneration mexican americans are less likely to be college graduates by age 26 both groups are more likely to be pursuing school than whites this difference is large and significant after controlling for background differences including differences in parents education occupation table 7 presents the occupational distribution by raceethnicity and generational status whites are less likely to be in lower status occupations compared to blacks and mexican americans39 percent among the third generation and 36 percent among the second generation at the other end of the distribution smaller percentages of blacks7 percentand mexican americans5 percent among the third generation and 4 percent among the second generationare in the highest status occupations compared to 11 percent of whites all three race generation groups are significantly less likely to be higher status occupations the adjusted differences are presented in the third column of table 8 even in the adjusted model thirdgeneration mexican americans continue to have lower rates of being in higher occupational categories compared to whites african americans are less likely to be in the mid to lowand mid to highstatus occupations compared to whites racialethnic differences are extensively reduced once we control for education since education is a strong predictor of occupational status and mexican americans have the lowest education 12 still education is not able to explain all of the disadvantage faced by thirdgeneration mexican americans in income as they get older at age 19 all of the racialethnic and generational groups have relatively low incomesaround 6000 to 7500 these low levels of income are probably due to the fact that most 19yearolds are working for the first time in lowpaid jobs or working parttime and attending school in the next six years following 1993 income among whites increased most sharply by 1999 whites have incomes of 25500 while blacks have incomes of 20800 thirdgeneration mexican americans have income levels of 19000 and secondgeneration mexican americans have incomes of 21800 just as their income gains were greatest college completion rates among whites also rose most sharply in this sixyear period showing the link between education and income income as shown in table 9 whites are less likely to be in the lowest income group in 1999 compared to blacks and mexican americans at the other end of the distribution smaller percentages of blacks and mexican americans are in the highest income group all three race generation groups earn significantly less than whites once the control variables are held constant the adjusted differences show that thirdgeneration mexican americans appear in the midhigh or highest income categories at lower rates similar to our findings with occupational status education explains much of the differences in income level by raceethnicity still education is not able to explain all of the income disadvantage faced by thirdgeneration mexican americans our crucial finding is that thirdgeneration mexican americans have lower levels of education schoolwork activity occupation and income than whites not only are these comparisons statistically significant when no other factors are included in the model but they are significant in the multivariate analysis that controls for parents socioeconomic status and other key factors we find that thirdgeneration mexican americans lag in completing college achieving higher status occupations and earning higher incomescredentials and outcomes that define middleclass status controlling for parental characteristics explains some of the differences between secondgeneration mexican americans and whites which is due to the especially low achievements of immigrant parents on the other hand controlling for parental characteristics did not explain much of the disadvantage for thirdgeneration mexican americans our findings are consistent with telles and ortizs extensive study of latergeneration mexican americans discussion while the assimilation model has been useful in explaining socioeconomic incorporation for european groups in the united states the model is of little utility for understanding mexican americans considering their third generation disadvantage based on our analysis of national data we find virtually no generational progress between the second and third generations on a wide range of socioeconomic indicators the educational gap between mexican american and whites remains constant and large into the third generation for instance secondand thirdgeneration mexican americans have less than half the rate of whites in completing college moreover both the adjusted and unadjusted differences between thirdgeneration mexican americans and whites are statistically significant in all of our multivariate analyses as are some of the blackwhite differences thirdgeneration mexican americans are disadvantaged on several socioeconomic dimensions appearing to hit a ceiling in us society by analyzing a younger cohort from a national sample our study adds to the prior research documenting third generation disadvantage among mexican americans segmented assimilation a variation of assimilation theory is also inadequate for explaining third generation disadvantage for example we do not find evidence of permanent poverty or participation in the underclass therefore the predictions by segmented assimilation scholars that mexican americans will be outside the mainstream or experience downward assimilation are unsupported rather we document how mexican americans strive to get ahead as indicated by continuing to pursue higher education at later ages yet finding it difficult to achieve goals like obtaining a college degree on the other hand the progress from immigrants to their secondgeneration children is by itself consistent with assimilation theory moreover when we consider that mexican immigrants start off with human capital that is well below that of the vast majority of americans of any race the large gains from immigrant parents to their useducated children are unsurprising the gains of the second generation may also reflect the immigrant parents optimism about greater opportunities in the united states relative to those in their country of origin in contrast that optimism is lost among the third generation which grows up with usborn parents that expect more compared to immigrants but face limited opportunities for mobility the second generation advantage has been celebrated in several assimilationoriented studies for instance kasinitz and his colleagues applaud the schooling and early labor market outcomes of secondgeneration dominicans compared to thirdand latergeneration puerto ricans this raises concerns since by naming puerto ricans as samerace peers to dominicans kasinitz et al acknowledge the racial categorizing of latinos yet they do not problematize the racial disadvantages faced by puerto ricans moreover these disadvantages among thirdgeneration puerto ricans are similar to those we document among thirdgeneration mexican americansboth suggestive of racializing processes 13 despite evidence that mexican americans do not follow the expected assimilation trajectory scholars who favor assimilation invoke optimistic explanations one explanation emphasizes the success of some mexican americans as part of a heterogeneous mexican american population however heterogeneity is not particularly useful since all groups are heterogeneous similarly mexican american individuals can be found throughout the educational and occupational hierarchy yet what matters for the purposes of evaluating assimilation theory is the consistent disadvantage of the mexican american population behind whites in the end even champions of assimilation like alba and his colleagues admit that a large portion of the mexican american population is especially disadvantaged another explanation focuses on how the second generation feels more successful than their lowstatus immigrant parents as we have already noted the improvements between immigrant parents and their secondgeneration offspring are unsurprising considering the especially low status of immigrant parents however that members of a disadvantaged group deemphasize their disadvantage or do not use successful whites as a reference point does not mean that we should limit our interpretations in a similar manner moreover many thirdgeneration mexican americans which were not included in zhou and lee or other major studies of immigrant incorporation are unlikely to feel more successful than their secondgeneration parents given their lack of mobility relative to their parents because secondand thirdgeneration mexican americans have not reached parity with whites it is imperative to employ objective definitions of success our findings align more with the workingclass stagnation or delay perspective that bean and his colleagues propose in their study of mexican americans in los angeles they show that the education levels of thirdgeneration mexican americans are similar to the second generation and lower than those of whites these findings are similar to our education findings however our results regarding labor force integration differ bean et al show that the third generation is well integrated into the labor force and their income levels are similar to whites and higher than the second generations in contrast we show that the income levels of the third generation are significantly lower than that of whites and similar to the second generation the prospects for the fourth generation are not optimistic when we consider that telles and ortiz found that fourthgeneration mexican americans do no better than the third generation that mexican americans disproportionately move into or persist in the working class is indicative of the barriers to mobility that mexican americans face the educational process is key to understanding these barriers certainly some mexican americans are successful due in part to public policies such as affirmative action still thirdgeneration mexican americans on average do worse than whites as children mexican americans disproportionately attend underfinanced and poorly resourced public schools with less experienced teachers and the absence of a challenging curriculum additionally a number of studies have shown that mexican american students confront racialized expectations by teachers and counselors that stigmatize them as intellectually inferior unmotivated or less worthy than students in general as they enter the job market education underlies their economic success at later stages low levels of schooling lead to lower occupational status and lower income locking many mexican americans into a future of lower socioeconomic status their persistent low status appears to indicate that a process of racialization begins with educational disadvantage which in turn affects economic outcomes the disadvantages faced by mexican americans are not limited to the educational system throughout a century of continuous immigration mexican immigrants have consistently occupied the lowest paid and least valued jobs in the us economy mexicans continue to be the largest immigrant group and comprise the majority of undocumented immigrants thus making them the most stigmatized immigrant group additionally mexican americans of all generations share residential and labor markets which promotes the stereotypes and racialization of mexican americans irrespective of generation immigration policy which has created a large category of undocumented mexican immigrants also contributes to the limited gains of mexican americans even into later generations the lack of legal status for many in combination with racialization is likely to further impede the social economic and political progress of future generations also the fact that mexican immigrants disproportionately hold undocumented immigration status leads to stereotypes and the categorical thinking that fails to distinguish between natives and immigrants such nativism and stereotyping harm mexicans and denies them equal education among other opportunities and this ultimately heightens racial and ethnic disparities even mexican americans with deep roots in the united states are perceived as foreigners and thus excluded from full participation in american life this designation as being persistently foreign makes the mexican americans case different from that of african americans or european americans since assimilation is inadequate for understanding our findings what then explains outcomes for mexican americans we argue that mexican americans are sorted into and find themselves in a racially stratified society while we do not have direct evidence of racialization our findings are consistent with racialization frameworks that the third generation disadvantage is so consistent in a comparison of mexican americans and whites when controlling for key factors is indicative of an experience that is distinct from that of whites regarding their trajectories of integration in the united states therefore we observe that beyond the second generation mexican americans face third generation disadvantage and are sorted into the american racial hierarchy in a position below that of whites thus consistent with a racialization perspective notes 1 alba and nee also argue that east asian groups from the earlier era of mass immigration in the nineteenth century have become part of the mainstream 2 portes and his colleagues may have overstated the argument by using language like underclass persistent poverty and downward they were particularly motivated to explain the persistent poorer outcomes of secondgeneration mexicans as compared to other groups which included residing in poorer neighborhoods hence the connection to concepts like the underclass however the empirical evidence does not support downward assimilation especially regarding educational outcomes this notion is more consistent with other outcomes like teenage pregnancy smoking drug use gangs and imprisonment where the second generation fares worse than immigrant parents educational outcomes are better explained as stagnation beyond generation two 3 kasinitz and his colleagues emphasize the second generation do better than thirdand latergeneration minorities such as puerto ricans and african americans 4 jennifer lee in an opinion piece argued that mexican americans can be considered the most successful group of all because they start out behind most other groups 5 telles and ortiz the legal reality prior to civil rights era operated on a whitenonwhite basis for example the onedrop rule could be considered an example of a whitenonwhite distinction since the racial boundaries are clearly drawn around whites however this rule was largely directed to blacks and not particularly at nonwhitesnonblacks also only whites were granted full citizenship rights and noneuropean immigrants were from excluded from becoming citizen lastly the civil rights legislation of the 1960s awarded protection from discrimination to latinos asians and native americans in addition to african americans 8 race and ethnic classification is based on questions posed to the student about which group they most identify with consequently respondents of a mixed race background are free to select the category that is most relevant to them 9 we cannot make the critical distinction between individuals of unmixed mexican ancestry and those who are partly mexican and partly anglo a distinction that in all analyses aligns with numerous differences in social situation and experience however since those of mixed mexican and white ancestry have slightly higher socioeconomic outcomes than nonmixed mexican americans the inclusion of mixed persons works against our argument if we had been able to remove mixed persons the outcomes of the third generation might be even lower 10 some respondents in generation 15 could have an undocumented immigration status however we have no way of knowing whether this is the case since national education longitudinal surveys do not ask about immigration status 11 we do not present the results for our full models in the full models we find the effect of parents education is as expected in that respondents with mothers or fathers who finished high school or went on to college are significantly more likely obtain a college degree or to be attending school on the other hand mothers and fathers education did not a significantly predict occupation or income family income predicts respondents education occupation and income young women were more likely to have completed college or to be attending school but they have significantly lower occupational status and personal income than young men respondents education significantly affected occupational status and personal income the full models are available on request 12 differences by raceethnicity and generation do not change much when parental socioeconomic status and gender are held constant however when education is introduced into the equation differences by raceethnicity and generation are reduced considerably 13 other latino groups such as puerto ricans dominicans and central americans are frequently racialized author biographies vilma ortiz is professor of sociology at ucla her research addresses broad theoretical issues on racialethnic stratification and social inequality particularly on socioeconomic experiences of latinos in the us she and telles are coauthors of the awardwinning generations of exclusion mexican americans assimilation and race edward telles is distinguished professor of sociology at university of california santa barbara his research focuses on mexican americans in the us and race in latin america in addition to cocoauthoring generations of exclusion he is author of the awardwinning race in another america and coauthor of pigmentocracies ethnicity race and color in latin america

whether the education and economic accomplishments of latergeneration mexican americans fit the assimilation or the racialization perspectives is hotly debated on the one hand the assimilation perspective assumes that immigrant groups including mexicans are welcomed to us society and by taking advantage of educational and economic opportunities can be upwardly mobile this prediction fits the narrative that the united states is exceptional in providing ample opportunity for prosperity and success to all groups in contrast to assimilation racialization perspectives predict persistent disadvantage of particular ethnoracial groups that are located in the bottom rungs of a racially hierarchical society and who have experienced a long history of oppression exclusion and stigmatization blauner 1972bonillasilva 2003feagin 2006omi and winant 1986 to address these competing perspectives this article examines education occupation and income among mexican americans compared to blacks and whites among a recent cohort of young adults we argue that mexican americans experience a distinct third generation disadvantage which contrasts sharply with the previously documented second generation advantage kasinitz mollenkopf and waters 2010 assimilation theory seeks to explain the progress of groups as they incorporate into a new society over time and across generations the classical assimilation model predicts and explains the incorporation 707223s rexxx10

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leadership skills led to the establishment of hazard kentuckys first ever stroke survivor and caregiver support group carole frazier ba is a community health worker with kentucky homeplace in appalachian kentucky she provides vital health assistance to underserved families with multiple morbidities and is a trained facilitator in wellness recovery action plan before her work as a community health worker she provided many years of service in regional schools abstract scholarship on idioms of distress has emphasized crosscultural variation but devoted less attention to intracultural variationspecifically how the legitimacy of distress may vary by context in which it is expressed social position and interaction with medical categories of distress this variation can pose challenges for interventionists seeking to establish culturally acceptable ways of identifying distress and creating relevant resources for recovery we describe efforts over 3 years to identify and adapt a culturally appropriate evidencebased intervention for depressed rural appalachian women though the prevalence of depression among rural women is high limited services and social barriers restrict treatment access formative research revealed varied understandings of distress depression was medicalized as a treatable condition stigmatized as mental illness accepted as a nonpathological reaction to regional poverty and gendered caregiving responsibilities rejected as worthy of individual careseeking and diminished in comparison to other competing forms of distress in a small pilot trial we applied an implementation science perspective to identify and implement appropriate evidencebased programming for the context we outline how we reached appalachian women despite these diverse understandings of depression and established a flexible medicalization introduction for nearly 40 years medical and psychological anthropologists have urged sustained analysis of crosscultural experiences of distress in order to understand variation in its expression and the contexts that provide it with meaning heeding this call anthropological scholarship on distress describes the syndromes that appear in different cultural contexts outlining the embodied experiences links to deep cultural meaning and indigenous treatments to alleviate such distress reviewing this work decades in nichter reflected that anthropological studies have all too often emphasized one mode of expression he sought to draw attention to the sociopolitics that privilege certain forms of distress while generating alternative means of expressing distress revealing great diversity in the interpretation of distress intraculturally at the center of this approach is a focus on transaction to understand how meaning is negotiated between different parties responding to the environment and how the response to distressor absence of responseshapes the continued expression of distress social positionincluding gender class and ageshapes who is allowed to express distress and in what way when distress cannot be expressed in forms that are culturally valued it is more likely to be repressed unrecognized or stigmatized the norms of expressing and interpreting distress change in response to social shifts and societal upheaval this literature demonstrates how debate is inherent to the expression and interpretation of distressthat who expresses distress matters the form of expression matters to its interpretation and that the meanings of distress shift over time we ask how these characteristics of distress under debate can be applied to improve care we focus on the experience of depression among rural women living in appalachiaa region where the meaning of distress has changed considerably in the recent generation yet where appropriate quality care remains challenging to access challenges of intervention crossculturally idioms of distress hold great significance for care management by revealing the social economic and relational contexts in which distress is expressed in so doing idioms of distress can illuminate what strategies would be adaptive or maladaptive for a given context yet many researchers are skeptical of treating distress warning of the cultural assumptions inherent within definitions of mental health pathology that underlie intervention in particular critics note the increasing medicalization of depression since the 1980s in which biomedical definitions of depression and its treatment have expanded in popular consciousness in healthcare settings and through commercial products to treat depression such medicalization has transformed sorrow and sadness into illnesses to be treated with medication the process of biomedical intervention itself transforms whatever the patient experiences into a psychiatric entity that fits within its classificatory schemes this process may potentially translating biomedical terms in ways that drastically misunderstand patients experiences such as changing the moral meaning of mental health experiences as a result of biomedicines individualistic focus many treatments have shifted the moral responsibility for maintaining mental health to the individual depoliticizing the problem and largely ignoring the wider social and institutional context of individuals physical and mental states and behavior and the deficiencies of the society in which they live ultimately moral interpretations of distress that draw attention to broader social pathology may be best situated to reduce suffering provided they are grounded in understanding how such ailments are also embodied by individuals to realize this shift interventions must address the larger inequalities shaping mental distress the contributions of culture and the influence of organizational environments on provider care still with much of this literature placing the patient or person at the center is there room for culturally grounded interventions that address how broader groupsnot just individualsmay experience distress that is under debate further how can interventions respond to varied expressions of distress not only in providerconsumer interactions but through reconceptualizing the types of providers offering care the settings in which care is provided and expanding the support provided shifting meanings of distress in appalachia in 2014 we began research on the experience of distress and depression among appalachian women in order to understand epidemiological data that showed high prevalence of depression in appalachian kentucky and rural women in us more broadly historically nerves has been a syndrome in the region characterized by feelings of nervousness fear anger depression and physical agitation understood to be caused by harsh social conditions and stressful social events yet contemporary research on rural women more broadly shows that more women identify their symptoms as depression and in appalachia use the expression nerves less often such a shift may indicate increased medicalizationthat clinical categories of depression may be more widely embracedor it may represent interaction between emic and etic categories of mental health as rural areas have become more exposed to directtoconsumer advertising and treatment delivered through telemedicine and mobile technologies many initiatives have concentrated on increasing care for rural women with depression by expanding access to mental health specialty care in rural settings yet research on rural settings demonstrates that considerable barriers remain including expectations that women independently manage their distress persistent stigma and extensive shortages in mental health services guided by the suggestion that culturally grounded interventions must understand patients predicaments and devise solutions based on their individual family and community resources we adopted an implementation science perspective to understand and address barriers and employ resources across systemic organizational provider and individual levels we initiated intervention planning through the replicating effective programs framework a conceptual model that identifies local needs applies these understandings to identify appropriate evidencebased practices and examines the local context to understand how programs need to be effectively implemented in local organizational contexts through partnership with community partners methods intervention adaptation as shown in table 1 from 20142016 we elicited the perspectives of appalachian women with depression and the diverse healthcare providers who offer care to them in interviews and focus group discussions our team included research coordinators and collaborators based out of the center of excellence in rural health and their community health worker program kentucky homeplace collectively the team possessed extensive ties in the community and vast experience in appalachian health disparities work we pursued our overall goal to adapt and implement a culturally grounded intervention for women in appalachia through the course of five different stages formative exploration adaptation review and intervention in table 1 we describe the multiple phases of this work by goal participant type and data collection method in phases 1 and 34 we recruited women who felt down and evaluated depression with a standard scale but purposefully sought women with varied perspectives on depression as an illness category including identification with resistance to and less familiarity participants with depression were predominantly white reflecting the demographics of appalachian kentucky with 954 people identifying as white 17 identifying as black and 13 identifying as hispanic we made efforts to oversample african american participants however we found that depression stigma was an enormous barrier to followup in phases 23 we sought the expertise of a range of healthcare practitioners who serve women in the region some of whom identified as depressed and others who did not but still might engage in treatment we reached out to primary care providers the main providers of mental health services in this rural area as well as mental health specialists who provide psychotherapy in integrated care settings as well as community mental health centers in addition we relied on the perspectives of chws lay health workers posted in the surrounding rural counties who provided care coordination for underserved rural residents and facilitated health programs chws often had more sustained contact with their patients and were able to identify those who likely had depressive symptoms even if they did not identify with medicalized depression all participants were briefed on study procedures and given the opportunity to ask questions as part of the process of informed consent throughout we were in touch with wrap developers and staff about our goals receiving technical assistance during the implementation process to ensure the adapted program was delivered with fidelity all phases of the study were approved by the university of kentucky college of medicine institutional review board intervention outcomes primary outcomes collected at baseline and after the intervention included depression severity and rumination an outcome that can capture more subtle changes in mental health coping than depressive symptoms alone though we had employed the cesd for the earlier study phases we switched to the use of the phqsymptoms of depression and includes more accessible language secondary outcomesall measures consistent with previous wrap trialsincluded hopefulness quality of life and selfperceived sense of recovery on an exploratory basis we measured social support and mental health service use and satisfaction at the conclusion of the intervention we conducted individual phone interviews with intervention participants asking about their perceptions of effectiveness and acceptability additional quantitative and qualitative data was collected on implementation and feasibility that is not presented here qualitative data analysis we used thematic analysis to guide our interpretation of the data across phases building on themes derived from the literature on rural mental health idioms of distress and implementation science different codebooks were generated for each phase of the project to address separate research questions for each codebook initial analysis was guided by broad review of the transcripts to identify initial themes code definitions were developed gradually through an iterative team process of comparing themes across transcripts and differentiating between code boundaries once formally defined the first and second authors applied codes line by line to the transcripts in the maxqda data analysis program coded data segments were compared across cases to identify patterns differences by participant type and to identify outliers which were resolved in followup team discussions analysis was presented to communitybased team members for feedback and checking at the end of each study phase quantitative data analysis descriptive statistics of outcomes were determined paired ttests were used to compare preand posttest scores and effect sizes were calculated using cohens d results several broad themes appeared across the studys phases first we describe the varied debates about what depression was in the region second participants discussed how deep needs and service disparities posed major limitations to creating an intervention within traditional clinical mental health services third participant perspectives on the range of interpretations of distress in the region aligned well with recoverya philosophy social movement and therapeutic orientation driven by consumers of mental health services fourth participants recommended that we strategically engage with medicalization employing its moral authority to encourage participation while avoiding its hierarchical relationships by focusing on adapting a broad intervention that addressed recognized needswithout defining those needs specifically we avoided the powerful consequences of the negotiation involved in interpreting distress we briefly present results from the adapted intervention pilot trial we found significant declines in depression severity depressive rumination and significant improvements in participant perceptions of their ability to deal with daily problems and accomplish goals participants in the intervention commented on how the adapted group intervention helped them to deindividualize their distress as an individual pathology while enabling them to voice their own individual distress within their social worlds part i program adaptation varied understandings of depression we found varied understandings of depression and distress as we talked to women and their healthcare providers many naturalized depression and feelings of being down as a reaction to the harsh social and economic conditions in the region which made it extremely challenging to get by much less imagine a future in the region many equated depression with a category of people who took part in specialty behavioral healthcare referring to patients with serious distress one provider explained they do have bad nerves but they dont identify with services offered in community mental health centers for others depression was an illness for which they would take medication but not mental illness a term connoted people who were more different who need their treatment and their groups because of these mixed connotations of the severity implied by the label depression some women who understood their feelings to indicate depression were careful to hide this from others fearful they would be seen as crazy incapable of performing their jobs or caring for their children older women described gradual generational shifts in the conceptualization of depressed feelings with increased contemporary understanding of depression as an illness and more interest in pharmacoand psychotherapy to treat depression some who attended church resisted medicalized depression identifying their feelings as part of their own character to be resolved through prayer while others insisted that psychiatric treatment was the only venue in which they could seek help for distress they attempted to conceal in church providers and women with depression admitted that even when they identified their distress as depression it did not feel as real or as urgent as the physical comorbidities common in the area chws noted that their participants dismissed psychotherapeutic treatment saying i dont have time to go to town for 2 hours to just go over there to talk but chws questioned the deeper meaning in this evaluation posing do they think theyre not worth it or that they can beat this on their own as we describe in more detail elsewhere many women found it hard to differentiate their distress as depression when so many other family members expressed similar vulnerability many women struggled to find outlets in which they could voice their distress and have it validated one provider reflecting on the reticence of appalachian women to seek care for depression described i think sometimes women feel guilty for taking time for themselves and their own stuff because they have families in this setting people were willing to legitimize the distress of depression but expressed ambivalence about how real it was how exactly it should be dealt with and whether it deserved to be dealt with even women who engaged with a more medicalized understanding of depression continued to debate the meaning of their distress as we show elsewhere limitations of adapting traditional mental health services both women with depression and diverse healthcare professionals remarked on the challenges of building sustainable interventions in a rural system with limited capacity as one woman commented we have nothing here one social worker who described her own experience with depression admitted if someone were to call me at work and say look i need help i wouldnt know where to send them to still many women managed to access care in primary care settings and at times from mental health specialists yet with a few exceptions womens description of their clinical experiences resounded with frustration which often resulted in fragmented treatment engagement healthcare providers emphasized the challenges in providing quality care due to time constraints and excessive needs in traditional mental health services delivered in primary care and specialty settings most women did not receive the intensity of care that they neededin everything from the therapeutic encounter to the coordination required to access care participants remarked that the hierarchical nature of interactions between patients and providerswhether primary care or mental health specialistsheld multiple consequences providers professionalism alone could be aversive to women from considerably different social backgrounds particularly those with negative experiences in overburdened rural service settings referring to the way in which providers position was embodied one chw explained the patients averse response when they walk in and im in heels and all that theyre like shes another one of them that aint going to help me providers were felt to not only have the capacity to apply stigmatizing labels and uncover sensitive situations undergirding womens distress but also to have the power to reveal this information in ways that could threaten their employment or custody of family members its scary because theres a doctor label behind their name explained one woman youre like okay this doctors going to find something and somethings going to be taken from me at the same time participants were skeptical that women in the region would participate in any intervention oriented explicitly around mental health because they felt that this distress was either less real or potentially dangerous as one woman with depression said a lot of the places here put depression down as a disease… but a lot of people dont want to be put in the category of a mental illness that scares them if depression was put under a virus they would be fine with it in addition to stigma mental health was felt to be too difficult to prioritize in a region with such varied perspectives on distress participants of all types agreed the greatest challenge would be getting people there just getting people to decide that theyll sit in front of this group and say in front of a stranger that theyre depressed for women to attend the program one community health worker insisted our program must look like just a group of women having snack instead of being a bunch of mental health people that needs their issues addressed mental health recovery provides room for diversity we chose an intervention based around the recovery philosophy that enabled us to make room for diverse understandings and experiences of depression but could be delivered outside of traditional mental health services emerging from a movement of mental health consumers recovery is an approach to mental health that stresses overall wellbeing consumers interpretations of their mental health and their own efforts to manage itthus pushing away from clinical models of care that are hierarchical emphasize pathology and can impose unrealistic plans for progress specifically we chose the recovery intervention wellness recovery action planning that is oriented around wellness and selfmanagement an evidencebased intervention tested in randomized clinical trials wrap serves as an augmentation to clinical mental health treatment wrap employs nonclinical terms to describe mental health and is delivered in a group format by peer providerspeople who have experienced mental health challenges themselves who become certified to provide wrap typically trained peer facilitators lead 1216 hours of content in group meetings that introduce participants to the concept of recovery and guide participants to create their own wellness toolkits and plans for crisis in line with evidencebased guidelines requiring participants to be engaged in concurrent treatment we recruited participants engaged in treatment recoverys focus on wellness and absence of clinical mental health language would enable us to capture a broad group of women the recovery intervention that we chose however was one that could respond to multiple interpretations of distress while straddling the category of depression as mental illness many felt that the group orientation of the intervention would enable women with varying interpretations of distress to see themselves within a shared experience rather than a singular label with this in mind women could consider their participation gradually they can be thinking about it there is other people who feel the way i do and have the same problem and that might ease the door open for somebody providers and women endorsed the wellness emphasis within the program as one chw reflected we have to present it in a way without saying oh its all about depression its a way to feel good…to maintain your everyday life…and not let it get you stressed out overwhelmed further diverse providers suggested building on the chronic disease selfmanagement concepts of the intervention that might be familiar to women in a population with high rates of comorbid chronic disease when people think of selfmanagement explained another chw its like initiative to help themselves but it allows them to be in control more unlike the medicationfocused treatment typically received by most rural women in primary care participants recommended that we recruit for the program through language that focused predominantly on symptoms that will capture a whole range of folks who might say i dont sleep good my appetites not good im really irritable a lot but i dont have depression in addition chws suggested that they could identify women whom they served through care coordination that experienced significant distress but likely would not seek care for depression outside pharmacotherapy one chw envisioned that she would explain the program to one of her existing clients by saying you know how you always say that thats just the way it is and it aint going to change id say but it could change though in this rural area with few people who publicly identified as consumers of mental health services and no peer provider workforce we opted to deliver wrap through chws lay health workers with extensive knowledge of and ties to the community our participants suggested that chws relational style of care could help address some of the limitations of existing services chws explained that the women with whom they worked needed reassurance particularly because many of them had multiple negative experiences in healthcare and some felt unable to rely on others sustaining contact was vitalif an entire week passed and they dont hear from you then theyre thinking well they dont care they just want me up there in that session you know but have they called to check on me providers noted that the relationship itself was meaningful arguing that she must let women know that i do care that they come that that does matter to me in this sense participants recommended that the relationship with chws would be more high touchcharacterized by more intensive communication because most women had struggled to find receptive family and community support positive nonhierarchical communication would be crucial to any intervention you just have to make them feel like youre on their level that youre not above them at all unlike providers with advanced medical training community health workers would avoid the clinical mental health language that reinforced hierarchies during treatment encounters even as we had chws serve as peer facilitators we implemented wrap in fidelity with core principles flexible medicalization based on the input of women with depression and healthcare providers we adapted the program through flexible medicalizationusing medicalization strategically to legitimize participation but avoiding psychiatric terminology and differentiating the program from traditional treatment women found it hard to prioritize care for their depression because it was less real and because gendered obligations for caregiving subsumed their individual needs for women with too many other people depending on them…admitting that theres an issue reflected one provider well they just dont have time for it yet providers and women alike explained that a doctors referral would help them to realize that seeking care was important in rural healthcare settings where patients see primary care providers for physical and mental health most people will trust recommendations from their provider explained one practitioner some recommended that the program be implemented as part of care planning within appointments rather than presenting wrap as a casual choice that women would opt in to holding the program at a medical site would enable women to identify the program in a more culturally acceptable way rather than likening it to mental health services that bore stigma women wouldnt have to call it anything it could just be going to the doctor because we opted to locate our wrap trial in the same building as a federally qualified health center and the offices for chws the program benefited from the legitimacy of existing care participants would think explained one chw that i go to the doctor there i go visit the community health worker there everything is confidential you know so theyre having it there so this has to be legit even as we wanted to encourage women to seriously consider care for their distress we took steps to ensure participation was voluntary participants had to voluntarily reach out to the study coordinator to learn about our wrap study while we encouraged providers to refer their patients to the program we neither informed providers of participants decisions to take part nor did providers followup with potential participants about their decisions to participate we described study procedures to participants during a formal consent process enabling participants to ask any questions or decline participation clarifying that their decisions would have no influence on any other services they would receive at the health center with which we were affiliated with wrap designed as an augmentation to clinical treatment only women current engaged in treatment were eligible for our study however formative themes on debate about treatment led us to anticipate that participants treatment experiences would be varied some would likely adhere fully to treatment regimens and formulate wellness plans including deeper treatment engagement others might engage more sporadically in treatment and reject clinical care in their recovery plans still providers and chws expressed concern that adaptations to wrap included implementation strategies that would enable chw facilitators to draw on the support of mental health clinicians if wrap participants expressed severe distress during sessions conversely women expressed fear of being perceived as crazy or outofcontrol citing the fear of psychiatric institutionalization if their words were misconstrued to address the sometimes problematic procedures applied in crisis and the need for additional support for severe aspects of depressive illness we consulted with wrap developers and mental health specialists evaluated onsite resources and assessed chw facilitators own comfort drawing on these perspectives we designed flexible procedures to address the emergence of extreme distress that drew on womens understanding of their distress social supports and existing services i even as we linked the program to primary care through referrals and site we avoided full embrace of medicalized depression stakeholders warned us to differentiate the program from traditional pharmacoor psychotherapy treatment due to the past negative treatment experiences of many women if they have some issue with mental health care or they havent been treated well commented one provider it might be good to emphasize that this program would be different it must be clarified suggested one woman with depression that were not here to give you any kind of medication were not here to judge you on anything were just here to talk and listen and try to help you in this way participants suggested that medicalization could increase the priority of depression care while acknowledging the negative experiences many had already faced in treatment settings part ii adapted intervention results quantitative findings preand postintervention outcomes pairedsample ttests of survey responses before and after the wrap intervention showed significant improvement in four areas related to participant symptom burden and recovery strategies participants reported decreased overall depression severity as measured by phq9 decreased rumination on depression as measured by rrs improved ability to deal with daily problems as measured by echo and improved ability to accomplish goals as measured by echo due to our small sample size we also report effect sizes the intervention resulted in large effect size for the improved ability to deal with daily problems as measured by echo and medium effect sizes for depression severity as measured by phq9 decreased rumination on depression as measured by rrs improved ability to accomplish goals as measured by echo decreased symptoms as measured by echo and decreased overall rumination on the rrs a small effect size was seen for the ability to deal with social situations as measured by echo and decreased brooding as measured by rrs other subscales did not show significant improvements and some measures showed little impact of the intervention see table 3 for the full listing of responses qualitative findings individualizing distress as a voice and deindividualizing distress as problem anthropologists have pointed out how the philosophy of recovery is generally oriented around the individual potentially conflicting with collectivist orientations toward wellbeing we were surprised to hear how many participants voiced an appreciation of the individualistic focus that enabled them to navigate their immense social demands differently though we had initially focused our research on women because of the gendered patterns of depressions presentation the gendered focus resonated with consumer and healthcare provider stakeholders advising us on intervention adaptation the need was for something like where women can come and meet and they can discuss what they need repeatedly providers pointed to the weight of social demands on women they felt were at the root of their depression it trickles back down to some strong woman somewhere has to be the one whether shes strong or not she has to be the one to do it in line with this emphasis women noted that the largest impacts of the intervention on their mental health were related to the ways that they negotiated their family relationships its like the weight of the world went off our shoulders reported one woman before her adult son would stay with her and take over now he cant do that because wrap has taught me to stand up for myself and to be alright with telling people no and to reach out to other people instead of accepting others demands felt to be social obligations numerous women voiced how they now felt it was acceptable to voice their own desires to say no when they did want to oblige others requests other women stressed how participation in the program affirmed their individual needs amid everpresent obligations to care for family members chws had warned us that with the women we hoped to reach thats one thing you run into with women that nurture thingi take care of my family and im last the kids the family the husband and the house the chickens all come before mom or the wife or the woman does shes last in contrast commenting on her experience in our trial one participant explained one thing in the program stood out with me was something about i deserve this like i deserve a day to myself or a day to do something i havent done before and i think i needed though women faced considerable pressure to handle their family challenges independently some indicated the relief of feeling that now i can reach out and ask people its just awesome its a totally different feeling participants voiced how the group delivery of the program enabled them to see people with similar problems many women reported being reassured by the familiarity of the challenges that their fellow group members shared at the time you think im the only one going through this shared one participant but then you learn that no youre not the only one having women decide their level of participation in the group freed women from having to create group consensus about experiences strikingly participants did not frame their similarity in terms of their mental health but instead their experience of similarly challenging social conditions you meet people who have the same problems you have but in a different form in the group there were women who were working and kind of struggling some who were going to school trying to get a job there were some other women that we made these judgments that they were better off financially but still we have some of the same things i think it was good for me to see the group of people coming together and sharing on that basis removing hierarchy in the group setting not only removed judgment but also the perception of different life experiences discussion though research on idioms of distress has brought great attention to the debate inherent within the presentation of distress the few scholars who have engaged with this dynamism in therapeutic application of idioms of distress have done so outside of the us here we have examined how appropriate treatments can be identified and implemented when distress is under debate in a us setting using the example of depression and distress among women in rural appalachia we focus our discussion on three key areas 1 the dangers and possibilities engendered by expanding the categories of mental health intervention 2 how flexible medicalization can be productive to address distress under debate and 3 the potential of recoverybased interventions to offer therapeutic spaces for individualized and social distress in contrast to intervention strategies that respond to particular distress idioms or syndromes we have shown that it can be productive to engage with diverse expressions of distress and the shared conditions understood to be at its root rather than responding to one specific distress idiom such a strategy attempts to avoid the powerladen transactions highlighted in research on the idioms of distress in which only certain types and voices of distress are legitimized but in intervening upon broader experiences of distress does our approach further what medical anthropologists critique as bracket creep such a critique draws attention to how psychiatric diagnostic criteria have expanded to include more behavior as pathological and the enlargement of intervention goals to address increasingly more social problems bracket creep can transform the original meanings of distress and ultimately obscure the social causes at its root instead placing the onus of change upon individuals in the case of our intervention expanding the brackets of distress to include women who had significant symptoms of depression but who identified as down stressed or overwhelmed and only in some cases depressed enabled us to explore a variety of meanings around distress it also allowed us to reach women who described significant isolation and shared similar problems generated by difficult social conditions but engaged with services and clinical diagnoses in very different ways like most others our intervention did not focus on changing the structural causes of the inequality that played a large role in many of our participants distress however overwhelmingly our participants noted that the peerfocused nature of the group intervention and content on selfmanagement enabled them to see that their distress was not their fault nor were they alone in experiencing it participants indicated the critical intervention effect of learning to voice their distress about their social demands predominantly in terms of their gendered burden to care for family members while we do not know how such distress was received we do know the relief that women reported in stating their own needs and also reaching out for help in new ways future intervention work in the region could amplify the impact of this recovery intervention through broader strategies that address the harsh economic conditions furthering womens suffering further future research must address the needs of rural women of color whom we were challenged to reachwomen who often face even deeper intersectional stigma and spatial and socialeconomic isolation diverse stakeholders recommended that we strategically medicalize distress and intervention strategieslegitimizing distress by describing our mental health intervention as a medical necessity while avoiding the hierarchical clinically circumscribed nature typical of rural mental health services in this region our participants drew attention to the multivalent meanings of medicalization in this rural settingthe trust that can be invested in primary care providers even when they are felt to be at times overwhelmed or insufficient and the deep hesitation toward engaging with mental health providers due to the fear of being labeled as mentally ill making the case for distress and depression a medical necessity through doctors recommendation enabled women to allow themselves such care despite their considerable social demands while the location of the intervention at a medical establishment allowed women to gloss their participation in wrap as merely going to the doctor we resisted clinical categories and treatment when describing the intervention itself which though identified as evidencebased is not classified as mental health treatment we suspect that for some participants as shown in the broader literature participation in our program may have been a means to express distress whether participation in the program communicates that distress socially to others or resists dismissal by other providers in this way selective medicalization can enable the communicative ends of idioms of distress particularly in settings where social expectations limit the expression of distress the adaptations that we made to wrap based on our preliminary included delivery of wrap through chws serving as peers employing wrap in their own lives additional outreach between chw facilitators and participants the option for participants to be referred to wrap through their primary care provider and holding the program in a medical setting however our primary innovation was to employ an intervention based on recovery philosophy for a population that did not consider themselves to be mental health consumers and for whom standard clinical care is the only available treatment option yet in so doing we crossed an often unnamed boundary between intervention strategies most often applied for those with serious mental illness and those with common mental disorders however the fact that we tested wrap among a different populationone that was not only rural but also not strictly consumers with smimay account for the fact that we found no impact of the intervention with several measures traditionally used to assess the impacts of wrap like the hope scale and recovery assessment scale previous trials of wrap have included participants with more extensive involvement in community mental health centers that include recoveryfocused programming questions remain as to the longitudinal impacts of flexible medicalization for wrap participants also engaged in mental health services what is resolved in debates about distress findings from our study here do not show a resolution of debates about the terminology and labels of distress however our study does show that participants find relief in the recognition of their distresswhat is agreed is that their distress exists and deserves the attention of participants and others to attenuate such distress nor do we illuminate participants decisions postintervention to pursue further care in traditional clinical care or in recovery spaces however we suspect that the flexibility enabled in wrap selfcare planningwhich can include biomedical treatment alongside other treatment systemsmight not pose a contradiction for patients indeed research on medical pluralism in appalachia and elsewhere anthropologists have been skeptical of recovery philosophy because of its emphasis on euroamerican forms of individualistic personhood which potentially excludes collectivist models of personhood valuing relatedness and restoring social personhood through the healing process our experience with this recoverybased intervention shows its potential to offer therapeutic spaces for individualized and social distress even for a group whose gendered caregiving obligations are vital to sustaining kinship womens strong affirmation of their newfound ability to say no to family membersindicating a more individualistic notion of personhoodindicates the need to think beyond personhood as either individualistic or collectivistic instead our findings support other work demonstrating that recovery interventions must include careful consideration of how participants navigate the stresses and harness the support of their close social relationships our experience suggests the flexibility of this program to address the ways that crossculturally the disproportionate burden of domestic and relational labor is connected to women absorbing their own emotional challenges one limitation of the material presented here is our lack of focus on implementation of the adapted intervention due to the scope of the study we have not described for instance the experience of primary care providers referring participants to the program or the experience of the chw facilitators or how wrap could be delivered longterm alongside clinical care in addition though primary care providers expressed great interest in the study their busy schedules severely restricted their participation limiting our ability to fully describe implementation strategies for primary care referral our future work will concentrate on the critical implementation factors needs to support practitioners and organizations to address distress under debate in group interventions that may limit the personcentered care that has been the emphasis of previous work in addition in future work we will delve more deeply into measuring different aspects of recovery in order to understand what is salient in this cultural context future large scale trials that include an equal emphasis on effectiveness and implementation will be critical to evaluate whether recovery programs like wrap may be appropriate to address distress in wider populations such research must interrogate not only the impacts of wrap as an intervention on distress and mental health outcomes but also test how well implementation strategies can be feasible acceptable and appropriate for rural women in distress conclusion as much as research on the idioms of distress urges attention to crosscultural variability equal emphasis is placed on variation within particular cultural contextsand the ways that social position social changes and medicalization can shape multiple experiences of voicing and interpreting distress even as distress may be under debate people seek resolution for their suffering sometimes exhausting multiple options when systems for care have not adapted to the changing meanings of distress in this case study we have shown how recoverybased interventions enabling flexible interpretations of mental health can be combined with strategic engagement with healthcare institutions in order to provide options for care even when distress is under debate ii later in our project based on the advice from a new collaborator we switched to the use of the phq9 because it is consistent with dsmv symptoms of depression but more friendly for communitybased settings due to its accessible language 1 participant racial backgrounds reflect the demographics of appalachian kentucky which is a predominantly nonhispanic white population 954 people identifying as white 17 identifying as black and 13 identifying as hispanic 2 the vast majority of providers had served in different healthcare locations during the course of their careers many with experience across community mental health centers public clinics hospitals and outreach we include the text of our procedures here in the case of participants expressing extreme distress one facilitator would bring the participant outside of the room and she would talk to the participant they would ask her what can we do to support you if she needs a prompt the facilitator would ask her to identify a support person that she can call if she wants medical help the facilitator could offer to set up an appointment for her in the onsite clinic immediately or if when sessions are after regular business hours the facilitator could accompany her to the psychiatric hospital or emergency room facilities immediately adjacent to the intervention site note we never needed to use these procedures during the course of our small trial

her research explores womens health social relationships and rural mental health disparities ryan jenkins ba is a medical student at the university of kentucky college of medicine he has contributed to research on patient perspectives on pharmacotherapy and depression interventions amongst rural women as well as plausibility processing and memory encoding of facts learned from written narratives

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social ties beyond nonresident family are an important form of locationspecific capital yet very little is known about their role in residential mobility there are several ways that individuals personal relationships might be linked to their residential mobilityone of those ways is via individuals perception of their neighborhood having family and friends living close by might help individuals form attachments to their communities facilitating place satisfaction and rootedness these ties might also reflect the local areas collective efficacy a characteristic of closeknit communities whereby individuals exchange information and resources with each other thus insofar as having nearby ties is a reflection of collective efficacy a lack of ties might also signal diminished neighborhood satisfaction leading to outmobility 1 at the same time having nearby kin and friends might lead individuals to evaluate their environment differently in either case it stands to reason that proximate family and friend networks are linked to residential mobility by way of neighborhood satisfaction drawing on longitudinal data from the los angeles family and neighborhood survey and examining interneighborhood residential mobility i test the familyled migration framework for residential mobility i also examine the effect of having nearby friends on individuals decisions to stay or move out of their neighborhood in other words i examine the effect of intraneighborhood personal relationships on interneighborhood mobility subsequent analyses explore the ways that nearby family and friends impact residential mobility particularly through individuals perceptions of their neighborhood background and theory the role of nearby family and friends in residential mobility classical models of residential mobility generally focus on how individuals decisions to relocate are based on costbenefit analyses of moving versus staying individuals will consider a moveand potentially follow through on itwhen the benefits of doing so outweigh the costs in this way residential mobility and internal migration are important mechanisms for making advantageous adjustments especially housing realignments associated with life course transitions such as relationship dissolution or having children of course other factors can also inspire the decision to move including changes in employment child careschooling considerations and neighborhood and housing market conditions recently research and theory have pointed to the importance of family for longdistance moves the idea that individuals nonresident family can impact their relocation decisions is rooted in the notion that family is an important type of locationspecific capitalresources that are bound to a specific area these nontransferable assets which are maintained in shared spaces would be lost with relocation as such the magnetizing effect of family serves as an attraction for individuals to remain in an area or move elsewhere including returns to ones birth region after moving away or toward other places close to family thus having relatively few family members living in close proximity might produce less resistance to moving away compared to a community of nearby relatives in much the same way the qualitatively separate issue of having no family members nearby will also inspire a move elsewhere so i expect individuals with no nearby family members in the area to be more likely to move to a new neighborhood than those with family members nearby however people do not base social reasons for moving exclusively on family while a large amount of recent research has examined the impact of nonresident family on moving far less is known about the effect of nearby friends of course friendshipswhich are often rooted in reciprocal benefits and obligationsare also an important form of locationspecific capital indeed researchers have examined how peers and social networksgenerally speakingimpact other important life outcomes such as educational aspirations and choice of college major occupational choices and international migration these findings are not surprising because friends play an important role in individuals everyday lives through the provision of social and emotional support companionship and instrumental support however we still know relatively little about whether and how nonfamilial social ties are associated with individuals mobility this is possibly because surveys rarely ask about friends friendship is notoriously difficult to measure and the role of friendsas a form of locationspecific capitalis easily conflated with other nearby social relationships namely the family of those who have examined the relationship between nearby friendship ties and migration the measurements approaches and results have differed for example some have examined social reasons as a general motive for moving among which friends and family are included within seattle researchers found that individuals proportion of nearby friendsincluding having no friends in the area at allwas associated with mobility intentions but not actual mobility using the child development supplement of the panel study of income dynamics dawkins found that local social ties including childrens peer networks deterred residential mobility particularly for lowincome families in a british household panel study examination of how close friendships impact migration belot and ermisch found that individuals who identified up to three local friends were less likely to move over 20 miles away taken together these results support the idea that nonfamilial social ties are linked to individuals residential mobility accordingly i expect those with no nearby friends to be more likely to move to a new neighborhood than those with friends nearby the roles of family and friends for residential mobility are likely to differ not least because family members are a more prominent feature of social networks especially in the provision of emotional and instrumental support in a study of the effect of religious ties on moving away s m myers found some migrationdiscouraging effects for families without children these effects operated largely through the presence of nearby family but the findings did not hold for local friends using the same data as the current study sharp and warner found that the absence of familyas a major component of social isolationwas associated with residential mobility other factors including fear of the current neighborhood and the absence of friends were not significant in their final models of course there is likely to be some overlap between familial and nonfamilial networks in the neighborhood and consequently individuals will be less likely to move away from places with high proportions of both and possibly more likely to move away from areas with neither building on the earlier work of sharp and warner i therefore propose a separate hypothesis that the role of local friends and family for residential mobility operate in tandemand that the absence of family will reinforce the role of friends in other words the relationship between local friendship ties and residential mobility will vary based on individuals amount of nearby family because very little research has been done on the topic little is known about whether and how the role of family versus friends for residential mobility differs based on other sociodemographic characteristics particularly age which is an important correlate of social ties one study drew on a cross section of data and found that for return migration to the municipality where an individual grew up the importance of friends increased with age while the importance of family decreased these results were consistent with more general findings about the changing roles of social ties over the life course 2 still there is little reason to believe these findings would hold for the importance of local ties for intracity mobility in a densely populated urban area thus without a priori expectations i propose an exploratory question does the effect of nearby kin and friends on residential mobility differ by respondents age local ties neighborhood satisfaction and residential mobility nearby family members and friends do not operate within a vacuum in setting the groundwork for staying or leaving places are the context in which those social and familial interpersonal relationships are enactedand people form attachments to those people and places in this way personal relationships can be seen as important facilitators of neighborhood satisfaction as mesch and manor identified from the literature local social involvement in particular with friends and kin is the most consistent and significant cause of attachment to place and one common way researchers have operationalized place attachment has focused on peoples perceptions of the quality of their environment that is their neighborhood satisfaction recent research has found that the presence of local ties influences individuals perceptions of their neighborhood and having more nearby family is linked to higher neighborhood satisfaction as a form of locationspecific capital local ties can directly impact residential mobility but local ties might operate indirectly by way of neighborhood satisfaction for example the absence of local ties might affect decisions to move or stay by facilitating harsher assessments of ones overall environment and having many local ties might strengthen an individuals placebased satisfaction indeed in their concluding remarks mesch and manor asked would individuals with and without social ties but equivalent satisfaction with the local area express the same degree of attachment therefore i expect a lack of kin and friends to intensify neighborhood dissatisfaction and its subsequent effect on residential mobility the relationship between local ties and neighborhood satisfaction for residential mobility might not be so straightforward first it is possible to be satisfied with where one lives yet not be particularly attached to the place second local ties might serve as a compensating differential whereby individuals will sacrifice living in a more satisfying environment to remain close to their family and friends in the area individuals who are unhappy with their housing or neighborhood may remain merely because of their proximity to their family and friends this corresponds with classical stress models of residential mobility which argued that compounded environmental grievances usually based on lifecycle changes led to a move once a certain stress threshold was reached later models proposed that environmental dissatisfaction was the mechanism through which lifecycle changes led to subsequent mobility thus in addition to the mediation effect i also expect nearby family and friends to moderate the relationship between neighborhood satisfaction and residential mobility specifically i expect fewer nearby kin and friends to lead to an increased likelihood of moving among those who report greater dissatisfaction with their neighborhood altogether adapting recent calls to incorporate nonresident family into migration models i examine the importance of nearby family and friends on local residential mobility i also explore whether individuals assessment of their environment varies based on whether or not they have a nearby kin network andor social circle following from the research five main hypotheses are considered hypothesis 1 individuals with no nearby family members in the area will be more likely to move to a new neighborhood than those with family members nearby hypothesis 2 individuals with no nearby friends will be more likely to move to a new neighborhood than those with friends nearby hypothesis 3 the relationship between local friendship ties and residential mobility will vary based on individuals amount of nearby family hypothesis 4 a lack of kin and friends will intensify neighborhood dissatisfaction and its subsequent effect on residential mobility hypothesis 5 having fewer nearby kin and friends will lead to a higher likelihood of residential mobility among those who report greater dissatisfaction with their neighborhood to test these hypotheses i draw on two waves of panel data from los angeles countythe region includes 88 separate cities and many unincorporated areas spread over 4083 square miles the los angeles family and neighborhood survey sample includes a diverse set of neighborhoods varying from densely populated central city areas to relatively rural mountain and desert areas to the more suburban neighborhoods of the san fernando valley and the pacific coast the high rates of residential mobility coupled with social and spatial inequality within the dense urban geographically sprawling and ethnically diverse los angeles landscape make it an interesting context for studying local ties and residential mobility data and method this study draws on restrictedaccess data from the los angeles family and neighborhood survey a twowave panel survey based on a diverse stratified random survey of 65 census tracts in los angeles county the first wave of data captured information from 3085 households in los angeles between april 2000 and january 2002 with 2620 primary respondents the data were designed to represent adult residents of los angeles county at the time of the survey data collection was based on a multilevel stratified sampling design that sampled tracts within strata blocks within tracts households within blocks and respondents within households with an oversampling of individuals in poverty as well as households with resident children using state and county administrative data los angeles countys urban research division developed three strata based on tractlevel estimates of percent in poverty in 1997 these strata were used for the tract sampling based on tract poverty levels the primary respondents were fulltime noninstitutionalized residents of los angeles county who spoke either english or spanish residential mobility was among the primary topics the survey was designed to explore for a detailed report on the lafans design sampling and implementation see sastry et al wave 2 data were collected between august 2006 and december 2008 and captured reinterview information from primary respondents at wave 1 among those in the original sample 1177 individuals were interviewed for wave 2 all panel respondents who still lived in los angeles county were eligible for an inperson interview regardless of where they lived in los angeles county individuals from the original sample who were living outside los angeles county at wave 2 were eligible for a telephone interview to tap into tractlevel attractions data from both waves were linked to the los angeles neighborhood services and characteristics data the lansc is a database of contextual data files for los angeles county with information from a variety of sources on neighborhood services population characteristics housing characteristics family and household socioeconomic status and social services and facilities owing to cases with missing data the final sample for the current analysis is 1128 retention differed along several sociodemographic characteristics employed respondents women and those with higher education and income were more likely to participate in both waves of data collection individuals who reported being single at wave 1 were less likely to participate in the followup survey wave panel weights account for nonresponse attrition between waves and oversampling based on poverty status and children in the household 3 in addition to be consistent with the lafans sampling strategy the census tracts use 1990 tract boundaries variables all independent variables in the models were measured at wave 1 the dependent variable interneighborhood residential mobility was measured retrospectively at wave 2 table 1 presents descriptive statistics for the entire sample which was about half female and ranged in age from 21 to 92 years summary statistics are also presented separately for nonmovers and movers additional bivariate analyses are discussed in the results section but not shown in tables dependent variable the dependent variableinterneighborhood residential mobilityidentified whether primary respondents relocated to a different census tract between waves 1 and 2 4 independent variables the interviewer prefaced items about nearby kin and friends with the following leadin my next questions are about relatives or friends who live in this neighborhood but who do not live with you and to provide some geographic standardization respondents were asked to think of their neighborhood as the block or street you live in and several blocks or streets in each direction the items followed how many of your relatives or inlaws live in your neighborhood would you say none a few many or most the same question with the same response options was then asked about nearby friends because of the qualitative difference between having even some nearby kin and friends compared with having none results are also presented for a dichotomous measure that identifies the presence versus absence of nearby relatives and friends additional measures provided information at the individual household and neighborhood levels at the individual and household levels i included information on respondents age and sex respondents raceethnicity was coded as white black latino asian or another racialethnic classification respondents maritalcohabiting status marks whether the individual was married cohabiting or neither an ordered measure indicated the respondents number of children separate dichotomous variables reported whether or not the respondent was enrolled in school andor was employed an ordered measure for education identified individuals as having completed less than high school high school or the equivalent some college college or a postgraduate degree respondents selfreported health was classified as poor fair good very good or excellent a logged measure of household income was taken in the year prior to wave 1 housing tenure indicated whether the residential unit was owned else to control for the fact that individuals who reside in an area for a longer period of time likely develop social ties in the area an additional measure captures the duration of time at their residence at wave 1 this measure is based on the interview year and the year the respondent reported moving into their current residence individuals selfreported neighborhood satisfaction indicated whether the respondent was very dissatisfied dissatisfied neutral satisfied or very satisfied with their neighborhood a tractlevel variable measured the neighborhood poverty rate in 1997 the tractlevel estimates of percent in poverty correspond with tracts that were very poor poor and nonpoor based on census data several tractlevel variables identified other neighborhood dynamics in 2000 population density was measured as the tracts population divided by its area in square miles to facilitate interpretation the measure was divided by 1000 a proportional measure of overall tract racialethnic diversity is based on the formula diversity 1 a neighborhood context variable tapped into the median household price in the tract residential stability identified the percentage of individuals in the neighborhood living in the same residence in 2000 as in 1995 analytic strategy to test the first two hypotheses model 21 presents a logistic regression model with direct effects for all independent variables in addition to exploring individuals proportion of local ties model 22 uses dichotomous measures for the presenceabsence of nearby family or friends to test hypothesis 3 model 23 includes an interaction between nearby family and nearby friends to test hypothesis 4 table 3 presents a khb decomposition of the effect of local ties on residential mobility using neighborhood satisfaction as the mediator the khb mediation analysis compares the coefficients of two nested nonlinear probability models controlling for all covariates in table 2 the method decomposes the total effect of the independent variables nearby kin and friendship ties into direct and indirect effects on residential mobility the resulting coefficients are unbiased by issues related to the crossmodel comparisons of nonlinear models models 31 and 32 present the mediating effects of the proportion of nearby relatives and friends respectively models 33 and 34 assess the mediating effect of the absence of nearby family and friends to test hypothesis 5 a final model includes an interaction between nearby social and family ties and neighborhood satisfaction the results of additional analyses to address the exploratory question are discussed in the text but not presented in additional tables these models included all of the controls in table 2 model diagnostics for all multivariate analyses there was no severe multicollinearity in the models analysis of a correlation matrix indicated that none of the observed relationships between the independent variables in the models were very strong the strongest relationship was between education and median tractlevel housing costs results descriptive statistics and bivariate analyses because of the wide time frame between waves much of the sample moved to a new tract between waves 1 and 2 the average proportion of nearby relatives and friends is small the percentage of individuals with no nearby relatives or friends is more substantial this discrepancy is likely due to the distribution of the measures for nearby family and friends as mentioned descriptive statistics for the rest of the independent variablesincluding differences between movers and nonmoversare presented in table 1 in bivariate results individuals proportion of nearby relatives is significantly and positively associated with their proportion of nearby friends the proportion of nearby friends is positively associated with neighborhood satisfaction whereas the relationship between neighborhood satisfaction and nearby family is negative the baseline effect of nearby family on residential mobility is nonsignificant however the proportion of nearby friends is negatively associated with moving away multivariate analyses table 2 presents the results of a logistic regression for the relationship between local ties and residential mobility while there was no direct support for hypothesis 1 that having fewer relatives or friends nearby would be associated a higher likelihood of mobility having no nearby relatives is associated with a higher likelihood of moving based on these results there is no direct support for hypothesis 2that nearby friends are associated with interneighborhood residential mobility net of nearby family however the results of model 23 indicate that the relationship between nearby friends and residential mobility is attenuated by nearby family in other words friends deter interneighborhood mobility when individuals have fewer family members living nearby in auxiliary analyses the interaction between individuals proportion of nearby friends and the absence of nearby relatives is also significantly associated with moving away this highlights the contextual importance of friends for residential stabilitythey are indeed important particularly when there are few or no relatives living nearby the results in table 3 are based on the khb test for mediation based on the results of each model in table 3 there is no evidence that individuals proportion of nearby kin and friends fully or partially mediate the relationship between neighborhood satisfaction and mobility therefore the results do not provide support for hypothesis 4 table 4 displays findings in support of hypothesis 5 the direct effect of nearby friends is significant indicating that having more nearby friends is associated with a lower likelihood of moving away however the interaction term between nearby friends and neighborhood satisfaction is also significantso friends attenuate the relationship between neighborhood satisfaction and residential mobility at the lowest levels of neighborhood satisfaction an increase in nearby friends leads to a lower likelihood of moving away a graph of the average marginal effects of social ties on moving at each level of neighborhood satisfaction is presented in figure 1 results for interactions between no nearby familyfriends and neighborhood satisfaction are presented in supplemental appendix b the results for the control variables are in line with expectations based on previous research and theory the wellknown correlates of movingage home ownership and residential durationare all associated with a significantly lower likelihood of moving neighborhood satisfaction and tractlevel residential stability are also associated with staying last i examined interactions between nearby kin and friends and age to address my openended exploratory question about the changing role of familyfriends with age because the control variable results to address the question do not differ from those in other models i only discuss the substantive results in the text however all additional analyses are available upon request the results indicate that the role of nearby family members for residential mobility decreases with age these same results did not hold for nearby friendship ties sensitivity analyses a number of sensitivity analyses were run to check the robustness of the results first the primary independent variablesnearby kin and friendswere run as dummy variables although the continuous variables were not significant in the models testing hypothesis 1 the categorical versions indicated that the lowest proportion of nearby family was associated with a significantly lower likelihood of moving this finding helped justify the analytic decision to explore the dichotomous versions of nearby kin and friends the results of the mediation analyses were similar when using the continuous versus categorical measures of nearby kin and friends the only difference was that the mediating role of nearby family for residential mobility was very marginally significant for the moderation analyses the highest proportion of nearby friends significantly moderated the relationship between neighborhood satisfaction and moving when compared with having no nearby friends analyses run using categorical measures of individuals health and education did not lead to any changes in the substantive results discussion most research on personal relationships and internal migration has centered on the role of family with little attention paid to nonresident friends i examined the role of both family and friends for interneighborhood residential mobility within los angeles county providing a test of recent familybased migration frameworks for shorter distance mobility i also examined how individuals assessments of their neighborhoods visàvis their nearby kin and friends are linked to residential mobility the findings indicate that not having any nearby family is associated with a higher likelihood of leaving the neighborhood the role of friendships while less salient was nevertheless important but only as it mitigated the effect of family ties on residential mobility thus local tiesa component of locationspecific social capitalmight help retain individuals in their communities but in a less straightforward manner than anticipated still the results are in line with recent theorizing on the magnetic role of family for individuals to remain in an area or move elsewhere although the results did not point to any mediating effects they did suggest that having nearby friends moderates the relationship between neighborhood satisfaction and moving away researchers have consistently found that locationspecific capital matters for remaining in an area and the results of this study help explain why individuals might evaluate their community differently when they have social ties nearby choosing to remain in an otherwise unsatisfying environment to remain near their friends local social ties might also reflect a communitys social cohesion the social norms and bonds that enable individuals to trust each other these findingsalong with the results for the covariateshave important implications for community sociology more broadly in their identification of determinants of rootedness in israel mesch and manor drew on the competing concepts of the limited liability neighborhood and the liberated neighborhood the limited liability notion argues that place attachment is based on local relationships developed through residing in an area over time on the contrary the competing concept of the liberated neighborhood posits that social ties now more geographically widespread than ever before are less important determinants of place attachment than other factors namely individuals assessments of their environment the common thread in both arguments is that both consider place attachment in the context of individuals personal relationships my results support their notion of the limited liability neighborhood in that local ties were associated with residential mobility both directly and also indirectly by way of neighborhood satisfaction i provide some evidence that local relationshipsdeveloped over timefacilitate place satisfaction and thereby neighborhood residential stability building on the concept of limited liability i also found support for the longstanding notion that cumulative time in an area helps establish individuals rootedness homeownershipwhich is often linked to place attachmentwas associated with a lower likelihood of leaving the neighborhood in a more obvious way the results also show that longer duration of residence is associated with a lower likelihood of moving a final broad implication of these findings is that individuallevel characteristics are associated with neighborhood satisfaction and subsequent mobility in ways that tractlevel characteristics are not consistent with kasarda and janowitz and more recent findings my findings suggest that individuallevel characteristics and perceptions are stronger predictors of residential mobility than other neighborhoodlevel factors limitations and directions for future research although these findings help identify the ways social and family ties frame sociospatial constraints and opportunities for individuals residential mobility they are subject to several caveats one major limitation of the study is the crude measurement of individuals local kin and friends although i am confident that individuals can approximatewith some reliabilitytheir proportion of nearby close friends and relatives there is no way to ascertain whether and how my results would differ from those using other measurement approaches such as a name generator or asking respondents to enumerate their network ties in the absence of such data i can only hope that future research will build on these findings with stronger measures of individuals local ties a related avenue for future research might explore whether and how the quality of individuals local ties is associated with moving away for example some individuals might move away from negative or ambivalent relationships with their friends and family however recent research on individuals selfreported motives for migration suggest that this is a rare occurrence i was also unable to discern between strong and weak social ties which tend to differ in purpose function and importance weak ties are often linked to less social support in their joint analysis of friendship formation and residential mobility belot and ermisch found that identifying up to three close local friends was associated with a lower likelihood of moving 20 milesyet the frequency of interactions with those friends was not associated with moving an additional limitation is that the survey was conducted in los angeles county which means the results are not generalizable to other parts of the united states or elsewhere however at best family and friendship ties should matter lessif at allin a singlecity study because there are fewer obstacles regarding communication and interaction when compared with longer distance moves away from friendsfamily the results might also be biased because of differences in individuals perceptions of their neighborhood boundaries which may not coincide with census tracts however as part of the interview respondents were asked to think of their neighborhood as the block or street you live in and several blocks or streets in each direction this provides some degree of geographic standardization for responses that require application of neighborhood boundaries there are also issues with endogeneity for example individuals who are planning to move might invest less effort into making nearby friends it might be that those who have fewer friends or strained family relationships have similar personality characteristics to those who are more mobile conclusion local ties are meaningful sources of locationspecific capital that can exert influence on individuals residential mobility as buffers of the perceived environment local ties are also indirectly linked to residential mobility through residents neighborhood satisfaction at least within los angeles county it is worth noting that a move does not necessarily signal a problem with a neighborhood indeed the results support the idea that individuals with fewer local ties might in fact be moving closer to family and friendship ties elsewhere in terms of policy neighborhood development programsspecifically those in high turnover areascould help facilitate the creation and maintenance of social support among community members particularly emphasizing policy interventions and strategies to target socially isolated individuals at the same time these findings do challenge longtime notions that facilitating the development of local ties will lead to greater place satisfaction the results suggest that perceptions of the environment might differ based on who lives nearby relationships rather than about relationships themselves as such references to kin and friends denote the presence of nearby personal relationships 2 the term social ties broadly refers to nearby ties to both kin and friends 3 the los angeles family and neighborhood survey staff created an attrition adjustment based on the inverse of the predicted probability of nonresponse the logistic regressions included wave 1 predictors of nonresponse in wave 2 among respondents who were not known to be ineligible for an interview at wave 2 4 the interview method was different and there was less information collected from those who moved outside of los angeles county by wave 2 so they were not included in these analyses in addition the lafansallocated data weights apply only to panel respondents living within los angeles county relatedly several respondents relocated between waves but remained within the same tract i did not consider these respondents movers based on my operationalization of residential mobility at the shortest distance these individuals could have relocated into a different apartment within the same building or at the most extreme it could be clear across the neighborhood however sensitivity analyses indicated that the results did not hold for local moves that took place within the neighborhood acknowledgments the author would like to thank clara mulder christine peterson megan thiele and the four anonymous reviewers for their advice and helpful comments on early versions of the manuscript funding the author disclosed receipt of the following financial support for the research authorship andor publication of this article this article is based on research funded by the european research council under the european unions horizon 2020 research and innovation program orcid id brian joseph gillespie 29977179 supplemental material supplemental material for this article is available online notes 1 this article is about proximity as an important prerequisite forand facilitator ofclose personal

residential mobility is a complex process that includes individual agency and constraints as well as institutional and structural forces in the united states issues of income social class raceethnicity gender and ability all play a dynamic role in shaping who can move and who can stay in their homes and neighborhoods as it is often overlooked in migration studies researchers have recently called for a stronger focus on the role of personal relationships in individuals mobility behavior eg mulder 2018 although housing adjustments and arearelated reasons are the most common motives for shortdistance moves social reasons are also important thomas gillespie and lomax 2019 in particular friends ie

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3 background globally an estimated 703 million people were aged 65 years or above in 2019 1 population is aging rapidly in many parts of the world including bangladesh a south asian country where the current legal provision identifies individuals 60 and over as older adults 2 according to the estimates for 2019 the population of 60 in bangladesh was over 13 million which is projected to increase nearly threefold to 36 million in 2050 3 along with several chronic conditions mental disorders including depression are prevalent in older ages 4 data from the global burden of diseases and the world health organization indicate about 264 million people aged 60 years and above have depressive symptoms 56 despite the outrageously high prevalence of depression among older adults in lowand middleincome countries compared to highincome countries it has received fairly low attention in many lmics including bangladesh 7 the emergence of coronavirus disease 2019 pandemic which has already taken 1393227 lives and added more than 58 million to the global burden of disease 8 has aggravated the psychological toll on the general population particularly among the older population who are at an increased vulnerability to severe illness and mortality historically the mental wellbeing of the population has been disrupted in largescale outbreaks and pandemics for example during the h 1 n 1 influenza virus outbreak in 2009 anxiety among the uks general population increased by 1030 9 similarly during the severe acute respiratory syndrome epidemic psychiatric morbidities depression and stress disorder increased 10 furthermore during the ebola outbreak in 20132016 in guinea liberia and sierra leone the psychosocial wellbeing of the people was seriously hampered 11 likewise stress anxiety depressive symptoms insomnia denial anger and fear are associated with the covid19 12 in bangladesh even prior to the onset of the covid19 pandemic mental health issues have not received attention in policy discourse recognizing the high burden of mental health disorders recently the government of bangladesh passed the mental health act 2018 but the implementation of this act seems challenging because of the fragile health system and inadequate mental health professionals 13 there is a lack of adequate mental health services in the first place but even those limited services are underutilized because the social stigma and stereotypes regarding mental illness discourage people from acknowledging their symptoms or seeking healthcare having said that the ongoing covid19 pandemic may have seriously aggravated the mental health conditions among bangladeshi older adults for several reasons to be noted here first with over 447000 covid19 confirmed cases and 6388 covid19related deaths as of 23rd november 2020 bangladesh is ranked 24th country in terms of the highest number of covid19 confirmed cases 8 second older adults are at increased risk of severe illness and mortality due to covid19 than younger age groups 14 third the high prevalence of noncommunicable chronic conditions such as hypertension obesity diabetes cardiovascular disease and chronic lung disease and comorbidities among bangladeshi older adults 15 increases their risk of severe health outcomes like poor selfmanagement of conditions poor quality of life and increased hospitalizations 16 moreover the unplanned lockdown and subsequent difficulty in accessing food health care medication and psychological support as well as social distancing and isolation could have exacerbated anxiety and depression in this particular group of population 1718 all these factors can interplay to worsen the mental health conditions among older adults in bangladesh amid this pandemic amidst the covid19 pandemic some studies from bangladesh have shed light on depressive symptoms and mental health among university students 19 and the general population 20 but to our best knowledge no studies have been undertaken to study depressive symptoms among older adults in bangladesh who are most vulnerable to the pandemic while such evidence is lacking in the bangladeshi context evidence from lmics shows that the prevalence of depressive symptoms and anxiety was overwhelmingly high among older adults during the covid19 pandemic 21 22 23 a 2019 study reported a 369 prevalence of depressive symptoms among bangladeshi older adults 24 the current study on the same topic amid the covid19 pandemic may complement our understanding in terms of correlates of depressive symptoms among the older population previous research from lmics including bangladesh noted several associated factors such as age low socioeconomic status presence of single or comorbid noncommunicable disease sleep disturbances and so forth 25 26 27 28 however our understanding of correlates specific to covid19 is lacking therefore it is of utmost importance to study depressive symptoms among the most atrisk population during the ongoing pandemic in this light the present study aimed to determine the prevalence of depressive symptoms and its associates among older adults of bangladesh the findings from this study might help relevant stakeholders in designing and implementing multisectoral approaches to address the mental health needs of this vulnerable and neglected group of people methods study design and participants given the viruss highly contagious nature and the subsequent risk of spreading through facetoface contact this crosssectional study was conducted remotely through telephone interviews the study was conducted by the aureolin research consultancy and expertise development foundation in october 2020 the primary challenge for this study was to develop a sampling frame to select participants and thus we utilized our preestablished registry which included households from all eight administrative divisions of bangladesh as a sampling frame considering 50 prevalence with a 5 margin of error at the 95 level of confidence 90 power of the test and 95 response rate a sample size of 1096 was calculated however 1032 approached eligible participants responded to the study with an overall response rate of approximately 94 based on the population distribution of older adults by geography in bangladesh we adopted probability proportionate to size approach to select older adults in each division 2 stratified random sampling technique was followed to select the targeted number of households from each administrative division one eligible respondent was interviewed from the sampled households in case of more than one eligible participant in a selected household the oldest one was interviewed the inclusion criterion was the minimum age of 60 years and the exclusion criteria included adverse mental conditions a hearing disability or inability to communicate measures outcome measure the primary outcome of the study was depressive symptoms measured using the 15item geriatric depression scale a widely used scale for measuring depressive symptoms among older adults in both clinical and community setting 29 briefly each item in the scale is measured as yesno questions after reverse coding of some negatively worded items a cumulative score of the 15 items with ranges 015 is calculated the total score was dichotomized into probable absence or presence of depressive symptoms 27 the gds15 scale has previously been validated and used among the bangladeshi older population 24 we also found it to be a reliable scale indicated by the high internal consistency among our study participants explanatory variables explanatory variables considered in this study were age sex marital status literacy family size family monthly income residence occupation living arrangements financial dependence on family for a living walking time to the nearest health center problem in memory or concentration presence of preexisting medical conditions feeling concerned about covid19 feeling overwhelmed by covid19 difficulty in getting food medicine and routine medical care during covid19 difficulty in earning during covid19 feeling of loneliness and isolation frequency of communication during covid19 receiving any financial support during covid19 and source of covid19related information the definition and description of the explanatory variables are presented in table 1 data collection tools and techniques a pretested semistructured questionnaire was used to collect the information through a telephone interview data collection was accomplished electronically using surveycto mobile app by trained research assistants recruited based on previous experience of administering health surveys in the electronic platform the research assistants were trained extensively before the data collection through zoom meetings the english version of the questionnaire was first translated to bengali language and then back translated to english by two researchers to ensure the contents consistency the questionnaire was then piloted among a small sample of older adults to refine the language in the final version the tool used in the pilot study did not receive any correctionssuggestions from the participants in relation to the contents developed in the bengali language statistical analysis the distribution of the variables was assessed through descriptive analysis given our variables categorical nature chisquare tests were performed to compare differences in the prevalence of depressive symptoms by explanatory variables with a 5 level of significance we used binary logistic regression models to explore the factors associated with dichotomized depressive symptoms the initial model was run with all potential covariates and then using the backward elimination criteria with the akaike information criterion final model was selected adjusted odds ratio and associated 95 confidence interval are reported the area under the curve and hosmerlemeshow test indicate that our model fits the data well all analyses were performed using the statistical software package stata we found that the participants in the highest income category had nearly 60 lower odds of depressive symptoms than those in the lowest income bracket financial dependency as indicated by dependency on family members and receiving financial support during the pandemic was associated with higher odds of depressive symptoms participants with preexisting medical conditions had 91 higher odds of depressive symptoms and those living at distant from health facility had 53 higher odds than their counterparts results characteristics of the participants factors associated with depressive symptoms social isolation captured in terms of living alone less frequent communication during pandemic perceived loneliness and isolation from others was associated with higher odds of depressive symptoms discussion to the best of our knowledge this is the first nationwide study assessing depressive symptoms among the older adults in bangladesh during this covid19 pandemic compared to the 2019 prepandemic prevalence estimates of 369 among bangladeshi older adults 24 our study reports a 32 point increase in depressive symptoms which could be a proxy measure to suggest the troll of the ongoing pandemic on older adults mental health the prevalence of depressive symptoms reported in this study is relatively higher compared to prepandemic estimates from bangladesh 2530 india 31 and pakistan 32 however a recent online survey among bangladeshis aged 18 and above conducted during the covid19 pandemic reported a 472 prevalence of depressive symptoms quantified using depression anxiety stress scale 21 20 notably in that study almost three in five participants were students and one of the eligibility criteria was bangladeshi citizens and not explicitly those residing in bangladesh hence it could be biased by bangladeshi nationals abroad who are likely to experience greater emotional stress due to changing immigration policies amidst the pandemic international travel restrictions and family members wellbeing back home additionally we also believe that our prevalence estimates are underreported due to the phone interview technique as participants might have felt it difficult to elaborate and record their responses by phone 3334 the statistically significant correlates in our study could be broadly categorized into three themes economic status health status and social connectedness poor socioeconomic factors such as lower family income financial dependence on family and receiving financial assistance during the pandemic were associated with higher odds of depressive symptoms notably there is consensus in the literature regarding the protective role of higher ses against depression 2526 the underlying mechanism linking depression with ses is multitude and complex higher ses reduces everyday living stress by ensuring better access to daily needs including food housing and transportation it also means affordability and access to healthcare including mental health services 3536 ses is also a way to establish social prestige social network and selfesteem 3738 financially selfdependent individuals are endowed with such resources that help to buffer the impact of stress on depression relatedly and consistent with previous studies among older populations 252628 we found that being distant from a health facility increased the likelihood of depressive symptoms with the background information that owning a private motor vehicle is within the privileges of the rich in bangladesh being distant was an indication of difficulty in accessing health services during the covid19 time residing far away from health facility also means easily and timely inaccessible diagnostics preventive and curative services for covid19 and for other conditions which could have further aggravated the stress among our study population given that they are aware of their vulnerability since the news is widespread that both case fatality and severity is more in older people like the cultures of many other south asian countries in bangladesh older family members are revered and cared for by family members nevertheless abuse and abandonment cases are also increasing especially when children view their older parents as financial burdens 3940 the lockdown imposed by the bangladeshi government to curb covid19 spread in the country caused economic turmoil among many bangladeshi families which could have also impacted the caregiving and providing for older family members thus our participants financially dependent on family may have experienced changes in family caregiving and increased conflict which may have impacted their mental wellbeing 26 lack of or inadequate social connectedness indicated by living alone less frequent communication with friends and family during the pandemic and perceived loneliness and isolation meant increased vulnerability for depressive symptoms which is in line with previous studies in china pakistan and bangladesh 254142 there is widespread consensus in the literature that social connectedness causally protects and promotes mental health 43 social connectedness impacts mental health through mechanisms involving promoting healthy behaviors access to health and buffering stress 4445 the unplanned lockdown and social restriction amid the pandemic contributed to the lack of social interactions and family visits increasing the emotional and psychological stress preexisting medical conditions were positively associated with depressive symptoms among our participants which is in line with previous studies that noted higher stress anxiety and depression among older adults with noncommunicable chronic conditions 46 physical and mental health are overlapping domains poor mental health is a risk factor for chronic physical conditions and vice versa 4748 both poor physical and mental health have many common risk factors such as those related to lifestyle that explain the overlap 49 furthermore in a resourceconstrained setting such as bangladesh people with preexisting medical conditions who need routine medical checkup and medications may frequently worry about being unable to access those essential needs 50 and that worry could have been worsened during the pandemic due to prolonged shutdown and transport restriction and subsequent critical shortages of drugs supply and shutdown of health centers 51 in the light that people with preexisting medical conditions are vulnerable to covid19related deaths 16 it is logical to assume that our participants with an underlying condition are at more risk of adverse health outcomes policy implications the findings of the current study also supported by previous studies documenting highly prevalent depression among older bangladeshis have significant policy implications for combating and preventing depressive symptoms among older adults in bangladesh both during and after the covid19 pandemic our findings also suggest the need of psychosocial support for older adults from lowincome families and living alone was at risk additionally existing mobile telehealth facilities may be expanded to include targeted psychological counseling to the older adults who are poor having preexisting noncommunicable chronic conditions who depend on family caregiving and lives at distant from public health care facility increasing awareness of mental health issues among family members may be important to identify symptoms and encourage treatmentseeking and medical adherence and open dialogues on depression to reduce stigma finally to sum up the government of bangladesh should call on the findings of this study to achieve the sustainable development goals aimed to reduce mental health problems through promotion and prevention and providing comprehensive and social care in communitybased settings 52 strengths and limitations of the study this is the first nationwide study covering all the eight administrative divisions of the country and providing an insight into prevalent depressive symptoms among bangladeshi older adults amid this covid19 pandemic however our study has some limitations as well first we prepared our sampling frame based on the available householdlevel information in our data repository thus selection bias is possible second in the absence of prepandemic estimates we cannot assert that the increased prevalence of depressive symptoms noted in our study could be attributed to the covid19 pandemic conclusion the present study found a high prevalence of depressive symptoms amidst this pandemic among older adults in bangladesh which needs urgent attention from stakeholders various associated factors could be intervened managed and solved by taking appropriate measures otherwise the burden of depression may lead to a high cause of cognitive dysfunction among bangladeshi older adults we also suggest the need for screening of depressive symptoms among the most vulnerable group such as people with preexisting medical conditions where health care providers can intervene to avert the worsening of health condition appendix 1 see fig 1 availability of data and material the data are available on reasonable request from the corresponding author prevalence of depressive symptoms overall 401 of the participants had depressive symptoms the bivariate association between depressive symptoms and different explanatory variables are shown in table 3 the prevalence of depressive symptoms was significantly higher among the oldest age group ethics approval the institutional review board of the institute of health economics university of dhaka bangladesh approved the study protocol and the guidelines of the declaration of helsinki were followed in every stage of the study consent to participate all participants enrolled in the study provided voluntary verbal informed consents

purpose depression one of the most common mental disorders is upsurging worldwide amid the ongoing coronavirus disease 2019 covid19 pandemic especially among the older population this study aims to measure prevalent depressive symptoms and its associates among older adults amid the covid19 pandemic in bangladesh methods this crosssectional study was carried out among 1032 older bangladeshi adults aged 60 years and above through telephone interviews in october 2020 we used a semistructured questionnaire to collect data on participants sociodemographic and lifestyle characteristics preexisting medical conditions and covid19related information meanwhile depressive symptoms were measured using the 15item geriatric depression scale gds15 the binary logistic regression model was used to identify the factors associated with depressive symptoms results twoinfive participants showed depressive symptoms on the gds15 scale poor socioeconomic characteristic such as low family income dependency on the family for living recipient of financial support during the pandemic was associated with higher odds of depressive symptoms participants with preexisting medical conditions had 91 higher odds of depressive symptoms social isolation captured in terms of living alone aor 211 95 ci 111401 less frequent communication during pandemic aor 155 95 ci 107226 perceived loneliness aor 225 95 ci 147345 and isolation from others aor 245 95 ci 162370 were associated with higher odds of depressive symptoms conclusions our study found a sizeable proportion of study participants with depressive symptoms amidst the ongoing pandemic the findings of the present study call for the urgent need for mental health support package targeting this vulnerable group of population

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introduction wellbeing among elderly citizens is a significant contemporary theme according to the world health organization population aging and urbanization are two global trends that together are major forces shaping the twentyfirst century 1 urban growth and an aging population form the crux of the current global demographic 2 like the broader population the worlds elderly citizenry continues to become more urbanized 3 increasingly urban research is paying attention to the health of elderly people health encompasses more than the absence of diseasemental and social wellbeing are significant contributing factors preserving and developing biological physiological and mental functions as well as social activity as the population ages is a dynamic process 4 health includes being recognized and valued in a social context social interaction comprises unacknowledged rituals tacit understandings covert symbolic exchanges impression management techniques and calculated strategic maneuverings 5 facetoface interaction of even the simplest sort is a socially intricate operation 5 public space is an important sphere in which people can maintain a sense of connectivity and social engagement in their later years it can provide psychological comfort and motivate social behavior former research indicates that an agefriendly city offers a supportive environment that enables residents to grow older actively within their families neighborhoods and civil society and offers extensive opportunities for their participation in the community 67 several approaches to defining aging exist in prior research chronological age like sex and race is a means by which individuals automatically categorize others 89 cues to age include physical appearance like hair and facial morphology as well as verbal and nonverbal communication 10 11 12 the who lends credence to the rising number of residents aged 60 years or over 13 neugarten distinguished the youngold and the oldold 14 he finds stereotypes about the elderly arise from observing the oldold and that these stereotypes are overgeneralized to the youngold 1415 numerous studies demonstrate that older adults are not always perceived as a homogeneous group 15 16 17 18 19 20 21 this paper focuses on the youngold who predominantly make up the activeelderly with relatively good health and who frequently use public space in urban areas urban public space can be an elderlyfriendly environment suitable for addressing and accommodating the challenges facing an aging population some projects however ignore the real needs of the elderlynotably elderly women gender differences show that beyond the biological differences it is culture with its social structure including division of genderrelated roles societal functions and social status that has been a more influential factor in determining gender differences in quality of life 22 elderly women have distinct physical and psychological features they generally have as little as 3768 of the muscle strength of males 23 in later life men can gradually lose an inch in height women may lose about two inches 24 loss of height results in a lower center of gravity making it difficult for elderly women to control physical balance biological behavioral and environmental factors all contribute to the global higher life expectancy of women 25 men die younger in all countries 2627 elderly women have more problems performing the activities of daily living and have a higher risk of inflammatoryrelated diseases 28 in addition elderly women often suffer more psychological pressure a sense of inferiority and alienation than men 29 according to wangs research the proportion of urban elderly women who feel lonely in social situations is up to 2309 conversely the same holds true for about 1686 of urban elderly men 29 this indicates that elderly women experience more negative social psychology than their male peers aging is a complex process encompassing both personal and social factors 30 social health includes interpersonal ties and the degree to which individuals are involved in their community 31 outside activities are beset with challenges for elderly people who encounter more hazards than the younger population 32 on an accessibility front once spaces are designed to accommodate the elderly they become more userfriendly for all groups 33 conceptualizing public spaces as places of aging facilitates a clear encouragement for the elderly to broaden their spheres beyond private spaces this is a vital opportunity to promote health through the benefits of outdoor activity as part of a daily routine 34 qualitative studies have shown that older adults and people with disabilities have higher demands on accessibility orientation visual relationship speed and resting possibilities 3536 beijing is the site of this case study the capital of china the city is home to more than 21 million residents and 16 urban suburban and rural districts 37 as of 2020 the elderly population in beijing has risen to 29 million 38 around 44 million population age between 55 and 75about 21 of the total population 38 with such a highdensity elderly population it is vital to explore how the public space is shaped in the metropolis three communities of beijing have been targeted community baiwanzhuang community luyuan and community jianshebudayuan community baiwanzhuang and luyuan are both located at the west city district this district covers the western half of the old city and is home to approximately 1 million inhabitants highdensity communities historical streets and modern commercial plazas form the districts physical environment community jianshebudayuan is situated in the haidian district haidian is the education center of the city consisting mostly of universities and research institutions community baiwanzhuang was constructed in the 1950s it is filled with twisting lanes and smallscale neighborhoods the houses are laid out in strange and complicated patterns somewhat akin to a labyrinth 39 communities luyuan and jianshebudayuan were both constructed in the 1990s they represent relatively modern communities with modern urban design and space shaping modalities the rationale behind the case study selections includes three aspects firstly the selected communities are located in the densely populated districts of beijing city the trend of population aging in the districts is on the rise 38 the communities can work as typical cases to explore older adults wellbeing secondly according to the latest detailed regulatory plan for the functional core area of the capital the selected communities are included in the priority renewal areas 40 thirdly public spaces of the selected communities are relatively old and staleness there is an urgent need to improve quality to shape an agefriendly urban environment figure 1 twisting lanes and smallscale neighborhoods the houses are laid out in strange and complicated patterns somewhat akin to a labyrinth 39 communities luyuan and jianshebudayuan were both constructed in the 1990s they represent relatively modern communities with modern urban design and space shaping modalities the rationale behind the case study selections includes three aspects firstly the selected communities are located in the densely populated districts of beijing city the trend of population aging in the districts is on the rise 38 the communities can work as typical cases to explore older adults wellbeing secondly according to the latest detailed regulatory plan for the functional core area of the capital the selected communities are included in the priority renewal areas 40 thirdly public spaces of the selected communities are relatively old and staleness there is an urgent need to improve quality to shape an agefriendly urban environment figure 1 presents the photos of community baiwanzhuang community luyuan and community jianshebudayuan this paper focuses on social interaction in public spaces and the associated wellbeing of elderly women it uses a beijing case study to address the requirements of and challenges to social interaction for elderly women in public space the research has three major goals an analysis of the types and characteristics of the social interactions of elderly women the relationship between requirements for effecting social interaction this paper focuses on social interaction in public spaces and the associated wellbeing of elderly women it uses a beijing case study to address the requirements of and challenges to social interaction for elderly women in public space the research has three major goals an analysis of the types and characteristics of the social interactions of elderly women the relationship between requirements for effecting social interaction for elderly women and effective public space shaping outlining principles for guiding public space shaping towards an agefriendly urban environment the research question asks what are the qualities of urban spaces which facilitate healthimproving social interaction for elderly women accordingly the potentiality of public space as contributing to the agefriendly urban environment is analyzed assessing the benefits of social interaction for the wellbeing of elderly women materials and methods around 240 elderly women aging between 55 and 75 from three communities in beijing participated in the field survey there are 5812 households in the communities in total including 2089 households in community baiwanzhuang 2127 households in community luyuan and 1596 households in community jianshebudayuan 41 in community baiwanzhuang elderly population is around 1692 37 and more than 100 older adults are above 90 years old 42 in community luyuan elderly population is around 1722 37 in community jianshebudayuan the elderly population is around 1292 37 the survey took place over 2 weeks between 1 and 15 april 2021 the methodological framework is comprised of three phases phase one consisted of behavior observation and data collection from the three beijing communities targeted for observation observing behavior enabled a general understanding of social interaction behaviors of elderly women in the three communities the elderly womens ages were asked to identify observation targets aging between 55 and 75 data collection from observation during phase one recorded the time and interactions happening in public spaces the results were indicative of the types and characteristics of social interaction among elderly women according to the general understanding of elderly womens social interaction behaviors major public spaces were chosen to be investigated in phase two the second phase covered mapping for the survey selected public spaces such as multiscale squares and green gardens were mapped and in order to analyze the social interaction routines of elderly women the result reflected the relationship between social interaction requirements of elderly women and public space shaping in order to corroborate observations and mapping of the first and second phase the survey between local elderly women was launched in phase three phase three consisted of group interviews questionnaires and qualitative and quantitative analysis elderly womens willingness and preferences for public space shaping were asked and analyzed the result was three principles that can effectively guide public space shaping towards an agefriendly urban environment the authors collected data in each phase for elderly women and effective public space shaping outlining principles for guiding public space shaping towards an agefriendly urban environment the research question asks what are the qualities of urban spaces which facilitate healthimproving social interaction for elderly women accordingly the potentiality of public space as contributing to the agefriendly urban environment is analyzed assessing the benefits of social interaction for the wellbeing of elderly women materials and methods around 240 elderly women aging between 55 and 75 from three communities in beijing participated in the field survey there are 5812 households in the communities in total including 2089 households in community baiwanzhuang 2127 households in community luyuan and 1596 households in community jianshebudayuan 41 in community baiwanzhuang elderly population is around 1692 37 and more than 100 older adults are above 90 years old 42 in community luyuan elderly population is around 1722 37 in community jianshebudayuan the elderly population is around 1292 37 the survey took place over 2 weeks between 1 and 15 april 2021 the methodological framework is comprised of three phases phase one consisted of behavior observation and data collection from the three beijing communities targeted for observation observing behavior enabled a general understanding of social interaction behaviors of elderly women in the three communities the elderly womens ages were asked to identify observation targets aging between 55 and 75 data collection from observation during phase one recorded the time and interactions happening in public spaces the results were indicative of the types and characteristics of social interaction among elderly women according to the general understanding of elderly womens social interaction behaviors major public spaces were chosen to be investigated in phase two the second phase covered mapping for the survey selected public spaces such as multiscale squares and green gardens were mapped and in order to analyze the social interaction routines of elderly women the result reflected the relationship between social interaction requirements of elderly women and public space shaping in order to corroborate observations and mapping of the first and second phase the survey between local elderly women was launched in phase three phase three consisted of group interviews questionnaires and qualitative and quantitative analysis elderly womens willingness and preferences for public space shaping were asked and analyzed the result was three principles that can effectively guide public space shaping towards an agefriendly urban environment the authors collected data in each phase observation and data collection observation and data collection served to gain an understanding of the social interactions of elderly women within the nominated communities observation is the process of scrutinizing and describing the social interaction behavior of elderly women it was a method of collecting information of watching elderly womens activities and recording it for analysis in a later phase during field observation in the nominated communities social interaction type place period and a detailed description of each community were noted in recording sheets data collection was another significant step in this phase data summarizing the number of elderly women who enter a public space for social interaction frequency of social interaction and distances between home and public space were collected in order to analyze the characteristics of social interaction behaviors mapping the purpose of the second phase was to reveal the relationship between requirements for social interaction of elderly women and public space shaping many types of public space may provide places for social interaction in the nominated communities mapping facilitates an understanding of the public spaces site selections design and shaping effects mapping tools utilized included scale plate digital level and a drawing implement once the public space measurement data were collated a series of computeraided plans could be generated with digital software developed and marketed by autodesk company 43 autocad is a computeraided design and drafting software running on microcomputers with internal graphics controllers 44 autocad was used to generate digital plans with internal graphics controllers survey methods were used to study a randomly selected sample of older women in the nominated communities by talking with them and recording their activities through posters flyers and inquiries participants learned about the purpose and content of the survey they could take part in the survey by filling out questionnaires or verbal communication the surveys were semistructured enabling a mix of qualitative and quantitative data to be collected topics included whether participants made full use of the public space their most and least favorite elements of the public space and their willingness to spend time with friends there the survey results identify ways in which the design of public space affects elder womens enthusiasm for social interaction survey and analysis interviews and questionnaires were the survey techniques used to explore the principles that could guide public space shaping towards an agefriendly environment interviewing is a qualitative research technique that involved asking openended questions to facilitate conversation with the elderly women of the sample communities interviews were unstructured with a thematic approach rather than a rigid question structure questionnaires were used to understand the satisfaction of elderly women with current public spaces and comprehend their conception of a public space ideal for social interaction valid returned questionnaires consisted of 96 from community baiwanzhuang the questionnaires addressed a range of themes and included closedand openended survey questions the content consisted of three sections first was basic information including age health status and family composition the purpose of collecting basic information was to understand situations of questionnaire participants second was social interaction activities in participants leisure times of day including when leisure times were how long they stayed in public space what activities they usually did what kind of facilities in public space they preferred and which public space they used the purpose was to understand elderly womens specific social interaction preference third were requirements of and satisfaction with public space including likert scale questions related to atmosphere satisfaction of different public spaces enthusiasm engagement and social participation motivation the purpose was to understand what kinds of public space can be friendly and accessible to elderly women respondents answered the questionnaire anonymously data security and privacy were protected and used exclusively for the purpose of this academic research ethical approval was given officially data collected through interview and questionnaires were analyzed in this phase quantized data such as time number of elderly women using public space number of elderly women who chose different social interaction activities were statistically summed up and expressed as bar graphs pie graphs and line graphs descriptive data such as elderly womens feedbacks about enthusiasm and motivation were summarized as guiding principles for public space design results and discussion social interaction of elderly women results from observations and questionnaires indicate that most of the social activities of elderly women are familycentered their interactions took place largely in the smallscale squares and green places of their neighborhoods which form the primary public space for elderly womens communication social interaction types included group exercise leisurely chatting strolling babysitting and other activities data from the questionnaires and interviews illustrate the percentage rates of social interaction types within the three communities in community baiwanzhuang 43 of survey participants preferred to chat with friends and neighbors in public spaces strolling and group exercise were also popular the elderly women of community luyuan spent more time chatting for leisure group exercise took second place followed by strolling in community jianshebudayuan elderly women preferred chatting and strolling group exercise also featured as did other activities and babysitting inkeeping with wangs statement the investigate data indicated a preference for gentle activities such as chatting or strolling over more tiring ones wang also found that urban elderly women some 8808 of the questionnaire participants had an interest in communicating with others 29 the same was true for 8015 of rural elderly women when leisure times were how long they stayed in public space what activities they usually did what kind of facilities in public space they preferred and which public space they used the purpose was to understand elderly womens specific social interaction preference third were requirements of and satisfaction with public space including likert scale questions related to atmosphere satisfaction of different public spaces enthusiasm engagement and social participation motivation the purpose was to understand what kinds of public space can be friendly and accessible to elderly women respondents answered the questionnaire anonymously data security and privacy were protected and used exclusively for the purpose of this academic research ethical approval was given officially data collected through interview and questionnaires were analyzed in this phase quantized data such as time number of elderly women using public space number of elderly women who chose different social interaction activities were statistically summed up and expressed as bar graphs pie graphs and line graphs descriptive data such as elderly womens feedbacks about enthusiasm and motivation were summarized as guiding principles for public space design results and discussion social interaction of elderly women results from observations and questionnaires indicate that most of the social activities of elderly women are familycentered their interactions took place largely in the smallscale squares and green places of their neighborhoods which form the primary public space for elderly womens communication social interaction types included group exercise leisurely chatting strolling babysitting and other activities data from the questionnaires and interviews illustrate the percentage rates of social interaction types within the three communities in community baiwanzhuang 43 of survey participants preferred to chat with friends and neighbors in public spaces strolling and group exercise were also popular the elderly women of community luyuan spent more time chatting for leisure group exercise took second place followed by strolling in community jianshebudayuan elderly women preferred chatting and strolling group exercise also featured as did other activities and babysitting inkeeping with wangs statement the investigate data indicated a preference for gentle activities such as chatting or strolling over more tiring ones wang also found that urban elderly women some 8808 of the questionnaire participants had an interest in communicating with others 29 the same was true for 8015 of rural elderly women data from observation and questionnaires show the preferred time of social interaction elderly women in the sample communities predominantly interacted socially during mornings and afternoons as figure 4 indicates 0900 to 1000 and 1600 to 1700 were peak periods of social interaction in community baiwanzhuang about 17 elderly women chatted in a public space between 0900 and 1000 and 25 from 1600 to 1700 in the early morning most elderly women liked to stroll with friends few chose to interact socially in public spaces at noon from late afternoon until evening elderly women engaged in chatting strolling and babysitting in community luyuan elderly women preferred to chat stroll and do group exercises from 0900 to 1000 in the evening they tended to do group exercises such as square dancing and martial arts as well as engage in leisurely talk babysitting occupied the smallest proportion of a day chatting and strolling in the morning were also popular in community jianshebudayuan twentysix elderly women chatted in a public space from 0900 to 1000 and 22 between 1600 and 1700 twentythree elderly women strolled with friends or neighbors from 0900 to 1000 and 20 at 1600 until 1700 group exercise babysitting and other social activities frequently happened from 1600 to 2000 these data indicate that elderly women tend to stay indoors during the midday period tion elderly women in the sample communities predominantly interacted socially during mornings and afternoons as figure 4 indicates 0900 to 1000 and 1600 to 1700 were peak periods of social interaction in community baiwanzhuang about 17 elderly women chatted in a public space between 0900 and 1000 and 25 from 1600 to 1700 in the early morning most elderly women liked to stroll with friends few chose to interact socially in public spaces at noon from late afternoon until evening elderly women engaged in chatting strolling and babysitting in community luyuan elderly women preferred to chat stroll and do group exercises from 0900 to 1000 in the evening they tended to do group exercises such as square dancing and martial arts as well as engage in leisurely talk babysitting occupied the smallest proportion of a day chatting and strolling in the morning were also popular in community jianshebudayuan twentysix elderly women chatted in a public space from 0900 to 1000 and 22 between 1600 and 1700 twentythree elderly women strolled with friends or neighbors from 0900 to 1000 and 20 at 1600 until 1700 group exercise babysitting and other social activities frequently happened from 1600 to 2000 these data indicate that elderly women tend to stay indoors during the midday period survey results also reveal that elderly women preferred familiar places for social interaction public spaces are expected to be safe environments which meet the physical and psychological security needs of elderly women many people chose to age in a place where they used to live preferring social interactions in a familiar secure environment the us center for disease control and prevention defines aging in place as the ability to live in ones own home and community safely independently and comfortably regardless of age income or ability level 45 as wiles et al indicate aging in place was seen as an advantage in terms of a sense of attachment or connection and feelings of security and familiarity in relation to both homes and communities 46 the data from observations depict the primary locations where the elderly women of the sample communities interacted socially clear areas and smallscale squares around residential buildings were the most common choice of elderly women in community baiwanzhuang elderly women liked to chat or babysit close to their own houses in addition the square in the southwest corner of the community functions as the public center of the community on average eight elderly women interacted socially in this space in the afternoons community luyuan features a central square in the middle of the community social interactions happened in this square from morning to night areas in the northern area of the community also provide public space for social interaction especially from afternoon to evening in community jianshebudayuan elderly women liked to socially interact in the small square in the west area of the community from the afternoon until evening the small square is a stimulus for social activities psychological security needs of elderly women many people chose to age in a place where they used to live preferring social interactions in a familiar secure environment the us center for disease control and prevention defines aging in place as the ability to live in ones own home and community safely independently and comfortably regardless of age income or ability level 45 as wiles et al indicate aging in place was seen as an advantage in terms of a sense of attachment or connection and feelings of security and familiarity in relation to both homes and communities 46 the data from observations depict the primary locations where the elderly women of the sample communities interacted socially clear areas and smallscale squares around residential buildings were the most common choice of elderly women in community baiwanzhuang elderly women liked to chat or babysit close to their own houses in addition the square in the southwest corner of the community functions as the public center of the community on average eight elderly women interacted socially in this space in the afternoons community luyuan features a central square in the middle of the community social interactions happened in this square from morning to night areas in the northern area of the community also provide public space for social interaction especially from afternoon to evening in community jianshebudayuan elderly women liked to socially interact in the small square in the west area of the community from the afternoon until evening the small square is a stimulus for social activities observations in the communities reflect that social interactions within the sample communities can be grouped into three distinct categories the first of these is basic social interaction including for example leisurely chatting and babysitting these interactions happen largely around houses and closed yards in green places between residences and in the entrances of houses and alleys elderly women might walk about 10 min to arrive at the target public space communication is predominantly between families relatives and close friends the second category is neighborhood social interaction interactions in this category include strolling and gentle group exercises they occur in outdoor squares green areas or public centers elderly women might walk about 20 min to arrive at their destination these social interactions occur most often in the afternoon and evening and communication is commonly between neighbors the third is an extension of neighborhood social interactions representative interaction types include group exercises such as square dancing martial arts and ball games elderly women may need to walk or take public transportation to arrive at the public space in about 30 min social interaction in this category may be between strangers elderly women may experience anxiety about leaving home and negotiating access to extend the scope of their neighborhood social interaction public space for elderly womens social interaction three forms of public space provide places for elderly womens social interaction these are open form semiclosed form and closed form open form public spaces like that in the midarea of community luyuan can be surrounded by roads they preserve scenic views of the adjacent landscape elderly women tend to access this form of public space for group exercises or chatting flexible usage and the large population capacity of this type encourages social activities semiclosed form public spaces exist in all sample communities they may be located between two buildings and an open place the surfaces of adjacent buildings partially conceal the public space enabling a measure of privacy as a result intimate conversations between close friends may happen in this form of public space closed form public spaces are usually smallscale and surrounded by buildings or greenery they provide a sheltered space in which elderly women can sit for a while or communicate with family friends or neighbors although typically close to houses and easily accessible these forms have less of a direct line of sight so may present a security risk to older women in the entrances of houses and alleys elderly women might walk about 10 min to at the target public space communication is predominantly between families rel and close friends the second category is neighborhood social interaction interacti this category include strolling and gentle group exercises they occur in outdoor sq green areas or public centers elderly women might walk about 20 min to arrive a destination these social interactions occur most often in the afternoon and evenin communication is commonly between neighbors the third is an extension of neig hood social interactions representative interaction types include group exercises s square dancing martial arts and ball games elderly women may need to walk o public transportation to arrive at the public space in about 30 min social interac this category may be between strangers elderly women may experience anxiety leaving home and negotiating access to extend the scope of their neighborhood soc teraction public space for elderly womens social interaction three forms of public space provide places for elderly womens social inter these are open form semiclosed form and closed form open form spaces like that in the midarea of community luyuan can be surrounded by roads preserve scenic views of the adjacent landscape elderly women tend to access thi of public space for group exercises or chatting flexible usage and the large popu capacity of this type encourages social activities semiclosed form public spaces e all sample communities they may be located between two buildings and an open the surfaces of adjacent buildings partially conceal the public space enabling a m of privacy as a result intimate conversations between close friends may happen form of public space closed form public spaces are usually smallscale and surro by buildings or greenery they provide a sheltered space in which elderly women for a while or communicate with family friends or neighbors although typically to houses and easily accessible these forms have less of a direct line of sight so ma sent a security risk to older women a selection of public spaces within the sample communities was analyzed th tral square of neighborhood mou and the open areas of neighborhood chen and n borhood zhongli in community baiwanzhuang were evaluated for public space sh and social interaction behaviors table 1 illustrates that both formal public spaces s the central square and informal public spaces like open areas within neighborhood be sites of social interaction elderly women use different spaces in different ways a selection of public spaces within the sample communities was analyzed the central square of neighborhood mou and the open areas of neighborhood chen and neighborhood zhongli in community baiwanzhuang were evaluated for public space shaping and social interaction behaviors table 1 illustrates that both formal public spaces such as the central square and informal public spaces like open areas within neighborhoods can be sites of social interaction elderly women use different spaces in different ways group exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings wood gallery benches clear area of neighborhood chen exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings wood gallery benches clear area of neighborhood zhongli exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings exercises with others take place most often in formal spaces while casual chatting and gentle exercise with friends is more frequently seen in informal spaces existing fitness equipment in these spaces is perceived as dangerous by some elderly women who consider it appropriate mainly for young adults in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings in community luyuan the central square and the clear and corner areas of neighborhood nanluyuan have been selected for analysis observations and mapping data are summarized in table 2 elderly women favor the community central square for group exercise square dance is a favorite of elderly women and the central square is usually a large paved open area smaller scale open spaces such as neighborhood nanluyuans clear area are more suited to babysitting and chatting elderly women prefer briefer communication in informal public spaces adjacent to residential buildings community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between formal open space with large scale direct connections to surroundings both visual and physical vibrant activities wood gallery benches community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between green space of no7 residence building community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between small square aside property management office community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between conveniently accessed close to secondary road fitness equipment sandpit community jianshebudayuan features public space shaping which incorporates botany most public space here is surrounded by greenery elderly women consider this community to have quality public space for social interaction they prefer to chat stroll with friends or do group exercises in the green space there is a strong requirement for community life among the elderly women and connections between them and the wider society are diverse they might be smiling or saying hello in the small square or chatting about shared interests public space with greenery and infrastructure is beneficial for communication and facilitates a sense of community and citizenship among elderly women principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between principles of agefriendly urban space shaping as a result of this research into the communities of beijing including the interviews with elderly women we propose three principles of agefriendly urban space shaping these principles apply specifically to youngold elderly women who are aged between 55 and 75 this demographic generally enjoys better health than oldold elderlies and are thus more eager to engage with their communities the first principle is one of security it is essential ensure safe public spaces exist for outdoor social interactions older people whether they are retired or working from home spend a much larger proportion of their time within the residential environment than do younger people 47 accordingly public spaces in residential environment are the main social interaction places for the elderlies encompassing more than agefriendly infrastructures the security principle addresses psychological security for elderly women for example public space shaping can avoid creating remote corners green belts should not be so long or high that they obscure sight allowing elderly women to observe their surroundings without obstacles helps them decide if a space is safe the research clearly demonstrates that elderly women prefer to attend square dances in the evening as a result evening lighting is necessary around public squares convenience is the second principle some elderly women reflect that social interaction in the community is a source of worry noisy environments motorways and a lack of pedestrian crossings prevent older women from venturing outside brach and vanswearingen indicates in older adults walking is slow less stable inefficient and the timing and coordination of stepping with postures and phases of gait is poor 48 this research is accordance the statement by observing elderly womens daily social interactions improved walking systems for the elderly are thus important in the process of public space shaping squares or green spaces are best if they provide barrierfree access for elderly women seats are also required as the elderly may need a rest anytime anywhere the third principal is comfort smallscale landscaped spaces are appreciated by elderly women they like chatting with friends and neighbors and enjoying sunlight in smallscale spaces a comfortable atmosphere facilitates a relaxed social psychology encouraging social interaction greening should avoid allergen or flocculent plants social interaction gives elderly women a sense of citizenship in the urban design field the voices of older people are often treated as secondary and are rarely integrated into plans for urban regeneration and physical transformation 49 public space in urban areas can be places of comfort for elderly women as they continue to age in the community conclusions quality public spaces in urban areas are a significant opportunity to encourage the elderly to interact socially this research highlights that public space should address elderly womens special social interaction behaviors needs and experiments through analyzing how elderly women interact and behave in the public spaces of the communities in beijing it was found that social interaction such as talking strolling with friends and group exercises is an essential part of the lives of elderly women one of elderly womens needs is maintaining communication with others to avoid loneliness this is in accordance with the findings of wang that more elderly women feel lonely in later life than elderly men 29 elderly people differ from the younger generation who tend to be more confident and independent in a social occasion temelova and slezakova also indicated how public spaces should be used is different among different generations 5051 this research argues that general public space shaping guidelines and standards cannot fully incorporate the social interaction requirements of elderly women just offering a separate blank open place in current urban design projects may fail to meet the broad spectrum of needs of different genders and ages public spaces suitable for elderly women are diverse social interaction may take place in central squares in clear areas between residences and at corner side entrances formal and informal public space can provide a variety of atmospheres to motivate a range of social interactions public spaces with greenery pavements seats and fitness equipment attract elderly women who come to meet with friends relatives and neighbors it is a challenge for urban planners designers and architects to establish comfortable environments that are inclusive and caring to its residents especially to the elderly people 51 by field investigating in communities it is found comfortable environments make elderly women confident to access facilities a strong sense of community is generated and community life becomes active if the public space caters to the needs of all age and gender groups public space that is safe convenient and comfortable can facilitate social interaction for elderly women and thus improve their health principles of security convenience and comfort generate elderly womenfriendly public space they support the social network enhancement and wellbeing of elderly women and stimulate participation and interaction in elderly womens later lives data availability statement data sharing is not applicable to this article int j environ res public health 2022 19 746

the worlds population is aging and becoming more urbanized public space in urban areas is vital for improving the health of the elderly by stimulating social interaction many urban design projects are advertised as agefriendly but ignore the real needs of the elderly especially elderly women for social interaction in urban public spaces insufficient attention is paid to the physical and psychological characteristics of elderly women when shaping public space this analysis addresses the question what are the qualities of urban spaces which facilitate healthimproving social interaction for elderly women methods include a case study in beijing field investigation mapping and qualitative and quantitative analysis the survey was carried out in april 2021 and concerned 240 women aged 5575 years results indicate that the social interactions of older women relate to both their physical and psychological situations public spaces can positively impact the psychological wellbeing and social participation of elderly women conclusions include insights regarding the relationship between social interaction and wellbeing among elderly women as well as proposing a series of principles for shaping public spaces for an agefriendly urban environment

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introduction growing research attention worldwide has focused on various aspects of the wellbeing of the unemployed including economic and material deprivation 1 physical health 23 mental health 4 social connections 5 spirituality 6 and emotions 7 most research reveals a negative impact of unemployment on those qualityoflife attributes 8 subjective wellbeing has become the most popular measure of quality of life life satisfaction and happiness reflect peoples living conditions 9 on the effect of unemployment on happiness in particular several studies indicate that unemployment is correlated with a lower level of happiness 10 however inconsistent findings do exist 11 analysts have found that unemployment is not necessarily negatively related to subjective wellbeing 12 in addition studies on employment status and various sociodemographic determinants have produced mixed findings 13 the latest official statistics show that in 2019 the emirate of abu dhabi of the united arab emirates recorded an unemployment rate of 69 an increase from 52 in 2018 14 unemployment in abu dhabi has apparent features of youth unemployment and gender differences 15 as the 2024 age group accounted for 220 of total unemployed and the female unemployment rate reached 148 in 2019 14 unemployment and emiratization challenges in the uae have been attributed to the structural imbalance of the demand and supply of skills the availability of lowwage migrant workers the segmentation of the labor market between public and private sectors and employee and employer perceptions 16 17 18 19 despite continuous and rigorous emiratization drives by the uae government unemployment challenges are likely to continue as are the negative implications of unemployment for the subjective wellbeing of the unemployed therefore policymakers need to better understand the differences in subjective wellbeing between the employed and the unemployed and the significant determinants of happiness of the unemployed in the context of abu dhabi to design effective policies for helping the unemployed cope with different facets of their lives therefore the rationale for conducting this study is to examine the subjective wellbeing of the unemployed in abu dhabi and understand the factors that contribute to their happiness this study aims to provide a multidimensional perspective on the issue of unemployment and contribute to the existing literature on the negative impact of unemployment on individuals psychological and social wellbeing by considering economic social and health determinants this study seeks to inform policymakers and support the development of interventions and policies to improve the wellbeing of the unemployed population the present study utilizes the data from the third cycle of the abu dhabi qualityoflife survey to develop a path model to analyze the determinants of happiness for the unemployed in abu dhabi in particular we design and run a comprehensive path model for abu dhabi in which subjective health mental feelings income satisfaction ability to make ends meet and social connections are included and tested although subjective wellbeing has been examined for various groups of the population in the context of abu dhabi 20 21 22 including youth 2324 to our knowledge this is the first study aimed at unemployed in abu dhabi review of the literature the social determinants approach has advanced in many fields such as health 25 this studys social determinants of wellbeing framework examines how social economic and cultural factors influence wellbeing and highlight the socioeconomic systems critical role in subjective wellbeing 26 research shows that employment and work status significantly shape individuals happiness levels 27 while several studies on the relationship between employment status and happiness have reported mixed results 1328 most research reports that the unemployed are less happy than the employed 29 such a negative correlation between happiness and unemployment might not necessarily indicate a causal effect 30 and is likely to be influenced by individual and social characteristics 31 in the following sections we provide an overview of the relevant literature on the effects of various socioeconomic and health factors on the subjective wellbeing of the unemployed economic and financial constraints unemployment usually leads to reduced income and financial hardships negatively affecting the economic wellbeing of the unemployed 1432 the longterm unemployed in particular are more likely to have debt and other financial difficulties 33 declining income reduces a households ability to make ends meet and economic wellbeing in general 34 income has often been demonstrated to have statistically significant but small effects on subjective wellbeing 35 however ref 36 found that unemployment did not cause reductions in happiness for individuals whose household income levels substantially exceeded their minimum living requirement apart from instrumental value income and material resources help individuals cope with stress 37 thus poor financial situations and poverty make the unemployed vulnerable to stress depression and other mental health symptoms 4 researchers have also established the association between unemployment and unhappiness through insecurity 3 unemployment and health many studies report the relationships between happiness subjective health and mental health 38 unemployment increases the likelihood of poor physical health 39 and poor mental health 4 extensive findings in the literature indicate that psychological distress is a significant outcome of unemployment 40 unemployment could also result in certain unhealthy or unsocial behaviors that further deteriorate physical and mental health 41 several studies focus on psychological feelings and report that the unemployed reveal significantly worse emotional wellbeing 7 nevertheless ref 42 warned that caution should be exerted when estimating the longerterm effects of unemployment due to the nonrandom nature of exits from unemployment and other measurement issues addressing the relation between unemployment duration and health ref 43 suggested that the most deleterious effects on mental health may occur in the first two months of unemployment which many studies on unemployment may fail to capture social relations and connections unemployment contributes to rising relationship problems with family and friends 43 the pew 44 analysis of the us employment data showed how prolonged unemployment could strain personal relationships some observed that the unemployed generally feel worse than the employed when engaging with others in the same social activities 5 in sweden ref 45 examined the impact of adverse economic events because of unemployment on relationship quality and found that women suffered more than men work constitutes the basis for belonging and loss of work affects a workers identity and social life 46 social isolation and loneliness are widely recognized as among the most significant issues facing the unemployed 47 for example ref 48 provided evidence from the uk to show that being isolated or lonely is a significant outcome for the young and unemployed moreover some researchers point out that unemployment significantly influences an individuals motivation to achieve valued life goals 49 which is a significant aspect of both subjective and mental health 50 demographic factors demographic and socioeconomic factors must be factored in when studying employment status and happiness as unemployment affects people differently 42 ref 51 examined the gender difference in the relationship between healthrelated quality of life and employment status several empirical studies conclude that unemployed men have poorer mental health than women 52 while ref 53 reported that unemployed female managers encountered substantially greater sources of stress than their male counterparts in all aspects of unemployment some studies showed that the risk of depression increased in older age for females 54 the study in ref 55 indicates that unemployed youth show more negative experiences and lower quality of life than the reference group many studies focus on youth unemployment since it has direct economic costs and lasting negative impacts on mental health problems violence and social exclusion 56 marriage was found to have a more positive influence on the effects of unemployment on health in women than in unemployed men 57 higher education usually leads to a more positive impact on happiness 58 some focused on the level of education of educated unemployed adults according to age 59 unemployed parents and the psychological effects of joblessness on the family are also the subjects of examination 10 regional issues of unemployment the uae is part of the gulf cooperation council which is a collective of countries comprising bahrain kuwait oman qatar saudi arabia and the united arab emirates the gcc was formed based on these countries shared cultural political economic and social elements 60 it is worth noting that from a broader perspective the issues of unemployment seems to affect the broader arab gulf region 15 these issues are not new as the trend has been documented over the past decade 61 therefore it is essential to situate unemployment issues within the regional context as they are not limited to the uae the majority of studies have focused on the impact of unemployment on gdp 62 interventions to tackle unemployment and ineffective education 63 reform of labor market policies 64 and developmental and socioeconomic factors related to unemployment 65 however research on the negative impact of unemployment on individuals psychological and social wellbeing remains scarce with a study investigating subjective wellbeing and work among emirati youth 24 their findings indicate that being employed was a preventive measure against loneliness sadness and depression considering that the repercussions of unemployment on an individuals wellbeing may perpetuate unemployment even further this study attempts to contribute to the literature in this area for the uae and gcc region to provide policymakers with a multidimensional perspective on the issue of unemployment methods and design the survey the abu dhabi qualityoflife survey was designed based on several international social surveys and studies including the oecds better life index 66 the gallup global wellbeing survey 67 the world happiness report 68 and the european qualityoflife survey 69 it covers various dimensions and factors of wellbeing including mental feelings subjective health and happiness the survey was administered online in 2021 following a combination of convenience sampling and random sampling approaches covering all the emirate of abu dhabis regions the random sampling approach was conducted with the cooperation of a team of research assistants from the statistics center abu dhabi sampling weights were introduced to represent the various respondent categories in the achieved sample adequately for this study the final sample was composed of 4815 selfreported unemployed persons in abu dhabi variables the variables selected for the current study adhered to their theoretical relevance as indicated in the literature review as well as the statistical significance registered by their partial correlation and path analysis resulting in coefficients extensive statistical analysis including correlation and covariance analysis multicollinearity analysis and reliability analysis helped identify the final list of eight variables to be considered further in the path model for the happiness of the unemployed the assumed determinants include three main themes the first theme covered subjective health mentalpsychological or emotional feelings and isolation the second theme covered the socialconnectionrelated variables frequency of meeting with friends family satisfaction and quality time with family the economic wellbeing theme included the ability to make ends meet and income satisfaction different scaling was used for the items in the survey the happiness variable was measured on a 010 scale mental feelings was a composite variable reflecting eight signs of mental or psychological issues such as sadnessdepression worryanxiety fear and boredom measured on a likert scale with one indicating not at all and five indicating to a great extent the mental feeling variable exhibited a cronbach alpha reliability score of 0913 the remaining variables used in this study were all measured on a 5point likert scale for example the family satisfaction variable used a 15 scale from strongly disagree to agree strongly responding to the question i am satisfied with my family life the response to the question represented the ability to make ends meet variable using a 15 scale from with great difficulty to very easily statistical analysis the analysis started with descriptive statistics for the unemployed category of respondents the demographic information available in the qol3 survey included gender age nationality marital status education and region of residence for the path analysis we followed a stepbystep process we introduced one individual variable at every step by checking the fit statistic measures the analysis considered the happiness variable as the focus variable and the path analysis aimed to yield a path model and the estimates of associations that can explain the association pattern between happiness and other factors we considered specific statistics to keep the variable in the model or eliminate it as recommended three fundamental statistical values were evaluated the magnitude of the standardized coefficient the tstatistics and the significance level in addition variables that did not reflect any significant paths were eliminated from further consideration lisrel version 88 for windows was used to adopt the application of path analysis 6870 the relationships between the variables of interest were assessed using several statistical criteria of measurement that included maximum likelihood ratio chisquare root mean square error of approximation normed fit index nonnormed fit index comparative fit index root mean square residual goodness of fit index and adjusted goodness of fit index in addition to other indexes before using path analysis we performed several rounds of multiple linear regressions to examine the association between the independent variables and the assumed dependent variable further we used an analysis of variance to examine the differences in the happiness of the unemployed between and among different categories according to gender marital status age education attainment nationality and region of living we utilized spss version 22 for all the statistical significance tests and analyses 6971 results table 1 provides a summary of the demographic characteristics of the unemployed respondents in the survey the sample represents more females and more married respondents concerning age the 2635 and 3645 age brackets together account for 671 one in three unemployed holds a bachelors degree emiratis constitute 442 of the sample while nonemiratis account for 558 regarding residence location the majority are from abu dhabi followed by al ain a critical goal when using path analysis is to understand the patterns of correlationcovariance among a set of wellbeing variables and explain their variance with the model envisioned and specified 72 table 2 shows the covariances of the variables used in the path analysis in the path analysis the chisquare test indicates the difference between the expected and observed covariance matrices with a chisquare value of zero indicating little difference between the expected and observed covariance matrices the final model generated good fit indicators as shown in table 3 the abu dhabi model yields a chisquare with 7 degrees of freedom giving χ 2 df 15942 other statistics are also encouraging all these statistics indicate the high statistical quality of the path model figure 1 shows the final path model several model accuracy indicators and parameter values indicated acceptable or strong model structures table 4 shows the standardized path estimates and their associated zvalues and tvalues for all path model variables various direct and indirect determinants impact the happiness of the unemployed figure 1 indicates eight significant paths with noticeable direct impacts on the happiness variable these variables are income satisfaction feeling isolated family satisfaction mental feelings subjective health quality time with family frequency of meeting with friends and ability to make ends meet table 4 shows the standardized path estimates and their associated zvalues and tvalues for all path model variables various direct and indirect determinants impact the happiness of the unemployed figure 1 indicates eight significant paths with noticeable direct impacts on the happiness variable these variables are income satisfaction feeling isolated family satisfaction mental feelings subjective health quality time with family frequency of meeting with friends and ability to make ends meet figure 1 also illustrates that some variables mediate in exerting more association with happiness for example family satisfaction is the mediator between five determinants and happiness ability to make ends meet also significantly mediates income satisfaction feeling isolated and happiness quality time with family mediates happiness and income satisfaction the ability to make ends meet and mental feelings the path model shows that family satisfaction has a significant role in accounting for the happiness of the unemployed directly or through other determinants a total of seven significant paths are associated with family satisfaction table 5 reveals all the direct and indirect associations between the variables in the final path model the highest total effect is income satisfaction and making ends meet meanwhile family satisfaction is significantly influenced by income satisfaction for happiness the most significant total effect or association is from income satisfaction feeling isolated and quality time with family looking at the variable ability to make ends meet income satisfaction exerts a significant total effect it is worth noticing also that the mental feeling variable makes itself significantly present when we look at happiness family satisfaction and quality time with family additional analyses were conducted table 6 provides the mean and standard deviation of the unemployed and the employed regarding their happiness and the other determinants such results could assist in understanding the results of the statistical differences test that would follow the path analysis the variable ability to make ends meet had the highest percentage change followed by income satisfaction and feeling isolated for the unemployed the highest standard deviation is with happiness frequency of meeting with friends and quality time with family anova was employed to examine the differences in the happiness of the unemployed between and among the subgroups of age gender marital status education attainment region of living and being the head of the household results reveal significant differences between genders as females reported a higher level of happiness than males among the unemployed with different marital statuses the widowed separated and married enjoyed the highest level of happiness of 8028 7774 and 7231 respectively on the other hand the divorced and the single reported the lowest happiness means of 6412 and 6664 looking at the difference by age categories those with ages close to college graduation scored the lowest happiness those 50 years and above reported relatively higher happiness interestingly nonemiratis enjoyed higher happiness than emiratis as emiratis scored 6749 compared with 7224 for nonemiratis in terms of differences in groups by educational attainment those who can readwrite or have primary education scored the highest on the happiness scales and those with college degrees reported the lowest score regarding regions of living those unemployed living in the abu dhabi region reported the lowest level of happiness while those in al ain scored the highest those who reported being the head of the household showed significantly lower happiness scores than those who were not the head of the household finally the effect of the duration of unemployment on happiness was also investigated a simple regression of happiness being the dependent variable and the duration of unemployment as the independent variable produced a positive bscore of 0319 discussions the study of the happiness of the unemployed should look at the synergistic more extensive system that involves a wide range of wellbeing determinants the metaanalysis of longitudinal studies on the effect of unemployment on wellbeing suggests the significant role in this relationship of social and economic context gender and norms regarding work 8 in this abu dhabi study the path model offers a broader view that incorporates significant economic social and health determinants overall the results of the path model are consistent with similar research that factors in the combining effects of many wellbeing factors including physical health mental health social connection and economic wellbeing 3 4 5 firstly the abu dhabi study recognizes the economic wellbeing effects on the happiness of the unemployed both economic wellbeing variablesincome satisfaction and the ability to make ends meethave the highest effect on happiness such conclusions are supported by many other studies worldwide that recognize the financial burdens of unemployment 4 we offer evidence to support the arguments that associate unemployment with financial difficulties resulting from borrowing more and spending more savings 32 moreover this study reveals many associations between these economic wellbeing variables and social connection variables such as family satisfaction quality time with family and isolation similar findings are provided by 2173 in this regard the uae recently issued the unemployment insurance scheme as a mandatory program for all emirati and foreign employees in the public and private sectors to subscribe to from 1 january 2023 this policy offers a buffer of financial protection for the unemployed that was not available before furthermore these findings seem to support the uae governments recent aggressive financial initiatives to counter unemployment with the introduction of the nafis federal program to subsidize and incentivize uae citizens salaries in the private sector and offer a range of financially oriented benefits career counseling and training 7174 secondly the significant influence of mental feelings and isolation on happiness is underscored in most international research dealing with the wellbeing of the unemployed issues related to mental health and feelings of isolation and loneliness have received much attention 57 the findings from this study offer an initial glimpse of the wellbeing of the unemployed in this region the research findings in abu dhabi are consistent with the literature as unemployment may trigger stress depression and unhealthy and unsocial behaviors that negatively affect mental health 441 abu dhabi is home to migrant workers of many nationalities most unemployed migrants may suffer additional psychological and social isolation from moving to a new place and culture these findings corroborate an earlier study by 72 that explored determinants of the wellbeing of migrant workers in qatar being unemployed and looking for work in a new culture may be accompanied by homesickness emotional deprivation and isolation 450 the unemployed emiratis the majority of whom are youths are more likely to suffer from lower selfesteem loss of meaning in life and depression and anxiety these findings are significant for emirati youths as most federal and local employment initiatives seem to target this segment 15 more importantly the path model provides an alarming warning when it reveals that the happiness of the unemployed is characterized by a significant decrease in their social life and connections while a substantial reduction in contact with family and friends among the unemployed is not uncommon 5 it is worth emphasizing that emirati and arab youths tend to define happiness through a collective and social lens shaped by the arab culture and norms 23 this further supports social connections as a critical determinant of wellbeing in abu dhabi confirming that people with more social connections or better social contexts report higher life evaluations 22 although the two variables of quality time with family and family satisfaction are associated positively with the happiness of the unemployed they are negatively affected by mental feelings which is broadly consistent with the findings of other studies 4345 policymakers should consider such significant interconnections wisely when looking at the happiness of the unemployed in abu dhabi such evidence helps explain why unemployed emiratis stated lower happiness than their nonemirati counterparts in addition most migrant workers in abu dhabi may have lower prospects in their job hunting back home and are likely to be more optimistic about finding a job in abu dhabi than emiratis in abu dhabi unemployed females recorded higher happiness than unemployed males this result is relatively consistent with other studies that analyze the determinants of happiness such as subjective health and mental health 5152 where women recorded more positive scores than men this may be attributed to the cultural and social norms of the region where females are supported by their families until they get married 74 the cultural safety net may have contributed to their higher feelings of wellbeing even when unemployed the married reported a higher happiness score than the divorced and the single the same positive influence of marriage on subjective wellbeing is illustrated by 57 also as expected unemployed heads of households scored significantly lower happiness scores than those who are not heads of households which recognizes the burden of parenthood or being the head of a household during unemployment 10 those unemployed living in the abu dhabi region reported the lowest happiness this outcome may reflect the higher cost of living in the abu dhabi region than in al ain or al dhafra research elsewhere suggests a positive relationship between the level of education and happiness 58 however this outcome is not supported by the abu dhabi data theoretical contributions a review of the literature suggests that currently there is no overarching theory that explains both unemployment and wellbeing 7576 however there are several theories that explain the relationship between unemployment and wellbeing structural unemployment theory is a longerlasting form of unemployment caused by fundamental shifts in an economy and exacerbated by extraneous factors such as technology competition and government policy 77 structural unemployment occurs because contextual factors prevent employment jobs are available but there is a serious mismatch between what companies need and what workers can offer this is evident in the recent efforts of emiratization in the uae 1819 there seems to be structural barriers to employment within the uae context for both emiratis and expats the findings of this study provide support for the structural employment theory this study recognizes the significant role of social and economic context gender nationality and norms regarding unemployment these findings suggest that the structural factors related to employment play a crucial role in determining the wellbeing of the unemployed in another strain cole 78 combined elements from five theories to propose the integrated model of unemployment effects the integrated theory proposes that unemployment deprives people of important latent and manifest benefits associated with employment which in turn negatively impacts wellbeing poorer wellbeing adversely affects a persons motivation to engage in jobsearch activity or the acquisition of human capital skills that facilitate reemployment potential employers also avoid hiring individuals with poor wellbeing because they perceive them as less productive such individuals are therefore likely to remain unemployed for longer periods of time which in turn further negatively affects their lambs and wellbeing a vicious downward cycle may develop creating the risk of longterm unemployment this studys findings support coles integrated model as they reveal associations between economic wellbeing variables and social connection variables such as family satisfaction quality time with family and isolation these findings suggest that unemployed individuals wellbeing is influenced by their ability to find employment and maintain social connections the aforementioned unemployment insurance scheme in the uae which is a policy initiative providing financial protection for the unemployed further aligns with the principles of coles integrated model of unemployment effects as it aims to support individuals during their job search and mitigate the negative effects of unemployment conclusions in this study we explored a path model for the happiness of the unemployed in abu dhabi to understand the significant associations between their happiness and subjective health mental feelings social connections and economic wellbeing the results of the path model provide a clear view of the most significant factors that play essential roles in the subjective wellbeing of the unemployed for abu dhabi and the broader arab gulf region these findings offer an initial glimpse of unemployments psychological and social consequences on the individual level they may serve as a justification for more holistic intervention policies tackling unemployment unemployment is a negative experience that reduces happiness and imposes various economic social and health risks the resulting evidence of this study produces valuable insights for setting a set of policyrelevant moderators that consider the multidimensional connections between various wellbeing factors such as health income and social connections social policymakers in abu dhabi should remain vigilant given the evidence that unemployment leads to adverse mental health changes strained family relations and loss of contact with close friends a better understanding of the underlying associates of subjective wellbeing from the findings of this study could also promote the awareness and earlier identification of mental stress among the unemployed and the implementation of appropriate preventive policy interventions to facilitate their better adjustment policymakers should also consider further economic reforms to improve welfare and social safety nets for the unemployed despite the strong evidence of specific determinants of happiness for the unemployed the complexity of the associations between and among happiness and the determinants must be stressed especially when demographic and socioeconomic elements are also considered this may explain some of the mixed findings in the literature and justifies indigenous approaches to the study of the subjective wellbeing of the unemployed limitations and future directions the data collected for this study relied on selfreported measures which may be subject to recall bias or social desirability bias this could affect the accuracy and reliability of the responses provided by the participants furthermore the authors acknowledge the limitation of including only one model and relying on online panel data this limitation may affect the generalizability and reliability of the findings replicating the results in another study would strengthen the validity of the hypotheses and provide more robust evidence while this study considered several variables related to economic social and health dimensions there may be other important factors that were not included in the analysis these additional variables could potentially influence the happiness of the unemployed this study focused specifically on the context of abu dhabi and the gulf cooperation council region therefore the findings may not be applicable to other regions or countries with different sociocultural and economic contexts common method bias in this study was investigated by observing the htmt and vif however there have been developments in the field of method bias and more rigorous methods were introduced such as using a post hoc method to test if common method bias 79 80 81 is an issue in the analysis of the study findings for example the unmeasured latent method constructs which may be utilized in followup studies furthermore considering that variables were measured by multiple indicators a confirmatory factor analysis may be beneficial to test the measurement model fit in order to reach more robust results looking at the complex interplay of these variables a longitudinal study design might offer another angle of the social issue related to unemployment and wellbeing additional insights may be reached by tracking peoples experiences in unemployment over time and exploring the duration of the effectiveness of mediating factors data availability statement data available on request from the authors acknowledgments the authors thank the cooperation of all abu dhabi government departments and communities for assisting in the distribution of the survey

research consistently highlights the substantially negative effect of unemployment on subjective wellbeing this studys objective is to provide deeper understanding of the complex nature of the associations between happiness and unemployment which could enrich the duties of social policymakers when designing policy frameworks to improve the wellbeing of the unemployed the methodology in this paper employs a path analysis using the abu dhabi qualityoflife survey third cycle data with 4815 unemployed respondents the present study suggests a comprehensive path model to recognize the most significant associates of the happiness of the unemployed key findings indicate that income satisfaction and the ability to make ends meet have the highest effect on the happiness of the unemployed the model also reveals the strength of different mediation roles played by family connection quality time with family and the ability to make ends meet suggesting that financial difficulties resulting from unemployment can impact social relationships in addition the significant differences found between demographic groups based on age marital status gender and educational attainment are also investigated policy implications are briefly discussed

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introduction volunteer activist leaders are critical for sustaining and growing social movements the environmental movement in particular has grown substantially over the last decade while having a heavy reliance of volunteer groups as such volunteer leaders of environmental activist groups in particular play a critical role in sustaining environmental mobilization over time however activist leaders who engage in intense longterm activism often experience fatigue and burnout indeed research shows that new notforprofit organizations which depend on volunteers often struggle to persist over time effectively supporting volunteers engaging in leadership tasks for these groups remains a significant challenge yet the substantial literature investigating paid leadership is in contrast to the comparative lack of research on volunteer activist leaders who operate in a context with different motivations and incentives previous researchers have pointed to the unique dimensions of voluntary activist leadership volunteer activist leaders must recruit other volunteers mentor them and retain them they help form and maintain relations with partners while maintaining a groups vision and shaping norms about collective action all over the long term without renumeration new research is needed to provide insight into what influences volunteer activist leaders to persist with and balance the myriad tasks required for ongoing social movement mobilization the current study aims to address this research gap by investigating the factors that support volunteer activist leaders in continuing their efforts to do this interviews with environmental volunteer activist leaders were conducted and analyzed through the lens of resource mobilization theory rmt argues that resources underpin the emergence and survival of social movement organizations while rmt has commonly been applied to consider organizations as a whole given that volunteer leaders are crucial for acquiring and converting resources into mobilization and action we reasoned that insights from rmt may also identify factors that support individuals to persist as volunteer activist leaders and provide insights into how to overcome barriers to sustaining such leadership this study contributes to the field in two important ways first the broader leadership literature indicates that leadership behaviors are motivated by factors such as status high renumeration and agency however in the volunteer space the research primarily examines the motivations and characteristics of leaders who are either paid to manage volunteers or lead nonactivist volunteer organizations such as community hobby or sports groups these voluntary associations may have welldefined roles and leadership positions such as president and secretary in contrast volunteer activist leaders have fuzzy illdefined roles no renumeration no particular status and a record of ongoing struggle and failure furthermore research examining volunteer participation in activism most commonly focuses on what motivates individuals to participate in collective action usually on a oneoff or occasional basis these occasional volunteer behaviors may be driven by different motivations than sustained volunteer activist leadership behaviors the current research therefore explores a type of leadership that has not been the focus of past research our second contribution to the field is to extend the rmt framework to interrogate the complex dynamics of volunteer activist leadership the motivations of individuals who are simultaneously resource managers and mobilization resources themselves given the theoretical validity of rmt in explaining longterm mobilization this approach will advance our understanding of how rmt applies to both volunteer activist organizations and the individuals who form them this understanding can then assist volunteer activist organizations in prioritizing the acquisition of resources which may have the greatest impact in sustaining their volunteer leaders theoretical background and research questions resource mobilization theory rmt examines the influence of resources on the emergence and activities of social movement organizations while earlier social movement theories suggested mobilization was driven by irrational alienated individuals sharing a common grievance rmt argued that grievances alone could not explain mobilization instead mobilization is a rational process of organization which develops only when aggrieved individuals can acquire sufficient outside resources to act organizations with access to fewer resources and less capacity to manage them are less able to act on their grievances in general a resource refers to any asset able to be drawn upon by a person or organization to aid their functioning three broad resource categories were identified in early rmt literature human resources such as volunteers and staff material resources such as money or land and organizational resources such as network connections between groups additional categories such as cultural or moral resources have also been identified which can include symbolic objects such as images and icons cultural resources can also include socialpsychological factors such as spiritual values leaders charisma a groups vision and mission and shared identities as well as aiding mobilization rmt postulates that organizations with greater access to resources will be more likely to persist indeed some scholars argue that the primary barrier to ongoing activism is lack of resources rmt therefore may provide a useful lens to consider the factors influencing ongoing volunteer activist leadership given its central role in maintaining activist organizations over time resources and volunteer activist leadership in this section we consider what resources have been identified as important to sustaining activist groups and reflect on the extent to which they may apply to individuals who engage in leadership tasks for those groups sourcing human resourcesindividuals willing to engage in both oneoff and ongoing activities on behalf of the groupis central for social movement organizations given their aim to mobilize large numbers of individuals to act collectively for a cause in general rmt research on the use of resources in volunteer contexts has often assumed that paid human resources will be responsible for the acquisition and management of financial material and other resources that attract volunteers and structure volunteers experiences in contrast social movement organizations primarily depend on volunteers to acquire and manage these resources themselves social movement organizations are often also heavily dependent on longterm volunteers for organizational tasks indeed some studies show that over twothirds of nonprofit groups have no paid staff at all while the majority also have no formal organization status that enables them to acquire or manage financial resources accordingly research has suggested that the most common responsibility of volunteer activist leaders is the acquisition and management of human resources namely recruiting and retaining other volunteers however it cannot be assumed that additional volunteers are necessarily a positive resource for volunteer activist leaders volunteer teams often have high turnover rates and while some volunteers have useful skills others can assist only in unspecialized tasks furthermore volunteer leaders must manage volunteers in an environment where many traditional management processes are less effective they may not have welldefined authority particularly in decentralized or nonhierarchical activist groups as a result of these factors some scholars have also argued that specific leadership related resources such as charismatic authority may play an important role in mobilizing individuals in the social movement context in groups using radical tactics leaders may face a higher degree of personal risk when organizing volunteers in fact traditional command and control management styles may be highly ineffective in volunteer activist groups the growth of movements describing themselves as decentralized or even leaderless suggests that some groups may even reject the idea of leaders entirely instead volunteer activist leaders may find that volunteer demands reduce their capacity to offer longterm leadership similarly material resources such as funding and office space may be challenging for volunteer activist leaders to manage without paid staff to assist while increased financial resources have been shown to increase a groups ability to mobilize individuals research from the broader social movement and activism literature suggests that it can also have the opposite effect consuming time and energy in fundraising reporting and accounting requirements while influencing the type of advocacy organizations can engage in critically research demonstrating that more financial resources are linked to increased activism is based on organizations with paid staff to manage these resources another common resource identified in rmt literature is network connections referring to connections between groups within a larger movement these connections act as a resource as they can increase a groups recruitment opportunities and facilitate informationsharing however as with human and financial resources volunteer activist leaders may find network connections difficult to manage lack of time to establish and maintain connections alongside competition among groups can impact network strength given these mixed findings the extent to which network connections and material resources enable volunteer activist leaders to sustain their efforts in the longterm remains unknown outside of rmt research some studies suggest that positive interpersonal connections can influence individuals participation in activism over time feelings of empowerment solidarity commitment connection to the cause belonging and friendship with others in the group can be drawn upon by volunteer activist leaders as resources which facilitate their ongoing participation collective identities and shared struggles may also play important roles as psychological resources binding individuals to movements these findings suggest that volunteer activist leaders with stronger and more positive social relationships with group members may continue their volunteer efforts for longer the current study a wide range of resources have been identified as important for sustaining groups engaging in activism yet despite volunteer leaders critical roles in organizing these groups we know comparatively little about the resources which specifically support and sustain them given that sustaining activism over time is difficult this study seeks to advance our understanding of resources which may assist environmental activist groups to retain their voluntary leaders this is important when considering that leaders may exit groups due to mental or emotional exhaustion the loss of these leaders can then lead to reduced organizational effectiveness or even the decline and disappearance of volunteer organizations in their entirety better understanding what resources volunteer activist leaders need to continue their leadership is therefore beneficial in light of the importance of social mobilization in driving the changes needed to address our environmental crisis in this study we focus specifically on environmental activist volunteer leaders experiences we conducted a qualitative analysis of semistructured interviews with 21 environmental volunteer activist leaders to identify what resources they use and how these resources influence their sustained voluntary engagement in leadership behaviors to help shed light on this topic we examine the following three research questions • what resources do volunteer activist leaders identify as important to their role • what barriers and opportunities do volunteer activist leaders associate with these resources • how do they perceive that these resources influence their volunteer leadership activities and ongoing service method participants volunteer activist leaders were recruited through contacting specific environmental groups identified in the australian environmental movement to ensure a diversity of participants we contacted groups who were active in different australian regions and focused on different environmental issues groups were asked to share the interview request with their teams to ascertain interest with 21 activists offering to participate all interviewees engaged in leadership activities such as organizing or leading projects or the group the sample comprised 14 women and 7 men aged 23 to 80 their experience of activism with local grassroots groups entirely dependent on volunteers ranged from 5 to 40 years a total of nine participants undertook activism on conservation and protection issues such as the preservation of forests and marine environments seven participants focused on climate change with the remaining five participants focusing separately on sustainability mining nuclear pollution and renewable energy issues procedure interview questions covered five broad areas the activists personal motivation to engage in activism their campaigning goals their strategic and tactical campaign approaches their engagement with other groups within the broader environmental movement and their experiences as volunteer leaders questions were asked in broad terms in order to gather a wide perspective on participants use of resources without specifically leading activists to prioritize or identify any one resource over another the interviews were semistructured enabling participants to freely discuss their perceptions experiences and opinions about environmental activism within each of the five broad areas participants were prompted with follow up inquiries such as could you explain that further or why do you think the outcome was a successfailure all interviews were conducted by the first author and took place in may 2018 either in person or via telephone the interviews lasted on average one hour and were recorded and transcribed analytic procedure transcribed interview data was coded through a thematic qualitative analysis process following braun and colleagues this process involved a first stage of repeated close reading of all interviews to gain a comprehensive sense of the material a list of resources that interviewees said they drew upon in order to maintain or enhance their leadership activities was then collated following this a coding frame based on the themes identified in round one was created to guide a second round of deductive coding undertaken using nvivo software text excerpts identifying resources mentioned by participants were then reviewed to identify whether participants stated that the resource was useful or not useful in supporting their ongoing activities all coding was undertaken by the first author of this study with 20 of the data secondcoded in three stages of review and discussion intercoder reliability was selected as the method to ensure credibility of results and prompt discussion of a common conceptual framework across the research team assessing reliability was considered relevant for this study given that rmt literature provides welldefined resources relevant for organizations that our data could be compared against the final krippendorffs alpha and cohens kappa reliability scores was 0848 indicating a high level of agreement between coders results resources six resources important for helping volunteer activist leaders achieve success emerged from the data time network connections money volunteers social relationships and community support time was the only resource unanimously described by all 21 participants as both sought after and providing a universally positive influence on their ability to engage in volunteer leadership tasks however time was also the resource all volunteer leaders described as being the most difficult to acquire participants highlighted how managing the resources of network connections money and volunteers was a difficult balance to maintain within the limited time resources available and in some cases reduced their ability to prioritize mobilization in the following sections we highlight each of these six resources and the ambivalence felt relating to their acquisition and management time time was the resource most desired by volunteer activist leaders with all participants saying they would prioritize gaining additional time over other resources furthermore unlike the two other resources mentioned by all participants there was no ambivalence or management challenges related to increased acquisition of time unsurprisingly a lack of time not only affected activists ability to recruit manage and retain their group members but also to design and implement their campaigns we didnt take that step of creating the campaign because of the time constraints i think thats the problem a lot of volunteers have on top of everything else that theyre doing just literally the fight thats involved and the emotional stress and strain and everything else its pretty demoralizing network connections the support provided by network connections with other groups was also mentioned by all 21 participants however significant ambivalence was expressed regarding the benefits and constraints of this resource many participants highlighted the positive support they have received from other environmental groups and the impact this made on their ability to succeed we do quite a bit with the other environmental group they were great they actually mentored us we got a grant which gave us funding to set our group up through that we engaged the other environmental group to send up one of their members to mentor us for 3 or 4 days to get some planning going yet despite the benefits of this resource most participants also noted that collaborating with other groups was challenging and often ineffective collaboration was particularly fraught when volunteer activist leaders sought to engage with staffed environmental groups with greater resources maintaining effective network connections took substantial time especially when these connections broke down or conflicts arose in addition some participants argued that poor network connections in general had resulted in the failure to build a strong united and powerful environmental campaigning sector about 10 years ago there was an alliance of all the big groups set up to speak to the government but for some reason that fell over or didnt achieve anything… i dont know how to do it but i know were not doing it i dont know what the answer is the small groups are pivotally important in their area theyre doing fabulous things its just theres no big picture money all 21 volunteer activist leaders discussed this resource as with network connections participants were ambivalent about prioritizing the acquisition of money with many participants also noting the complexity of how money can influence tactics and movement legitimacy some participants listed concrete campaign wins and other positive outcomes that money had enabled we managed to get a 20000 grant to run a research project in the local forest with the partner organization we set up 30 research sites and involved over 100 community members those sites are still there and still being researched over 10 years later however participants also noted how acquiring managing and acquitting funds often drained their time and energy which could be better focused on other activities the influence of money on tactical choice and organizational security was also identified by some participants environmental groups found that their access to funds affected their autonomy and strategic choice some volunteer activist leaders highlighted that while money enabled the acquisition of material resources such as office space and advertising the absence of funding provided greater freedom in their mobilization choices and personal values the sort of work we do is direct action… a donor would have to be quite secretive about it and certainly nobody would give you tax deduction… i dont think people who are trying to bring down a really deeply unfair and ecocidal economic system are typically paid very well volunteers twenty participants mentioned volunteer resources volunteers were critical in helping volunteer activist leaders achieve their goals however volunteer recruitment and retention were consistently identified as challenging this was predominantly due to the high demands that were placed on volunteer activist leaders to mentor train and manage new volunteers participants distinguished between volunteers who were able to complete welldefined tasks and volunteers who had initiative and were able to work autonomously participants argued that volunteers generally required high levels of training support and management and so volunteers with initiative were highly valued we make it clear to new volunteers that were already at full capacity ourselves if you want to be part of this you need to become part of the project team and take responsibility for yourself well skill you up and train you but were not going to be doing a long mentoring process we need you just to jump in boots and all … because that is quite a big ask our volunteer base for the actual projects committee and the management is quite small volunteers skills were also identified as important resources which could increase how efficiently volunteer activist leaders could organize their groups activities for example skills related to financial management and income generation were highly valued we do everything without money except with this campaign our volunteer is such a genius he decided that we needed to do a crowd funding thing and we did and we got 10000 so that campaign was very professional however many participants highlighted how voluntary leadership skills were different from taskfocused volunteering voluntary leadership skills were highly sought after by other volunteer leaders primarily because they had firsthand experience of the volume of work leadership roles entailed its easy to be a volunteer but being that next level volunteer is harder because you have more mental work you cant necessarily work as much in your other job because youve got to spend your time replying to emails thinking about how the meetings are going to be run contacting people for this and that organizing events thinking about how its going to go and matching up all the dots that sort of thing is a huge amount of work huge social relationships while rmt notes the importance of network connections between groups these connections also exist between leaders and their group members as well as between individuals within groups participants frequently noted that the quality of these peer connections was of critical importance in their own ongoing engagement in activist leadership twenty participants specifically highlighted the importance of positive social relationships in sustaining their activities primarily relationships with other volunteers within their groups these relationships generated ongoing positive emotions and participants described these relationships as critical to maintaining their ongoing desire to continue their volunteer work relationships functioned as personal rewards accrued through their volunteering i just love it i just love it ive learnt so much i spend time with really great people i hang out with scientists i am in the forest i can read the forest more i just love it i cant believe i got so lucky participants highlighted a range of positive emotions connected with these social relationships these included emotions such as joy solidarity and love which some participants linked to their sense of purpose and meaning you know its been very enriching to my life also to have such a strong purpose and to work with really awesome people community support community support was identified by 18 participants as an important and beneficial resource this was primarily due to the perception that community support could influence an environmental groups ability to prosper as well as increase opportunities to obtain other resources such as volunteers ive lived in other communities where i wouldnt be contemplating forming a group … but there have just been some historical events in our town that have allowed people to make some interesting decisions about shared ownership recycling and environmental care that make our campaign goal seem possible discussion volunteer activist leaders form the core of social and environmental movements and yet little is known about the factors which influence their sustained engagement in leadership behaviors in this study we interviewed 21 environmental volunteer activist leaders to identify the resources that helped or hindered their ongoing engagement in leadership activities six resources were identified that volunteer leaders identified as important to their role time network connections and money were resources mentioned by all participants while volunteers social relationships and community support were mentioned by most but not all participants our second research question considered the barriers and opportunities associated with these resources in line with classical rmt theory financial and human resources were focal for volunteer leaders money and volunteers were both seen to offer opportunities for volunteer activist leaders to increase the ability of the group to achieve their aims however volunteer activist leaders experienced significant barriers in acquiring and using these resources most particularly if they did not already have sufficient financial and human resources to assist with administrative burdens indeed unskilled volunteers could consume more resources than they produced due to training mentoring and supervision obligations our findings demonstrate that resource availability directly influences environmental volunteer activist leaders decision making for example participants noted how increased financial resources offered opportunities to expand activities while simultaneously presenting barriers to action some participants highlighted how financial resources facilitated longlasting projects however others noted how financial donors could influence the use of more radical or disruptive mobilization tactics some volunteer activist leaders sought to avoid this influence by undertaking zerocost activities or engaging in nonconfrontational activities others accepted that their choice to engage in radical tactics dictated a reliance on volunteer labor with little financial support furthermore our data provide further evidence of how network connections between and within groups can influence volunteer leadership some participants noted how their network connections provided strategic and financial support to their group however they also noted that establishing and retaining network connections demanded significant time while collaborating with network partners on projects could lead to disagreements around tactics and strategy research question 3 considered how these resources appeared to affect volunteer leaders activities and ongoing service as highlighted by a number of scholars choosing between resources involves tradeoffs between how the resources could be used and the administrative burden required to manage them however three of the six resourcestime positive relationships and community supportwere mentioned as resources which helped volunteer leaders sustain their activities without requiring tradeoffs or presenting barriers while rmt posits that network connections will be beneficial for sustaining groups our data suggest that the quality of the personal relationships within these networks may also be important positive relationships can be a resource of particular value to individuals themselves and this may be particularly important for individuals in voluntary leadership roles the beneficial role of these resources is consistent with other work in rmt showing relationshipswhether between groups or between individualsare important to volunteer groups our research focus was on volunteer leaders individuals who influence and engage with groups and therefore by necessity need to build relationships with other group members accordingly although our results support rmt in the resources that were identified by volunteer activist leaders we found that the resource which appeared to play the most important role in sustaining volunteer activist leaders was the personal relationships they formed within their teams these relationshipsmore than financial or human resourcesgenerated strong positive emotions which could bind teams together by fostering feelings of joy love and empowerment applied implications our findings suggest three areas where organizations can manage resources to better retain their volunteer activist leaders first larger organizations with greater resources can play an important role in helping volunteer activist leaders through provision of resources of particular value would be providing financial support or skilled volunteers these two resources may be especially helpful for sustaining smaller volunteer groups at early stages in their development our findings demonstrated how balancing financial and human resources created a catch22 for our participants resources could only be obtained if volunteer activist leaders already had the resources to acquire them as a result organizations with greater resources could seek to assist volunteer leaders by supporting the retention of skilled independent and motivated volunteers particularly skilled volunteers able to shoulder the burden of acquiring and managing financial and material resources to be distributed to others another avenue for support could be via building partnerships with businesses willing to offer pro bono services to environmental organizations which could provide financial management services as well as help develop networks and build organizational capacity skills and knowledge second participants noted how network connectionswhile challenging to initiate and managehad afforded mentoring and project development support at critical moments in their groups development those aiming to support a growing environmental movement could seek to organize and manage networking services such as events which bring together volunteer groups without adding substantial demands on volunteer activist leaders reducing competition between volunteer groups for example over grant opportunities could also assist in building network strength one mechanism for enhancing network connections is through fostering the development of movement infrastructure groups these can include groups which exclusively focus on the provision of training human resources management or funding services the development of movement infrastructure groups also offers promising avenues for supporting volunteer activist leaders in the postcovid19 context these groups could seek to build shared online spaces that facilitate relationship building and peersupport between volunteer activist leaders working on similar issues in different geographic contexts similarly centralized activism volunteering hubs could be developed potentially increasing volunteer recruitment by listing both inperson and remote volunteer activism opportunities third and most importantly positive social relationships within groups played a critical role in sustaining environmental volunteer activist leaders positive social relationships have been shown to support longterm activists to gain a sense of purpose from the environmental activism they engage in these positive feelings may help balance the anger and frustration which can drive initial participation in activism relatedly some research indicates that intrinsic motivation may be an important driver of activist behavior particularly when combined with enjoyment in undertaking those behaviors strong relationships with others in the group may therefore be a prerequisite to building the sense of belonging purpose and enjoyment which may sustain volunteer environmental activist leaders and their groups accordingly organizations should seek to develop and offer free and easy to access services specifically aimed at nurturing positive relationships in teams these can include group relationship building strategies mediation and on demand psychological support these services could be provided by larger established organizations which may help smaller groups foster positive group relationships and support any volunteer activist leaders who may seek help strengths limitations and future research the present research benefits from rich interview data with a range of environmental volunteer activist leaders many with decades of experience however given leaders close relationships with group members it would be of value to undertake a comparative analysis which compares insights on the resources which support volunteer activist leaders to those that support activists who are not leaders future research should also consider comparative analysis with volunteer activist leaders who have exited or are new to their roles in addition our study seeks to examine experienced environmental activist volunteers perceptions and experiences of the resources that sustain their leadership behaviors future research could build on literature noting the importance of leadership characteristics such as charisma to examine how particular leadership characteristics influence the mobilization and retention of group members over time furthermore while the focus on committed activists from a range of grassroots and professional groups is a strength of this study our findings are grounded in a single sociocultural context in australia environmental activism is largely able to occur freely despite a divisive political atmosphere activists therefore experience leadership in very different ways from those operating in more authoritarian or violent contexts where environmental activists and leaders have been kidnapped and murdered in recent years moreover our study population was ethnically homogenous and predominantly female identifying taken together these limitations imply caution in generalizing the findings reported in this study to a broader population of individuals involved in environmental activism leadership and a need for crosscultural and comparative research in future conclusion volunteer activist leaders play a critical role in driving the grassroot environmental activism required to address our global environmental crisis in this study we examined the resources which help or hinder volunteer activist leadership of environmental groups while financial human and network connection resources could support volunteer activist leaders to sustain their activities they were not always prioritized given the additional administrative requirements they generated conversely increased time community support and positive relationships were the resources most desired by volunteer activist leaders participants highlighted the importance of positive social relationships which generated positive joyful experiences sustaining their volunteer efforts and promoting their sense of purpose these findings indicate the importance of resources in understanding why some volunteer activist leaders persist over long periods of time despite ongoing declining environmental indicators and a worsening environmental crisis author contributions rg conceptualization methodology investigation data curation writingoriginal draft writingreview editing project administration cp writingreview editing kf conceptualization methodology writingreview editing supervision wl conceptualization methodology writingreview editing supervision funding open access funding enabled and organized by caul and its member institutions charlie pittaway was supported by australian government research training program scholarships but received no direct financial support for the authorship andor publication of this article publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

environmental activism organizations depend on recruiting and retaining individuals willing to engage in leadership tasks on a voluntary basis this study examined the resources which help or hinder sustained environmental volunteer activist leadership behaviors interviews with 21 environmental volunteer activist leaders were analyzed within a resource mobilization theory framework while six resources supporting sustained engagement in volunteer activist leadership behaviors were identified only three were sought by all participants time community support and social relationships money volunteers and network connections were considered valuable resources however their acquisition generated significant additional administrative burdens social relationships sustained volunteer activist leaders through fostering feelings of positive emotions connected with the group we conclude with suggestions for organizations seeking to increase retention of activist volunteer leaders namely larger organizations sharing their resources to reduce administrative demands on volunteer activist leaders in smaller organizations developing movement infrastructure groups to build and sustain networks and the prioritization of positive relationships within volunteer teams

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introduction 3 the first few decades of the twentyfirst century have posed innumerable questions and challenges to humankind about the present and the future thus generating high levels of anxiety and fear that are closely related to the unpredictability of the future and the threats that challenge human beings survival on earth anxiety and fear are also characteristic of a period that is marked by a myriad of changes in a diversity of fields that suggest a paradigmatic change in the project of modernity at the turn of the twentieth century into the new millennium these changes however have not been abrupt in fact scientists have not ceased warning that life on earth has been increasingly in jeopardy due to environmental degradation the pandemic has brought new economic societal and political challenges and it has disrupted consolidated globalization processes that were called into question when the planet was put to a halt it is unclear however whether the world has learned or unlearned the lessons taught by covid19 4 moreover the unpredictability of the future revolves around multiple concerns such as the future of peace and stability in europe when war has returned to the continent after decades of peace thus reviving the specter of a nuclear conflict 5 the controversy over whether artificial intelligence represents a huge scientific development or a threat to humankind and the reality of space tourism even when the globalization of poverty contributes to the existence of more than eight hundred million hungry people in the worldthe truth is that the list of anxieties and threats seems to be endless this essay attempts to bring together as well as put into dialogue the texts of two renowned observers and thinkers of our time pope franciss encyclical letters laudato si and fratelli tutti and the philosopher byungchul hans books the burnout society and the palliative society pain today pope francis is undeniably one of the most important influential and controversial world leaders currently and he is one of the most acute critical voices speaking against egoistic ways of living which are characterized by the prevalence of ones views and uncompassionate attitude toward the other and toward the planet which has been ruthlessly exploited han is a south koreanborn philosopher interested in the current state of modernity and its evils and he has focused his attention on topics such as societys alienation individual narcissism and the effects of the preponderance of the digital order on peoples lives among others though averse to intense social interaction and to interviews he has gained media visibility in recent years due to his prolific production of short philosophy books written in relatively simple language his books have reached a large readership thus consolidating his reputation as a contemporary thinker acutely aware of the cultural forces that degrade our humanity and hinder our flourishing 6 both thinkers notwithstanding the diverse nature of their texts demonstrate a true and genuine preoccupation with the future of the planet of human beings and of the nonhuman world the selection of my corpus results from the fact that all the texts under analysis thoroughly diagnose the evils of twentyfirst century society from different perspectives and call readers to action in various ways with a view to building a diverse future that is anchored on a culture that rests on responsibility ethics justice solidarity and fraternity even if at diverse levels all these texts have a programmatic dimension that displays a common preoccupation to care for what pope francis has called our common home 7 before moving on with my reflection it is important to clarify what led me to focus on these authors and these texts my interest in the common home started with the publication of the laudato si encyclical in 2015 in which pope francis not only warns about the deplorable state of the planet and its attendant environmental social cultural and economic implications but also calls for a cultural revolution with a view to caring for the planet this interest increased after participating in the research project common home and new ways of living interculturally public theology and ecology of culture in pandemic times at universidade católica portuguesa in lisbon 8 in april 2023 byungchul han came to lisbon to deliver one of the conferences commemorating the 50th anniversary of fch 9 titled the spirit of hope in this lecture the germankorean philosopher emphasized how his confessed spirituality as well as his cultivation of meditation and of a contemplative life have shaped his thought he also shared with the audience some aspects of his personal daily life and confessed that in the evenings he liked to wander unnoticed around berlin neighborhoods collecting magnolias his favorite flowers the contemplation of the beauty of magnolias at his home had according to his account the power to inspire him and to fill him with wonder the image of a philosopher waiting for darkness to fall so that he could collect blooming magnolias from berlin streets reminded me of how unique and thrilling the experience of awe can be and how the frenetic rhythm of contemporary life that has been imposed on us has increasingly deprived us of it to define awe i refer back to the first epigraph i selected for this essay taken from a chronicle written by the poet tolentino mendonça entitled turning to awe awe constitutes a rupture with the ordinary and routine humdrum setting in which we operate and in relation to which we have become indifferent however we only need this instant of grace to intuit the possibility of a deeper and more prodigious relationship with the real my interest in the common home intensified during and because of the pandemic when the unimaginable happened and the whole world was brought to a halt believers and nonbelievers did not remain indifferent to the image of pope francis in a completely empty vatican city on 27 march 2020 when he held an isolated service to pray for the end of the pandemic for those who were seriously ill or had lost their lives and for humanity as the pandemic touched us all 10 although it is obvious that special prayer during a rainy evening in the lent of 2020 was primarily a religious event i prefer not to evoke it from a religious perspective which explains why i do not intend to discuss the references to god or to the bible in the prayer 11 i opt to envisage the empty saint peters square of that evening as the microscosm of a sick planet and the solitary old man in white habit as a sage who by inviting people to join him regardless of faith ethnicity nationality or social status drew their attention to the fragile condition of ones existence and urged the community to care for the common home when attempting to characterize pope franciss evening prayer i associate it with a moment of awe due to its exceptionality and symbolism in fact the event enables me to reflect on awe as a feeling in its semantic richness of wonder dread terror astonishment and bewilderment according to the merriamwebster dictionary awe derives from the middle english aw awe ahe evoking ideas of terror dread extreme reverence veneration something to be feared danger and through successive borrowings from other languages including greek the notions of pain and distress 12 when people saw pope francis crossing saint peters square alone they were not thrilled despite being touched by the popes empathetic gesture of praying for the collective welfare regardless of peoples beliefs of attempting to soothe tormented souls of transmitting confidence strength and courage in the future people were aware of the vulnerability of human beings the awe then experienced was associated with the disruption the shock the terror and the fear resulting from the pandemic and its nefarious effects at that moment the whole world feared what might happen but that evening in march represented something else it was also a moment of revelation of the fragile condition of the planet and of human beings that called not only for a different relationship with the real but that to some extent also rendered the whole of humanity accountable for the future in other words the sickness of the world was not exclusively due to the pandemic what the pandemic did was to lay bare how sick the world was and to remind human beings of their indifference and numbness towards individual andor collective misfortune as the passage below evinces pope francis suggests in his homily that the pandemicstorm signals a much more serious malady that of human beings blinded by greed and egocentrism 13 the storm exposes our vulnerability and uncovers those false and superfluous certainties around which we have constructed our daily schedules our projects our habits and priorities it shows us how we have allowed to become dull and feeble the very things that nourish sustain and strengthen our lives and our communities the tempest lays bare all our prepackaged ideas and forgetfulness of what nourishes our peoples souls all those attempts that anesthetize us with ways of thinking and acting that supposedly save us but instead prove incapable of putting us in touch with our roots and keeping alive the memory of those who have gone before us we deprive ourselves of the antibodies we need to confront adversity the reference to the blindness of human beings leads me to my second epigraph taken from josé saramagos epigraph to his novel blindness if you can see look if you can look observe in a novel that many critics consider a dystopia saramago discusses a collective blindness an epidemic that he associates with a blindness of reason proposing a deeper level of visual acuity the novelist plays with the meaning of the verb reparar which in portuguese means both to notice to observe and to mend to repair or to fix which is not evident in the translation into english drawing on saramagos aphorism and on the context of a novel that depicts the humanity of human beings during an epidemic of blindness i contend that the experience of observing in its blend of meanings can be related to an experience of awe understood both as horror and fear wonder and revelation far from suggesting that pope franciss encyclicals and byungchul hans texts respond only to the concerns of the nobel prize laureate i argue that they engage with saramagos association of visual acuity with care in their diverse ways of presenting a thorough diagnosis of contemporary society and of its ills 14 what pope francis and han propose is ultimately a turning to awe 15 without which the future will be somber the selection of these texts is also related to the fact that laudato si and the burnout society were written before the pandemic and fratelli tutti and the palliative society appeared in 2020 during the pandemic i contend that the latter texts not only complexify and refine some of the main issues raised in laudato si and the burnout society but also offer solutions to navigate through these issues with a view to putting the texts that compose my corpus into dialogue i have identified topics that i consider central to both authors reflections and around which my reflection will revolve the common home its maladies and the call for renovation from fear and discipline to numbness the call for caring for the common home and the search for the culture of encounter caring for the common home pope francis and byungchul han in dialogue the common home is the designation pope francis uses to refer to the planet earth in his encyclical letter laudato si the expression should not be understood as a rhetorical expedient used to embellish the text in fact by referring to the planet as the common home pope francis is investing the concept with diverse meanings as the planet is not understood as a simple dwelling place or the habitat for a wide range of species it is presented as a home a space invested with affect 16 where people feel they are welcome and belong to but to pope francis the earth is more than home it is a common home which implies a sense of belonging to a community to a family and renders the members of the household responsible for it because pope francis views the planet as a common home he entreaties all people of good will regardless of faith to reflect on which planet future generations will inherit the sense of belonging is made explicit in the first lines of the encyclicals preamble when evoking saint francis of assisi the earth is presented as a sister 1 laudato si mi signorepraise be to you my lord in the words of this beautiful canticle saint francis of assisi reminds us that our common home is like a sister with whom we share our life and a beautiful mother who opens her arms to embrace us praise be to you my lord through our sister mother earth who sustains and governs us and who produces various fruit with coloured flowers and herbs because the earth and nature are sisters they suffer together it is in the second paragraph of the encyclical that pope francis places human beings as perpetrators of the harms inflicted on earth and nature associating the earth with the most abandoned and maltreated of our poor the characterization of the common home is deeply inspired by the figure of st francis of assisi who epitomizes the example of care of an integral ecology of humanityin sum of someone who was open to awe and wonder as the excerpt from paragraph 11 illustrates 11 if we approach nature and the environment without this openness to awe and wonder if we no longer speak the language of fraternity and beauty in our relationship with the world our attitude will be that of masters consumers ruthless exploiters unable to set limits on their immediate needs by contrast if we feel intimately united with all that exists then sobriety and care will well up spontaneously the poverty and austerity of saint francis were no mere veneer of asceticism but something much more radical a refusal to turn reality into an object simply to be used and controlled the popes concerns with the common home are further expanded in the first chapter of the encyclical entitled what is happening to our common home it is in the third chapter that pope francis discusses in more detail the human roots of the ecological crisis in chapter four he proposes an integral ecology that presupposes the convergence of environmental economic social cultural and moral preoccupations the accomplishment of this integral ecology implies a diverse positionality of human beings towards the environment culture and the other without which the respect for the environment and the end of inequality and injustice will not be viable byungchul han does not use the expression common home or refer to it in the terms proposed by pope francis however the philosopher recognizes that the world and human beings in particular are ill and need to undergo a process of healing in the burnout society he confronts life in the twentieth and twentyfirst centuries positing that the current century epitomizes a paradigmatic shift that implies the disappearance of otherness an aspect to which i will return his characterization of both centuries rests on landscapes of pathologies he contends that the twentieth century corresponded to an immunological age characterized by the dominance of an immunological pattern epitomized by a distinction between inside and outside friend and foe self and other this pattern rested on a dialectic of negativity considered a fundamental trait of immunity as the own asserts itself in and against the other by negating its negativity 17 the immunological age was marked by an immunological rejection that implied the negation rejection andor extinction of the other it is illustrated by the disciplinary society defined by the negativity of prohibition and mechanisms of coercion and repression and whose negativity produced madmen and criminals the twentyfirst century on the other hand is characterized by the dominance of neuronal diseases such as depression attention deficit hyperactivity disorder borderline personality disorder and burnout syndrome contrary to what happened in the previous century and because neuronal diseases follow the dialectic of positivity the current century is poor in negativity according to han harm can also come from positivity as it comes not only from the other or the foreign but also from the same in hans argumentation as the same does not lead to the production of antibodies the twentyfirst century is characterized by a nonimmunological rejection in other words rejection exists but it is a response to an excess of positivity that manifests in exhaustion fatigue and suffocation that are nonimmunological reactions han calls the society of positivity an achievement society a society of the yes we can due to its positive orientation expressed in a plethora of projects initiatives and motivation this achievement society is fueled by an excess of stimuli information and impulses producing therefore multitasking and hyperactivity that compromise the ability to contemplate and experience awe because achievement subjects are expected to cope with the excess of work and to attain high levels of performance they become predators and preys of themselves and are caught in a spiral of selfexploitation and narcissism that produces depressives and losers who listen mainly to themselves and whose ego is constantly fed by social networks this selfcenteredness results on the one hand in the progressive disappearance of the other on the other hand han posits that the achievement society evolves into a doping society the characteristics han attributes to the achievement subject are mirrored in laudato si when pope francis underlines how humanity has changed calling for the refusal of a superficial consumerist and monotonous society dependent on technology and its novelties which may be conducive to escapism and emptiness that prevent the experience of awe even if pope francis does not openly refer to human beings as predators and preys of themselves as postulated by han in the burnout society pope francis argues for a bold cultural revolution whose principles might be translated by saramagos aphorismif you can see look if you can look observe what is at stake here is not a more refined degree of acuity it is the portuguese meaning of to observe that ultimately implies that if human beings are not healed the planet cannot be cared for 113 but humanity has changed profoundly and the accumulation of constant novelties exalts a superficiality which pulls us in one direction it becomes difficult to pause and recover depth in life if architecture reflects the spirit of an age our megastructures and drab apartment blocks express the spirit of globalized technology where a constant flood of new products coexists with a tedious monotony let us refuse to resign ourselves to this and continue to wonder about the purpose and meaning of everything otherwise we would simply legitimate the present situation and need new forms of escapism to help us endure the emptiness 114 all of this shows the urgent need for us to move forward in a bold cultural revolution science and technology are not neutral from the beginning to the end of a process various intentions and possibilities are in play and can take on distinct shapes nobody is suggesting a return to the stone age but we do need to slow down and look at reality in a different way to appropriate the positive and sustainable progress which has been made but also to recover the values and the great goals swept away by our unrestrained delusions of grandeur the cultural revolution proposed by pope francis is hindered by the state of permanent anaesthesia that characterizes the palliative society han talks about because this society is dominated by algophobia it has become a society of survival that avoids reforms and transformations this reluctance derives from peoples fear or inability to endure pain because as han points out pain is negativity par excellence since the achievement society is dominated by positivity it is easy to understand why pain should be avoided at all costs inspired by nietzsche who refers to health as a form of incorporating pain han argues that p ain shakes up the habitual relations between meanings and forces the mind into a radical change in perspective that shows everything in a new light as opposed to pleasure pain triggers processes of reflection it gives the mind a dialectical clarity par excellence it makes the mind more perceptive it opens up a whole new way of seeing this another kind of visibility provided by pain counteracts the anesthesia resulting from the digital order that by responding to impatience and the compulsion of immediate access not only fragments attention and the experience of lingering making the world lose its aura its scent but also promotes the decline of human beings capacity for empathy according to han this decline is associated with the disappearance of the other as t he palliative society eliminates the other as pain the other is reified into an object the other as an object does not cause pain han posits that t oday we are utterly dominated by the egoeven dazed intoxicated by it the increasingly strong narcissistic ego in confronting the other mainly meets itself when it meets the other digital media also tends to promote the disappearance of the other by making the other available it diminishes the resistance of the other we find it increasingly difficult to perceive the otherness of the other the other deprived of his or her otherness can only be consumed a sensibility for the other presupposes an exposure that offer s itself even in suffering this is pain without this primordial pain the ego rears its head again its foroneself and reifies the other into an object the other is withdrawn from the grasp of the ego only with the egos pain of being exposed this pain as an ethical metaphysical pain precedes the kind of pain which i experience as mine it is a pain towards the other an original being exposed that is more passive than any passivity of the ego the pain of exposure which also precedes compassion renders a comfortable return to oneself the pleasure in oneself impossible the experience of pain causes disturbance and paves the way for the other because by exposing ones vulnerability the other ceases to be objectified in other words the vulnerability caused by pain brings not only the consciousness of the other but also makes compassion possible out of the texts under discussion the encyclical fratelli tutti 18 besides responding to many of pope franciss concerns in laudato si and hans preoccupations in the burnout society and the palliative society is the text that clearly offers solutions to human beings maladies in late modernity 19 inspired once more by the example of st francis of assisis life and work in the 2020 encyclical pope francis reminds us that the care for the common home is dependent on individual and collective efforts moreover he further elaborates on the suggestion made in laudato si that a cultural revolution is necessary to care for the common home this cultural revolution presupposes a new vision of fraternity and social friendship when l ocal conflicts and disregard for the common good are exploited by the global economy in order to impose a single cultural model grounded on limitless consumption and expressions of empty individualism this single cultural model is translated into a throwaway culture that not only discards people in a variety of forms such as racism but also fuels the fear of the other as a kind of barbarian to be defended from at all costs this cultural model leads to the construction of a culture of walls that prevents the encounter with other cultures and peoples pope francis connects the vilification and disappearance of the other with globalization and associated media developments he argues that despite having the potential to help construct a universal fraternity and foment a culture of encounter globalization processes have contributed to the globalization of indifference delusion and isolation which in line with hans reasoning is mirrored in the hollowness and vacuity of digital relationships because social media and digital technologies have brought the illusion of friendships in place of a culture of encounter they do not really build community instead they tend to disguise and expand the very individualism that finds expression in xenophobia and in contempt for the vulnerable in fratelli tutti the parable of the good samaritan is central to the discussion of the relevance of the culture of the encounter to care for the common home 20 the parable discusses how fraternal love is not conditioned by social economic or religious status as pope francis aptly notes in paragraph 62 love shatters the chains that keep us isolated and separate in their place it builds bridges the example of the good samaritan and the practice of fraternal love can therefore be the antidotes to help the achievement subjects of the palliative society to cope with pain and acknowledge the other in their difference this possibility is grounded on paragraphs 6567 of fratelli tutti where people of good will are invited to create and implement a new kind of social bond that will dignify the existence of human beings and resist social and political inertia as the extract from paragraph 67 illustrates the parable shows us how a community can be rebuilt by men and women who identify with the vulnerability of others who reject the creation of a society of exclusion and act instead as neighbours lifting up and rehabilitating the fallen for the sake of the common good at the same time it warns us about the attitude of those who think only of themselves and fail to shoulder the inevitable responsibilities of life as it is pope francis uses the parable of the good samaritan to present what he considers the paths of hope for the common home they are associated with a movement beyond oneself towards the other through bonds of friendship and love the pope contends that life does not exist without the interaction with the other for i n the depths of every heart love creates bonds and expands existence for it draws people out of themselves and towards others moving beyond oneself to encounter and love the other for who they are enables the creation of a social friendship and constitutes a possible solution to heal the achievement subjects of the palliative society who are caught in the trap of individualism 21 in fratelli tutti pope franciss reflection goes far beyond hans as the pope elaborates on the characterization of those who can be considered as the other the other encompasses all those who because they have a disability or some kind of disadvantage are considered a burden to society pope francis calls them existential foreigners or the hidden exiles who despite being citizens with full rights are treated like foreigners in their own country the implementation of social friendship and fraternity implies the acknowledgment of the worth of every human person always and everywhere everyone is called on to be solidary once we are responsible for the fragility of others as we strive to build a common future solidarity is seen first and foremost as a service to people and not to ideas which explains why it should never be ideological pope francis in sum calls for a global ethic of solidarity and cooperation which is a powerful strategy to resist the propagation of fear and mistrust that feeds various conflicts around the world 22 the cultural revolution resting on the cultivation and practice of fraternity based on social friendship and solidarity as suggested by pope francis can promote a diverse type of globalization in which the global and the local are interconnected and the differences among peoples are acknowledged and respected this way of caring for the common home potentiates the creation of a new global order that implies a better kind of politics which is key to the globalization of the most basic of human rights the implementation of this improved politics is dependent on the practice of social dialogue a fundamental ingredient to prevent and work through conflicts and to construct the most desired culture of encounter that will lead to individual and collective peace conclusions through the discussion of the ills of contemporary society all the texts under analysis illustrate in different ways how our common home is undergoing a period of major overhaul as to what can be considered a paradigmatic change in other words a period that points to a novel rupture to a new crisis in the project of modernity which is connected to the implications derived from various aspects such as hegemonic neoliberal globalization processes ecocide 23 and what can be considered a new moment of decentering identity and the subject in late modernity that deserves further analysis as far as this last aspect is concerned it is worth recalling stuart halls premise in the chapter the question of cultural identity in a book curiously titled modernity and its futures edited by hall held and mcgrew hall posits that conceptualizations of the subject change and therefore have a history according to hall in the period of late modernity the modern subject faced five major moments of decentering that are related to a series of ruptures in the discourses of modern knowledge the traditions of marxist thinking the impact of freuds discovery of the unconscious de saussures reflection on language as a social system foucaults disciplinary power and the impact of feminism both as a theoretical critique and as a social movement to halls list i would like to add a new moment of decentering the subject and identity that of the dominance of the achievement subject proposed by byungchul han a subject who lost in navelgazing and unable to cope with the negativity represented by the experience of pain lives in a state of numbness as a kind of blind man despite being able to see does not look nor observe to return to saramagos maxim the addition of the achievement subject to halls list is not a sign of pessimism however even if the hyperperforming paradigm of success and the principles of the burnout society are supported and fed by the neoliberal policies of hegemonic globalization the prospect of change is in sight the 2023 edition of the world youth day in lisbon proved that the seeds of hope sowed by pope francis in his encyclicals are being cared for by many young people who demonstrated interest in and engagement with calling into question the narrative of the homus consumens and working for the application of the principles of the economy of francesco if pope franciss seedling blooms the achievement subject described by han might perhaps be healed and the common home can be cared for with fraternity and solidarity the theme of the event addressed to religious and nonreligious people pope franciss precept and the images of 15 million people of all ages and origins gathering for the final mass constitute experiences of awe that prove that a culture of encounter is viable and that it is possible and worthwhile to care for the common home 24 this essay for drawing my attention to the fact that western philosophy refers to the greek word deinòn which evokes the ideas of fear fright something terrible the same reviewer reminded me that freud uses the term das unheimliche meaning perturbing uncanny and that heidegger uses the word unhemlich to translate deinòn which means bewildering and disorientating 13 parts of this quotation are also referred to in ft 32 14 consider that the texts belong to different genres even though an encyclical is also a philosophical text it is primarily a theological document a pastoral letter on catholic doctrine addressed to members of the clergy consider the distinction between home and house in various languages for example 17 hans characterization of the twentieth century as an immunological age corresponds to a recurrent pattern in philosophy that examines the relations between immunity conflict and community it was foucault who explored immunity to discuss the notion of biopolitics a term used to refer to the means and mechanisms through which power operates on and affects society in order to control and manipulate human life roberto esposito has thoroughly investigated the relationships between mechanisms of immunization and the community to discuss modern biopolitics in his most recent book common immunity biopolitics in the age of the pandemic he attempts to delineate a genealogy of the immunity paradigm within the project of modernity by examining the impact of the twofold process of politicizing medicine and medicalizing politics on community life and identity one of the most interesting aspects of espositos premises is his analysis of how immunity can turn against itself thus transforming into autoimmunity and its impact on the community for this discussion see rosàs tosas it is worth pointing out that in the burnout society han dismisses espositos immunological analysis claiming that the italian philosopher does not address contemporary problems in the palliative society han does not make any reference to esposito possibly because hans achievement society is not immunological despite the interest of hans characterization of the burnout society and its evolution to a palliative society the use the philosopher makes of medical language to address the paradigm shift in late modernity is problematic han does not refer to how bodies respond to autoimmune diseases when antibodies are produced to attack ones healthy cells in other words to when the self is considered by the immunological system as an other as a foreigner a potential enemy that it is necessary to fight against and eliminate how effective and fair are the parallels between the immunological age with the dialectic of negativity and between the society of achievement with the dialectic of positivity when autoimmune diseases are under discussion when raising this issue i do not aim to call into question or disqualify hans premises but i firmly believe the examination of autoimmune diseases may arouse new metaphors that will pave the way for new rationalities regarding compassion and the care for the self the other and the planet in sum for our common home on hans omission of autoimmunity see also note 17 20 the parable revolves around the aid provided by a samaritan to a jew who had been assaulted and abandoned on the road by burglars in a historical context when samaritans were considered as the other to be avoided none of the passersby who saw the man in need on the road helped him and aid came from someone who was not expected to provide help on how samaritans were considered in jesus time see ft 80 and 83 21 on pope franciss reflection on the dangers of individualism see ft 105 22 the adoption of this global ethics is crucial to change the way migrants are seen and treated they should not be considered as threats but as a gift for they bring an opportunity for enrichment and the integral human development of all 23 the struggle to have largescale environmental destruction recognized as an international crime prosecutable at the international criminal court is not recent but has acquired visibility in the last ten years until now the rome statute of the international criminal court lists four crimes genocide crimes against humanity war crimes crimes of aggression on this issue see the site of the stop ecocide international the activist greta thunberg is one of the main advocates for this cause 24 for information on the 2023 world youth day see among others the official site of the event available online lisboa2023orgen accessed on 29 july 2023 notes 1 o espanto constitui uma rutura com o quadro ordinário e rotineiro em que funcionámos e face ao qual nos tornámos indiferentes bastanos contudo esse instante de graça para intuirmos a possibilidade de uma relação mais profunda e prodigiosa com o real 2 the original in portuguese is se podes olhar vê se podes ver repara for the translation of saramagos novel into english see the 1990s balkan conflicts that tore apart former yugoslavia despite their violence and cruelty cannot be compared to the dimension of the russian invasion of ukraine in february 2022 6 beauchamp considers byungchul han the preeminent gadfly of our age when he discusses how difficult it is to define if someone can be considered a philosopher or not 7 when referring to the programmatic dimension of the texts under analysis and bearing in mind that pope francis is the leader of the catholic church and that byungchul han is catholic i do not associate their texts with any kind of proselytism 8 the project is coordinated by citer with the participation of researchers from cecc the project comprises 10 working groups and i am involved with the group called theopoetics aesthetics and performativity of the common home 9 fch is the acronym of faculty of human sciences at universidade católica portuguesa 10 international media widely covered the event that the vatican called an extraordinary prayer in the time of pandemic for images of the event and of the pope walking in a rainy and empty vatican see among many coronaviruschroniclepopeholdsdramaticsolitaryservicereliefcoronavirus61942 accessed on 20 june 2023 11 the text of the prayer is available online accessed on 20 june 2023 12 the concept of awe has gained particular visibility in the new millennium in the field of psychology as illustrated among others by various publications on the topic in frontiers journals keltner and haidt allens the science of awe white paper and keltner however the experience of awe and awe as a topic have pervaded the study of philosophy it is worth recalling that in metaphysics 982 b 12 ff aristotle attributed the beginning of philosophy to awe i am grateful to one of the reviewers of

the first few decades of the twentyfirst century have posed various challenges to humankind such as the worldwide impact of the changing patterns of globalization processes economic crises the pandemic the war in ukraine and the specter of deglobalization illustrate the unknown and unpredictable future is a reason for utmost concern for the contemporary society that byungchul han characterizes as an achievement societyone that is dominated by excessive positivity and that has evolved into a doping society this palliative society is such because it is unable to cope with pain and it is marked by a kind of permanent analgesia that prevents urgent reforms from taking place in this essay i examine how pope franciss encyclical letters laudato si 2015 and fratelli tutti 2020 by calling for an integral ecology which connects environmental economic political social cultural and ethical issues social friendship solidarity and the common goodinstill hope in the burnout society that han reflects upon urge action toward and encourage changes to overcome in the current environmental and human crisis as well as to building a diverse future that is not palliative

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introduction on 31 st december 2019 the 2019 coronavirus detected in wuhan china on 11march 2020 has been considered a global pandemic by the world health organization as at the end of april the virus has spread worldwide with fearevoking death reports 12 the severe acute respiratory syndrome coronavirus 2 is highly contagious it causes a respiratory illness that ranges from the common coldlike symptoms to more severe diseases 2 most of the infected patients complained of fever shortness of breath cough loss of smell andor taste sensation and might be infected asymptomatically in severe cases patients might suffer from pneumonia multiple organ dysfunction and death 34 the sarscov2 is a novel strain that is not specified in humans earlier it is a zoonotic illness that is transmitted between animals and people 5 in iraq the first case of covid19 was confirmed on 24 th february 2020 in alnajaf city by people who have visited iran therefore at the end of march 132020 the ministry of health and environment of iraq declared that the total confirmed covid19 cases were 101 6 the ministry of health in iraq started to respond and control the infection with the technical observation of the who center three governmental biological laboratories in baghdad basrah and erbil opened for covid19 outbreak testing 7 initially the measures that were taken by the iraqi authorities nationwide have succeeded in managing to slow the spread of the virus but the cases have risen sharply in the beginning of july 2020 in the first week of august 2020 mosul city recorded thirty times an increase in covid19 cases reported compared to the previous months while the reported national cases rose from 10000 to 120000 across the country 8 due to the escalating number of cases in mosul city many challenges were observed while trying to stop the virus from spreading the limited number of tests that can be carried out per day lack of quarantine facilities medical instrument hygienic preparation insufficiency low hospital capacities and no approved medicine or vaccine to prevent the covid19 therefore peoples preventive measures are important to protect themselves and others from the virus infection and control the spread of the disease 9 thus managing this crisis hangs primarily on peoples knowledge and practices toward this virus and follows all the precautions to prevent crossinfection and follow the who and the center for disease control and prevention 1011 who declared precautional strategies to curb the spreading of infections the none medical precautions are maintaining social distancing avoiding public gatherings avoiding direct contact with infected people and using personal protective equipment like face masks personal hygiene recommendations such as handwashing often with soap and water for at least 20 seconds especially after touching surfaces which also include an advice not to touch the nose eyes and mouth with unwashed hands and selfisolate when covid19 symptoms started 10 the knowledge and practices of the public toward covid19 play an important role in determining the willingness of iraqi citizens to change their behavior and identify the kind of intervention that is needed to correct the misconceptions regarding the virus highlight the poor knowledge toward the virus and disease development of new preventive measures develop covid19 awareness campaign and take precautionary therefore the current study aimed to assess the sociodemographic correlate of knowledge and practices of iraqi living in mosul towards covid19 during its rapid rise this studys results are expected to provide baseline information about iraqis level of knowledge and practices living in mosul and highlight misperceptions related to preventive measures the study outcomes will further plan for effective awareness campaigns required interventions and appropriate action from local authorities materials and methods study design a convenient crosssectional survey was adopted for the study the researchers use an online survey using google forms platform mosuliraqi individuals above the age of 18 and currently residing in mosul were able to participate in the survey the professional and personal networks of the researchers were used to reach a high number of participants to complete the survey the standardized general invitation letter with the link were sanded to respondents to participate in this study by by using the most popular communication and social platforms in iraq the questionnaire link was posted among specific facebook groups the members who clicked on the link were directed to the google forms and to reduce the missing data the participants were requested to fill all the questions of the questionnaire or else could not proceed to the next section after complete the answer to all questions the participant was directed to clicks on submit the google based questionnaire was designed in english and arabic languages in order to encourage the respondents adequate participation since arabic is the common language in mosul city study settings mosul is located in nineveh governoratenorthern iraq has a population of 664221 as of 2015 mosul city residents suffer from a fragile health system that barely meets their basic needs as many health facilities were destroyed in 2017 8 survey and data collection a total of 909 mosuliraqi participated in our study between 20 th june to 1 st july 2020 the specified sample size was determined by adopting the minimum acceptable size of a demographic subgroup with a ±5 margin of error and a confidence level of 95 1213 giving to this out of the total respondents of 1121 who filled the online google based questionnaire only 909 were included an incomplete survey of participants of 212 was excluded from the study leaving us with a completion rate of 81 questionnaire design the survey was an adapted version of questionnaires published previously 14 15 16 the questionnaire was reviewed validated and pilot tested by 21 iraqi people and 3 faculty experts at the university of mosul using whatsapp and telephone interviews to correct any question before sending it to the target population and is its attached as a in this study the pilot test result was not included in the study results the questionnaire consisted of an interface page and three main themes with a total of 37 questions the interface page included the title objective of the study information on participants privacy and instructions to fill the survey the three main themes included 1 demographic information of participants such as gender age education level marital status employment status coronavirus test coronavirus result and chronic diseases 2 knowledge related to the covid19 consisted of 15 questions divided into clinical presentations of virus the spread of the virus prevention and the risk factors 3 practices of participants toward covid19 outbreak which included 13 questions ethical considerations the research ethics committee at the university of sharjah uae approved this study by the reference number is rec20053101 as of 14062020 this approval also suffices for the surveys in mosul iraq since participation was voluntary and anonymous informed consent was sought from all the respondents prior to data collection the participant who declined consent were not permitted to participate in the survey and participants could withdraw from the survey at any time in line with stipulations of the world medical association declaration of helsinki ethical principles 17 data and statistical analysis data analysis conducted using statistical package for social software version 22 scale reliability was performed to ensure data consistency in knowledge and practice aspects using cronbachs alpha coefficient with total reliability of 0729 indicating good consistency 18 since the knowledge part measures four aspects which are clinical presentations the spread of the virus prevention and the risk factors internal consistency showed significance 0001 in the correlation between these components and total knowledge the frequencies of demographic characteristics were presented in frequency while knowledge and practice answers along with descriptive statistics were presented in frequency and mean ± sd participants knowledge and practice scores were compared with demographics factors using independentsamples ttest oneway analysis of variance to measure the knowledge participants were given yes no and not sure answer options to each survey question a true answer to each question was marked with 1 score while false answers and not sure were marked with 0 scores scores of total knowledge ranged from 015 a higher score signals a better knowledge level to practice measures participants were given always sometimes and never answer options to each item the always option was marked for 2 scores while sometimes was for 1 score and rarely was for 0 scores the total practice scores ranged from 026 the lowest and highest score of participants knowledges was 7 and 15 respectively while the lowest and highest score of practice was 14 and 26 respectively pearsons chisquare was used to determine the association between the explanatory and outcome variables we examined the factors associated with good knowledge practice and poor knowledge practices using binary logistic regression analyses a pvalue of less than 005 was considered statistically significant to identify the significantly associated factors with good or poor knowledge and practices a mean knowledge score of more than 12 indicated as good knowledge while less than 12 assigned as poor similarly a mean practice score above 21 indicated good practice and a mean practice score below 21 as poor practice the values have been determined by selecting a cut point of knowledge and practice based on the total mean score for all participants the cut point 12 for knowledge was chosen as the total mean score for knowledge was 129 any scores below 12 considered poor according to each participant score similarly with practice the total mean score was 2156 the cut point was 21 factors were selected with a backward stepwise method and the reference category was selected based on the higher total mean unstandardized regression coefficients and odds ratios and their 95 confidence intervals were used to quantify the associations between cofactors with knowledge and practice results sociodemographic characteristics table 1 showed that the majority of 558 were females and 351 were males more than half of the participants 495 aged 3049 years around 549 of respondents were married while 288 and 72 were single and others respectively about 567 were holding a bachelors degree while 234 108 were holding postgraduates and diploma or below respectively moreover almost 585 were employed while a smaller number of participants 198 126 were unemployed and students respectively chronic conditions reported by participants in our study 824 of the participants were healthy while 176 had chronic diseases the most common chronic diseases were diabetes 6 followed by asthma at 330 moreover 275 240 154 154 120 had chronic kidney disease severe obesity heart conditions chronic liver disease and chronic lung diseases respectively as shown in table 2 knowledge towards covid19 the mean knowledge score of 15 questions was the correct percentage rate was 8608 most of the participants 921 answered correctly that covid19 was caused by a virus the majority 941 knew that the incubation period range of this virus is between 214 days almost all participants had a high knowledge of 96 about the symptoms of a covid19 about 723 of respondents knew that no vaccine for this virus moreover 634 knew that no treatment was approved for covid19 until now when we asked if this virus is spread via respiratory droplets of infected people 931 answered correctly similarly a high proportion of 931 of the participants agreed that the virus could be transmitted via touching contaminated surfaces also 822 indicated that this virus was transmitted through the eyes nose and mouth just over half 594 reported that the infected person having no fever could infect healthy people and the majority of participants 941 recorded that children and young adults have to take measures toward covid19 about 762 of respondents reported the individuals should stay at home and go out only when necessary while all of the participants 100 agreed that they should avoid going to crowded places and the infected person with this virus should be immediately isolated in a proper place most of the respondents 96 answered that the virus is more dangerous for those with chronic disease patients and the elderly while 792 believed that smokers are more vulnerable to this virus the knowledge of participants toward covid19 is displayed in table 3 practice towards covid19 the mean practice score of 13 questions was the correct percentage rate was 758 we found that 921 of the participants started washing their hands frequently during covid19 similarly 921 indicated they had used sanitizer if the soap is not available while usual handwashing with soap for 20 seconds was recorded by 772 of respondents almost 832 of participants wore a mask when they go outside the home threequarters 723 of respondents maintain space between themselves and others when going outside and only 366 maintain the 2meter distance between them and others to prevent transmission of the virus about 88 of the iraqi respondents stopped going to crowded places recently however twothirds of the respondents 693 and 653 reported that they stopped visiting and kissing their relatives or friends when meeting them while 772 stopped the handshake during the greeting with others besides 812 were aware of the essential of sanitizing their hands after using cash and 752 of participants were aware of the importance of avoiding sharing their food with others the participants practices toward covid19 prevention presented in table 4 sources of information on covid19 participants indicated that the moh in iraq and social media such as twitter facebook youtube whatsapp instagram and snapchat were the main sources of information about covid19pandemic with 603 and 575 respectively followed by who press release 416 while 287 158 and 14 reported that they received their information from the news outlet family and friends and other sources respectively as presented in table 5 level of knowledge and practice as per sociodemographic characteristics of participants the knowledge level score showed a significant association across sociodemographic characteristics such as gender age education levels marital status and employment status the practice level score also showed a significant association groups moreover widows and divorced womens knowledge were higher than singles and married participants however there were no significant differences in practice the mean score of knowledge and practice of participants with high education degrees were better than participants with lower educational degrees employed respondents showed a higherlevel score of knowledge than nonemployed and students participants while there were no significant differences in employment status in practice neither education levels nor employment status had any significant differences in practice as depicted in table 6 binary logistic regression analysis table 7 shows the binary logistic regression analysis on variables significantly correlated with knowledge and practice about covid19 the odds ratios and their 95 confidence intervals in a bid to quantify the relationship between sociodemographic characteristics and the knowledge score and between sociodemographic characteristics and the practices score considering odds ratios equal to 1 shows no effect an greater than 1 shows variable increase the odds in good knowledge or practice and odds less than 1 shows variables decrease the odds in good knowledge or practice 19 overall the analysis presents a significant relationship between knowledge with age marital status and employment status the same table shows that the mean score of age �50 years reported better knowledge vs other ages no significant effect on the level of the knowledge has been observed within other ages similarly similarly divorced widows vs married and single participants were significantly related with a higher mean score with no significant influence on the knowledge level among married and single respondents employed people were significantly showed a better mean score of knowledge vs unemployed and retired respondents however unemployed were less likely to present a good knowledge moreover gender age education and employment status were significantly associated with good practices female gender reported a higher mean score of practices vs male the regression analysis significantly showed poor practices in male gender than a female with odds ratio less than 1 similarly age group of 3049 showed fewer commitments in the practices than other groups however participants with a collegelevel degree and below could significantly increase the effect of good practices level comparing with the participants with a postgraduate degree while employment status of employed and students reported a better practice score than unemployed individuals unemployed significantly showed poor practices than employed respondents as indicated in table 7 discussion the publics knowledge and practices play an important role in prevention by following the health guidelines to control the spread of covid19 the knowledge and practices of the general population about covid19have changed during the pandemic as a defense line against the disease the provision of baseline data regarding the level of individuals knowledge on clinical presentations transmission prevention and risk factors of covid19 virus will help highlight malpractices related to preventive measures making it critical for local authorities to plan suitable strategies to prepare and manage the spread of the virus the current study showed that the participants knowledge was high and had good practice measures toward covid19 similar to our findings several studies conducted in many countries have reported high levels of knowledge about covid19 among the the high level of knowledge among the participants in this study may be because most participants have a college degree or higher or due to the high level of media coverage including all media outlets and the impact of the pandemic on social life mandating that people follow the current results showed that most of the participants depend more on the ministry of health and social media to get their information about the covid19 in contrast to other studies among jordanian egyptian and pakistani populations that were using mostly social media as the main source of information 20 21 22 the study found that most respondents had a good level in prevention and control measures toward covid19 novel coronavirus indicating that some respondents practices were very good toward covid19 that the results reported on practice toward covid19 among the respondents were similar to those reported in the malaysian population 14 while being less than the chinese residents level of practice 4 this level of practice among the respondents attributed that the iraqi government took drastic measures in reducing the spread of the disease and the low number of cases in mosul at the beginning of the pandemic 23 our results using ttests anova and logistic regression analysis showed that there were better knowledge and accurate practices associated significantly with the female gender respondents above 50 years old employed respondents higher education and married respondents females and mothers show better knowledge and practices towards the covid19 precautions and preventions similar studies in malaysian and saudi arabia indicated that females had more knowledge regarding covid19 than males 1415 the high level of knowledge and practice among the participants above the age of 50 in our study is possibly due to understanding the higher risk of contraction and complications of the disease on the elderly and people with chronic diseases 2425 in our study respondents with a higher degree level had a greater knowledge level than the others similar findings were reported within malaysian and pakistani university populations 1422 majority of respondents confirmed that the covid19 disease is more dangerous in patients with chronic diseases and the elderly this has been confirmed from many studies published regarding the covid19 in china 2627 our results reported that 175 of the respondents had chronic diseases such as diabetes asthma and severe obesity were the common diseases among our participants a similar study among iraqi adults indicated that the common noncommunicable diseases were hypertension and overweight or obesity another study showed that diabetes and hypertension were the most prevalent diseases among iraqi people 2728 our results were compatible with many studies that showed similar significance in terms of better knowledge and practice of covid19 among the educated and employed people 414152930 finally the results indicated that more intense health education efforts should be directed toward respondents with the following sociodemographic characteristics male respondents respondents with lower educational levels younger respondents and unmarried respondents limitations since the study is a crosssectional study it was conducted within a short time during the pandemic moreover this study was an online survey that expected that the people with a higher level of education would respond to the survey as such it doesnt give privilege to the uneducated population and those with limited access to the internet and the results in this manuscript is not a representation of the total population of mosul iraq the study dataset was also selfreported and this practice is subject to courtesy bias or social desirability bias conclusion in general the current study provided a comprehensive screening of the knowledge and practices of the among a sample of mosul city population toward covid19 the participants had a high level of knowledge about the virus and good practice towards using protective measures which is significant towards controlling the spread of the virus the study recommends developing informative covid19 related campaigns targeted specifically towards those with the following sociodemographic characteristics those below the age of 50 those single married younger males and unemployed living in mosul city shamil mohamad mr abd almoneem and all those who contributed to reviewing and distributing the questionnaire we also thank mr ahmed omar addresscollege of medicine for the critical edition of english grammar all relevant data are within the paper and its supporting information files

since the world health organization who announced that the coronavirus disease covid19 is a worldwide pandemic many countries authorities including the iraqi authorities started responding and taking action to control the spread of the pandemic the publics knowledge and practices play an important role in curbing the spreading of the virus by following the health guidelines this study aimed to assess the sociodemographic correlate of knowledge and practices of iraqi living in mosuliraq towards covid19 during its rapid rise a crosssectional online survey of 909 participants was conducted among a sample of the mosuliraq population between 20 th june to 1 st july 2020 the survey included three parts 1 sociodemographic characteristics 2 participants knowledge 3 participants practices ttest anova chisquare and binary logistic regression were used a pvalue less than 005 p 005 was considered statistically significant the results showed a knowledge and practice mean score of 1291±167 and 2156± 292 with cumulative knowledge and practice of 86 and 76 respectively towards covid19 sociodemographic characteristics such as age marital status gender level of education and employment were statistically related with a higher mean score of knowledge and practice towards the virus as p 005 we concluded that the majority of the respondents demonstrate a high level of knowledge and practices towards covid19 except for respondents with sociodemographic characteristics such as those who were younger male respondents those with lower education and those unemployed as such campaigns that will increase the knowledge and encourage adequate preventive practice towards covid19 should be targeted towards this group

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introduction while hiv prevalence is low in bangladesh the number of hivinfected individuals is steadily increasing for example recent data indicate that in 2013 there were 370 newly reported hiv cases and 95 newly reported aids cases compared to 338 and 103 in 2012 as a result of this increase research into the social impacts of hivaids in bangladesh has emerged over time researchers have focuses mainly on measuring knowledge and recording public attitudes especially the attitudes of health care workers towards hivpositive individuals rather than describing the everyday experiences of hivpositive individuals such as relations between family members there is increasing recognition that hiv stigma may present distinct challenges for hivpositive parents with children research outside bangladesh has suggested that parents have to cope with their own stigma while at the same time dealing with social and personal issues associated with stigma due to living within hivinfected families this study examines parents experiences of stigma and discrimination while living with hiv within families in bangladesh methods a qualitative research design informed by grounded theory was used to describe and understand the everyday experience of stigma conceptually stigma is used in this study as a social construct that uncovers the social processes that mark the lived experience of living with hiv within a family context data were collected through indepth interviews with 19 hivpositive parents who lived with at least one child in a family recruited with the support of two selfhelp groups of hivpositive people in two settings namely khulna and dhaka in bangladesh after confirming the informants willingness to participate the first author conducted the interviews at the offices of the selfhelp organizations following consent the interviews were audiorecorded the duration of interviews ranged from 35 to 110 minutes some interviews were longer because the participants raised more follow up issues as a result of the recursive method of interviewing used informants were compensated for their time and their names were replaced by pseudonyms the sample consisted of 11 mothers and 8 fathers among the informants 16 were aged between 35 to 44 years about three quarters had five years of less of education and more than three quarters were muslim the interviews were conducted in bangla using openended questions the interview guide covered topics like for example responses to their diagnosis relationships and interactions with family extended family and community members how hivaids has affected everyday living data were analysed through nvivo 9 using a coding system after creating nodes the other data were coded into more refined levels that identify or relate to particular theme for example in order to understand the meaning of stigma and discrimination clusters of themes such as negative perceptions exclusion rejection and isolation contagiousness and breakdown of relationship were developed for this study results and discussion from the findings it is asserted that extended family members and community members held prejudicial stereotypes that were used to devalue hivpositive parents in the community the reaction from others towards them as hiv persons indicates a shift from selfidentification as normal to being identified and categorized by others as deviant as people held many misconceptions about hiv contraction the notion that hiv occurred only through extramarital sexual relations had much currency in the community most of the parents interviewed were presumed by others to be sexually promiscuous and perceived as the other a person of less value in their community and sometimes in the family unit it was therefore not surprising to hear stories of how people referred to parents living with hiv using derogatory terms which reinforced humiliation rejection isolation and social discrimination experienced by those living with hiv these local terms included 1 kharapkaj 2 kharaplok 3 kharaprog and 4 kharapkotha these terms situated hiv within a moral and normative framework and inferred that those who had contracted hiv had to use goffmans concept a spoilt identity for example kharapkaj has many meanings in bangladesh and is used as a broad term to describe behaviours beliefs attitudes and social norms values and standards that an individual transgresses in spite of having several meanings parents perceived that when others referred to the cause of their hiv status as bad practices they specifically implied sexual promiscuity or more particularly that the parents had extramarital relations with sex workers likewise in spite of having several connotations a total 13 parents perceived that when community members referred to them as bad person they specifically meant someone who had extramarital relations with female sex workers similarly all the interviewed parents perceived that when community members referred to their hiv status as bad disease they specifically meant that the parents had contracted it via extramarital sexual relations with sex workers for instance sattar indicated that community members believed that he contracted hiv after having sex with female sex workers and that he visited different kharapjaiga to meet with kharapmohila and suffering with hiv was the outcome of his bad practices sattar comments when the status of my disease was disclosed everyone blamed me they said okamkoreci tai vugteci people regarded me as a bad person they said that i had contracted this bad disease by visiting different bad places and meeting with bad women these narratives indicate that the stigma associated with hivaids often made established communal and extended familial relationships vulnerable extended family members feared being associated with hivpositive family members lest they were also perceived as hivpositive or labelled as having low moral standards for maintaining relationships with hivpositive individuals for instance abul reported that his brothers cut ties with him as they feared that by proxy they also may suffer stigma and discrimination while they wanted to maintain the honour of families by distancing themselves from abul this only perpetuated and exacerbated the stigma and discrimination he experienced from others abul observed my family has stopped loving me because of my disease they thought if they loved me other people would hate them they felt embarrassed to introduce me as their brother due to the stigma associated with hiv not only were the parents discriminated against but also were immediate family members especially children all the interviewed parents noted that the prevalence of rumours that hiv is transmitted through casual contact and interaction isolated them and their children from community participation in a study surkan and colleagues also reported that children were discriminated against simply for living within an hivaffected family parents were distressed to report that their children were sometimes accused by others of having hiv rahim described how one of his children was humiliated and rejected by their peers for being associated with a hivaffected family rahim recalled one day my elder son went to play with other children they quarrelled and bullied my son cruelly they told my son that your father is suffering from aids and you are also infected with that disease you will not play with us because if you come to us we will also be infected conclusion having hiv is generally believed to be an indication of impurity in bangladesh and hiv contraction is considered to be an outcome of having committed a sin in this way hiv is considered highly polluting and threatens not only public health but the extant social order the findings from this study support the strong sense of sexual morality in bangladeshi society in which premarital and extramarital sexual relations are strictly prohibited with real consequences for individuals and families the data reveal that the experiences of stigma and discrimination of hivpositive parents are heavily influenced by the sociocultural meanings of hiv that are constructed through interactions with families extended families and community members almost all the parents in this study reported that other people often reacted negatively towards them because of their hiv status perhaps this is because they present a greater threat to the existing social order than those already situated outside of it as others such as gay men and sex workers having acquired a new status the social order has to react visibly and swiftly to create a new deviant identity for these people and often this process places them outside of the community with real everyday consequences for their ability to interact socially in spite of having several limitations being a qualitative research ie samples were purposively collected from two selfhelp groups this pioneer study provides a picture of the extent of stigma and discrimination in the context of bangladeshi society within the context of the findings we argue that it is essential to formulate culturally appropriate intervention programs to educate people about the modes of hiv transmission and minimize irrational fears about hiv and aids it is important for future research to better describe the consequence of how family and community tension negatively influences people living with hiv and their children

with much of the focus on the risk groups families have often been less studied in hiv research further because of a focus on the aetiology and epidemiology of hiv the social impacts associated with hiv on families and neighbours are sometimes overlooked this study examined parental experiences of stigma and discrimination while living with hiv within a family context in bangladesh a qualitative research design using a grounded theory approach was used for this research data was collected through indepth interviews with 19 hiv positive parents recruited with the support of two selfhelp groups of hiv positive people in two settings namely khulna and dhaka in bangladesh the findings indicate that hivpositive parents held the view that they continue to experience significant stigma and their narratives clearly show how this affected them and their children a range of informal practices were enacted in everyday contexts by extended family and community members to identify demarcate and limit the social interaction of hiv positive parents parents highlighted a number of factors including negative thoughts and behaviours rejection isolation and derogatory remarks as manifestations of stigma and discrimination impacting upon them and their children because of their association with hiv

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introduction heritage tourism has received extensive attention from all walks of life in recent years agricultural heritage tourism is crucial to the inheritance and innovation of excellent traditional farming culture on the premise of fully respecting agricultural traditions and cultural diversity of heritage sites agricultural heritage tourism not only raises public awareness of cultural roots but also enhances the publics sense of cultural pride and identity meanwhile it promotes the cultural revival of agricultural heritage sites however agricultural heritage tourism has faced unprecedented challenges in current practice processes including the marginalization of traditional agricultural culture practices insufficient expressions of traditional cultural values and untapped dilemmas of potential for heritage awareness and local identity therefore it is urgent to conduct indepth discussions on agricultural heritage tourism agricultural heritage tourism is an indispensable part of heritage tourism but there is little related research previous studies were limited to resource developments protections and development strategies of agricultural heritage tourism in recent years scholars have mainly focused on community developments value analyses cultural management traditional landscape preferences and stakeholders however current research on agricultural heritage tourism mainly concentrates on development approaches and residents attitudes they lack a discussion of tourists attitudes and behavioral intentions toward agricultural heritage tourism from a cultural perspective meanwhile they also lack empirical research on tourists cultural identity in heritage sites from a micro perspective therefore this study aims to make up for the deficiencies of current research previous studies on the cultural identity of agricultural heritage included rural gastronomic heritage cultural landscapes ecosystems and benefit costs these studies mainly discussed the formation of cultural identity from the perspectives of residents and governments and they usually used case studies or qualitative comparison methods however they rarely carried out quantitative research from the perspective of creativity with the rise of cultural and creative tourism creativity with more novel ways of expressing culture has extended to many traditional cultural fields creative performances help enhance tourists cultural perceptions however agricultural heritage tourism is still mainly about landscapes and it has serious problems such as form simplifications and product homogeneities therefore creative performance as a breakthrough point can help open theoretical black boxes of tourist cultural identity formation in the process of agricultural heritage tourism how creative performances of globally important agricultural heritage systems affect tourists cultural identity is a pivotal question addressed in this study social identity theory provides a theoretical basis for cultural identity studies in tourism contexts the theory emphasizes that a process of social comparison provides stimuli for ingroups with similar characteristics to facilitate their transition from perception to identity based on this creative performance is a stimulus effect first from the perspective of knowledge transfer cultural and creative tourism provides tourists with opportunities for cultural learning it deepens tourists understanding of a common culture and thus enhances their psychological identity second in terms of a novel perception perspective heritage tourism elements are perceived by tourists in a novel way and awaken their pleasures they are consolidated through continuous exposure to cultural heritage and eventually form an individual cultural identity finally perceived authenticity motivates tourists to engage in creative tourism it facilitates tourists perceived novelty and influences the degree of knowledge transfer to cultural heritage accordingly we infer that the factors influencing the creative performance of agricultural heritage on tourists cultural identity include novelty perception knowledge transfer and perceived authenticity based on the above questions the objectives of this study include the following addressing a vital issue of how creative performance affects cultural identity exploring the role of novelty perception and knowledge transfer in the influence process of creative performance on cultural identity and analyzing whether perceived authenticity plays a regulating role this study explores the impact of creative performance on cultural identity by establishing a chain mediation model in figure 1 it not only bridges the research gap of the cultural identity of agricultural heritage tourists from the perspective of cultural creativity but also provides the antecedent theoretical path for the cultural identity of heritage moreover it expands the applications of social identity theory knowledge transfer and novel perception in the field of agricultural heritage tourism more importantly this study provides management ideas for an integrated application of creative tourism and agricultural heritage meanwhile it is conducive to the sustainable development of agricultural heritage tourism theoretical background and hypothesis development social identity theory social identity theory derives from an individuals knowledge of membership in a social group and the values and emotional meanings associated with that membership it reflects the central role of individuals in the group identity process and the unique attributes of individuals and involves three psychological stages social categorization social identification and social comparison in heritage tourism there is a link between the core identity attributes of individuals and specific heritage sites they visit and tourism is seen as a way of establishing maintaining and creating personal identity social identity theory lays a foundation for the sustainable development of heritage tourism first the social classification stage of this theory emphasizes the functional and hedonic values of tourism activities on the one hand agricultural heritage tourism endows heritage with the functions of products or services and the social identity embodied in the functional value of this product or service becomes part of the personal concept of the heritage tourism tourist therefore they reflect the behavior of tourists as a specific group in the tourism experience as well as the functional values associated with the identity of the tourist group and heritage creative products or services have practicality and help visitors to gain knowledge or information related to the heritage experience the accumulation and consolidation of knowledge and information further attracts visitors to heritage activities which are more likely to meet the learning needs of tourists regarding history and culture in the interaction process on the other hand in the current environment the expression of creative elements of agricultural heritage will give visitors a sense of pride and selfesteem from the uniqueness of the group to which they belong as creators and sharers of the value of agricultural heritage sites it will satisfy visitors inner expectations of heritage thus realizing their own psychological commitment to a unique identity generating emotional meaning and inspiring subjective feelings such as novelty and pleasure at the same time hidden cultural feelings also further improve tourists cognitive processes and defining abilities of selfconcept the above two processes highlight tourists perceptions of the function and hedonic values of agricultural heritage tourism in the social classification stage second the social identification stage of the theory advocates that individuals identify themselves according to groups common characteristics including cognition emotion and evaluation after heritage creativities have aroused tourists interests it creates the perception that tourists belong to a special group of agricultural heritage tourists and attracts them to a deeper experience of relevant tourism projects furthermore diversified projects focusing on the farming experience will make visitors emotionally suggestive further attract and satisfy tourists expectations for the uniqueness and novelty of agricultural heritage it also arouses a highlevel sense of enjoyment in tourists stimulates their positive attitudes toward heritage tourism generates positive or negative values about themselves in relation to their sense of belonging to a group of agricultural heritage tourism tourists and thus promotes their sense of identity with agricultural culture which will be consolidated with further contact with cultural heritage therefore this process reflects an evolution of the cognition emotion and evaluation stages in the social identification stage of this theory finally the social comparison stage implies that people with similar characteristics are classified as internal groups and thus they form unique groups as external stimuli creative performance and perceived authenticity convey special cultural symbols to tourists facilitating the formation of a cognitive process of social comparison between the internal and external groups of tourists in heritage sites and meeting tourists needs to acquire knowledge moreover knowledge learning further reinforces the image of the visitor as an agricultural heritage tourist by communicating to others that they belong to a social group of heritage sharers and participants they demonstrate the difference between themselves and those who do not visit the local area after acquiring heritage knowledge meanwhile it encourages tourists to share heritage knowledge and realize transformations from cultural cognition to cultural identity therefore core views of social identity theory support the relationship between the cultural identity of agricultural heritage and relevant elements such as creative performance novelty perception and knowledge transfer it provides theoretical support for the theoretical model construction of this study the mediating role of novelty perception and awakening of enjoyment novelty perception is determined by the degree of contrast between current perception and past experience and novelty seeking is an essential factor in measuring differences in individual tourists experiences of different destinations the creative performance of agricultural heritage involves cultural performances with real agricultural landscapes farming cultures rural folklore etc as the main content and it includes cultural expressions such as human stories and poetry according to the social comparison phase of social identity theory creative elements are considered as an external source of stimulation that will bring new experiences to visitors because in the process of creative heritage experience visitors will enhance their perception of something new from the new experience which is likely to refresh visitors previous potential impressions of heritage itself therefore positive creative performances at heritage sites may further attract visitors to engage with novelty previous studies have shown that heritage creative elements stimulate an individuals quest for novelty and heritage appeals stem from novelty seekers pursuit of creativity and a high level of involvement in creative activities thus first creative performances help attract tourists attention to novelties and stimulates their engagement second when tourists perceive something new it can to a certain extent meet their inner expectations stimulate their interest in the destination and generate positive psychological feelings for example cognitive psychology shows that high novelty helps increase visitors interest in a destination and helps them express their psychological feelings when they receive a new experience including stimulations and surprises finally novelty and practicality are the most prominent aspects of heritages creative products agricultural heritage systems stimulate a sense of novelty in tourists in agricultural culture by conveying creative elements such as heritage legends and knowledge of farming cultures to tourists thus it satisfies their expectations of novelty and stimulates a high level of pleasure this process is mainly motivated by heritage sites nature and novelty experiences therefore the following hypothesis is proposed based on the above theories and literature hypothesis 1 novelty perception mediates the relationship between creative performance and awakening of enjoyment as a tourismrelated intrinsic motivation the awakening of enjoyment reflects a visitors perception of positive emotions such as joy and pleasure during tourism experiences on the other hand cultural identity relies on the internal intention of selfperception and is a process of integrating heritage into the selfconcept social identity theory emphasizes that the formation of individual identification with a group is based on the cognitive affective and evaluative stages of social identity when visitors develop positive emotions about a particular environment they may develop behavioral intentions related to the tourism experience and when this positive emotion is sustained there is an ongoing cultural resonance and connection with the heritage site especially in the field of tourism the awakening of enjoyment reflects an individuals emotional state toward a preferred environment it acts as a mediating element between stimuli and behavioral intentions and makes it easier to build positive attitudes toward tourists experiences and create high levels of behavioral intentions this process involves factors such as the identification and internalization of personality in the creative tourism experience consistent with the social identification stage of social identity theory tourists perception of heritage novelty may induce positive emotions in tourists and when the positive sentiment is sustained it further attracts visitors to the culture in question ultimately sustained cultural interaction creates a sense of cultural identification with heritage for visitors in this study novelties such as agricultural legends natural scenery and folklore serve as environmental stimuli that are antecedents to inducing key emotional states in tourists creating opportunities for tourists to learn about local culture and deepening their interaction with cultural heritage therefore synthesizing the above theories this study argues that agricultural heritage sites rely on the novelty and uniqueness of creative tourism to awaken tourists sense of enjoyment stimulate their cultural resonance change their attitudes and intentions toward heritage tourism and finally enhance their sense of identification with heritage culture based on this the specific assumptions are as follows hypothesis 2 awakening of enjoyment mediates the relationship between novelty perception and tourists cultural identity hypothesis 3 novelty perception and awakening of enjoyment play a remote mediating role in the relationship between creative performance and cultural identity the mediating role of knowledge transfer and cultural learning knowledge acquisition is an interactive process in which visitors share knowledge and ideas during their experiences it represents the ultimate goal of information dissemination and it culminates in the sublimation of experiences hardy et al identified knowledge transfer as an essential indicator of intergroup membership in which knowledge and ideas are shared to create tourism products and experiences furthermore cultural learning is a crucial motivation for tourists to experience cultural differences and the functional benefits of travel according to social identity theory in the process of creative tourism experience elements such as unique customs and traditions of heritage sites accelerate the cognitive process of forming social comparisons between internal and external groups of tourists they satisfy tourists needs for heritage knowledge and the accumulation of heritage knowledge further enables a transformation from cultural awareness to cultural identity recent studies have shown that knowledge transfer is a key facilitator for individuals to acquire cultural learning especially in the field of heritage tourism the transfer of heritage tourism knowledge prompts visitors to share knowledge and disseminate information and ideas and thus they acquire heritage knowledge through cultural learning thus knowledge transfer drives behavioral changes in tourists furthermore in the field of creative tourism liu argued that creative performance is an essential element of cultural and creative tourism through which tourists can gain new knowledge offered by cultural heritage on the one hand when individuals experience heritage they also communicate and exchange creativity to contribute to improving knowledge and skills among themselves on the other hand creative performance helps tourists develop interests in the cultural heritage itself and thus share knowledge and ideas to promote innovation in tourism products and services in heritage sites meanwhile it maintains the competitiveness of heritage tourism destinations in short when tourists enjoy the creative experience of heritage tourism it is easy to achieve a transfer of heritage knowledge which helps enhance their own positivity to learn about the cultures in question therefore the following hypothesis is proposed hypothesis 4 knowledge transfer mediates the relationship between creative performance and cultural learning cultural learning advocates learning about cultural heritage preservation while creating a fantastic destination image for visitors it reflects tourists interest in consuming cultural heritage sites and represents an essential motivation for tourists reception of new cultures and tourism experiences in heritage tourism experiences tourists are often accompanied by learning about heritage culture and the results of cultural learning lead to an evaluation of the destination experience when cultural learning is accumulated and sustained it will lead to a sense of identity with the destination and this sense of identity further enhances the cultural learning of visitors and deepens the cultural connection between tourists and the destination which ultimately leads to a cultural identity for the heritage destination specifically visitors interest in heritage attracts them to engage in cultural heritage living experiences and ultimately gain the ability to learn new knowledge lin et al further asserted that when heritage travel is embedded with cultural significance the demands of tourists to benefit from knowledge inspire them to learn more about local cultures at a deeper level cultural learning relies on the conceptual representation of knowledge learning by tourists which in turn leads to an evaluation of the destination image importantly with the deepening of cultural learning visitors are more likely to acquire a sense of cultural identity with heritages overall when heritage knowledge is realized through cultural heritage creative tourism it attracts tourists to learn about heritage culture in depth which in turn consolidates their cultural identity with agricultural heritage sites therefore the research hypotheses are as follows hypothesis 5 cultural learning mediates the relationship between knowledge transfer and tourists cultural identity hypothesis 6 knowledge transfer and cultural learning mediate the relationship between creative performance and cultural identity the moderating effect of perceived authenticity perceived authenticity is described as an exploration of a specific social context and unspoiled original traditional authentic cultural activities that effectively reflect the uniqueness and sense of the history of cultures in the region in addition tourism and its environment can facilitate transient experiences inspired by perceived authenticity according to social identity theory perceived authenticity as a source of external stimuli that accelerates the degree to which visitors perceive cultural experiences by revealing the original elements of tourists with the development of cultural tourism perceived authenticity has become a critical factor in reflecting the traditional cultural aspirations of tourists and attracting them specifically the combination of creative performance and perceived authenticity contributes to the novelty and uniqueness of tourists experiences while creative performance is the best way to convey authenticity conservation and heritage the interaction between the two helps to enhance visitors knowledge understanding of heritage sites and strengthen the emotional connection between tourists and heritage sites in addition perceived authenticity is the basis for the sustainable development of heritage tourism agricultural culture heritage shows authentic farming cultures ancient villages and other original cultural veins which may interfere with tourists novel perception of traditional cultures unique charms and affect the interactive experiences of tourists with cultural heritage therefore this study argues that the interaction of authenticity and creative performance can promote novel perceptions of heritage for visitors and the following hypothesis is proposed in this study hypothesis 7a perceived authenticity moderates the relationship between creative performance and novelty perception perceived authenticity reflects the attractiveness of tourists involvement in tourism experiences visitors perceptions of heritage sites perceived authenticity include assessments of tangible and intangible aspects especially in the field of heritage tourism creative tourism enhances visitors access to heritage knowledge and deepens their connection to the history and culture of heritage sites meanwhile it creates opportunities for them to learn about cultures in fact tourists seek to expand their knowledge and thus unleash their creativity in the process of deep involvement in creative experiences which shows the inextricable relationship between creative tourism and knowledge transfer perceived authenticity by basing cultural encounters in tourism activities on authenticity mobilizes visitors attention to enhance learning about authentic cultures and it reflects the connection between culture and the tourism experience especially in heritage tourism sites visitors who participate in creative tourism are likely to deepen their learning about the authentic culture of the heritage through an authentic perception of the site thus the ultimate experience of complete engagement is obtained which facilitates the transfer of personal knowledge moreover in the context of cultural and creative tourism the desire for learning is often accompanied by a desire for authenticity as maccannell emphasizes cultural and heritage attractions become an obsession with experiential authenticity as visitors seek authentic experiences and the pursuit of authenticity makes it likely that those in the creative tourism experience will promote a desire for culture and the transfer of knowledge of heritage to the visitor because of the pursuit of authenticity in the experience in addition perceived authenticity is the key to gaining a competitive advantage in creative tourism locations as wang et al pointed out creative tourism uses perceived authenticity as a competitive advantage that can satisfy tourists need to acquire knowledge providing them with a memorable experience however while tourists gain creative experiences at cultural heritage sites perceived authenticity may also be used as a judgment criterion and tourists are resistant to it thus it will affect the effective transfer of heritage knowledge based on the above theoretical assertion visitors with perceived authenticity are more likely to show more positive knowledge transfer after a deep heritage creative experience therefore the following hypothesis is posited hypothesis 7b perceived authenticity moderates the correlation between creative performance and knowledge transfer methodology sample and data collection fujian province is one of chinas crucial cultural heritage conservation areas it has a unique traditional lifestyle and cultural and historical landscapes in recent years fujian province has pursued cultural tourism integration and regional cultural expansion strategies promoting the integration of diverse cultural and creative tourism in the region therefore the data of this study were obtained from surveys of jasmine cultivation and tea culture systems in fuzhou fujian china the tie guanyin tea culture system in anxi fujian and the white tea culture systems in fuding fujian and youxi fujian these four systems are all located in fujian province and they are representative of the important tea agricultural heritage sites in china among them fuzhou jasmine tea culture system and anxi tieguanyin tea culture system are globally important agricultural heritage systems tea cultural tourism in fujian province attracts hundreds of groups and organizations each year for tea tourism ecology etc therefore the case is typical and representative first after reviewing literature on creative performance perceived authenticity cultural learning knowledge transfer novelty perception the awakening of enjoyment cultural identity and other related topics we conducted a preliminary survey before the study our research questions and questionnaire design were discussed by stakeholders and the original measurement items were screened out for internal evaluation second we confirmed that the respondent was a visitor who visited the above four cultural heritage sites third four research assistants were invited to conduct shortterm training such as clarifying the purpose of the survey and the rules of the survey and declaring that no personal privacy issues were involved fourth through facetoface interview the respondents completed the questionnaires according to their true feelings furthermore we explained any questions that were unclear to the participants and we asked the assistants to check the questionnaires fifth the respondents were asked to fill in each questionnaire and small gifts were distributed as thanks sixth the questionnaire collection was carried out from december 2021 to march 2022 we distributed 500 questionnaires and 463 were returned we tested the validity of the collected questionnaires and after eliminating 57 invalid questionnaires due to incomplete or entirely consistent responses 406 questionnaires remained for data analysis the descriptive statistics of the respondents are shown in table 1 measurement in this study the english questions were translated into chinese using the doubleblind backtranslation method and independently translated into chinese by two professional frontiers in psychology 07 frontiersinorg translators in addition two translators who specialize in tourism management were invited to perform the back translation as a way to maintain consistency between the english scale and the chinese questionnaire the variables were measured on a sevenpoint likert scale with 1 representing total disagreement and 7 representing total agreement specifically referring to zhang et al four items were used to measure creative performance reflecting visitors perceptions of the creative elements of agricultural heritage was used to measure the extent to which the visitors perceived the heritage to be authentic four items from duman and mattila were used to measure novelty perceptions which reflect visitors perceptions of novelty at heritage sites finally the threeitem cultural identity scale by zhang et al was used to measure the tourists cultural identity with the heritage site we also used some demographically relevant variables such as gender age education level number of visits and average monthly income data analyses the means standard deviations factor loadings composite reliabilities and average variances extracted of each item are depicted in table 2 as shown in table 2 the values of cronbachs alpha values were all in the range of 08000896 indicating high internal consistency in addition the standardized factor loadings were above 0644 for each item in table 2 ave and cr were used to assess the reliability and validity with cr values greater than 07 and ave values greater than 05 they indicated the reliability and validity of the structure of this study table 3 depicts the means standard deviations correlations and square roots of the mean squared deviations for each conformation the correlations for all conformational surfaces were smaller than the square root of the mean explained variance thus there was distinctive reliability and validity between the dimensions to further measure whether the variables were highly correlated and thus there was a collinearity problem this study tested the values of the variance inflation factor of the independent and dependent variables the results showed that all vif values were less than 2306 the results showed that there was no collinearity in the study variables in addition this study strictly followed the appropriate steps to measure the issue of common methodological bias among variables using a wellestablished scale from an authoritative journal in this study harmans oneway test was used to calculate the loadings of all study indicators and the first factor extracted explained only 3812 of the variance which was below the 50 threshold therefore there was no issue of common method bias confirmatory factor analyses to test the individual construct factor loadings and check the structural validity the adaptation index was used to make judgments since all variables were univariate the overall model fit indicator was applied when performing the structural equation test the theoretically proposed sevenfactor model showed a better fit therefore it can be applied for further data analysis results first this study used structural equation modeling with amos 230 software to examine the mediating effects the program had the bootstrapping method with 2000 repetitions of sampling and the monte carlo approach to obtain 95 confidence intervals for bias correction and produced unbiased estimates second the moderating effect of perceived authenticity first creative performance has a significant positive effect on novelty perception novelty perception has a significant positive effect on the awakening of enjoyment and awakening of enjoyment also has a significant positive effect on cultural identity their standardized regression coefficients were β 0280 p 0001 β 0293 p 0001 hypotheses 1 and 2 test the mediating effects of novelty perception and awakening of enjoyment respectively as shown in figure 2 novelty perception has a mediating effect between creative performance and awakening of enjoyment this result supports hypothesis 1 awakening of enjoyment mediates the relationship between novelty perception and cultural identity supporting hypothesis 2 second hypotheses 4 and 5 pertain to the mediating roles of knowledge transfer and cultural learning respectively creative performance positively affects knowledge transfer knowledge transfer positively affects cultural learning and cultural learning positively affects cultural identity the standardized regression coefficients were β 0261 p 0001 β 0484 p 0001 and β 0248 p 001 respectively knowledge transfer mediated the relationship between creative performance and cultural learning cultural learning mediated the relationship between knowledge transfer and cultural identity therefore hypotheses 4 and 5 are supported third the results of hypotheses 3 and 6 indicate that novelty perception → awakening of enjoyment and knowledge transfer → cultural learning have a chain mediating effect on the relationship between creative performance and cultural identity table 4 shows that the 95 bootstrap confidence interval for the indirect effects does not contain zero in conclusion the mediating effects of this study are all supported finally table 5 summarizes the moderating results for hypotheses 7a and 7b models 1 and 3 represent only the control independent and moderating variables while models 2 and 4 add interactions the twoway interaction diagram of the regulatory effect is shown in figure 3 the results show that the interaction between creative performance and perceived authenticity on visitors novelty perceptions is insignificant perceived authenticity did not moderate the relationship between creative performance and novelty perception and hypothesis 7a is rejected in addition the interaction between creative performance and perceived authenticity had a negative impact on knowledge transfer as shown in figure 3 the simple slope test indicates that as perceived authenticity increases the positive relationship between creative performance and knowledge transfer diminishes therefore hypothesis 7b is supported conclusion and discussion first creative performances of agricultural heritage can enhance the cultural identity of tourists this study supports that creative performance still plays a vital role in the behavioral intention of tourists in the context of agricultural cultural creative furthermore the multiple chain mediators in this study follow the triggering mechanism of social identity theory this is consistent with the findings of sun et al that in the context of agricultural heritage tourism we can enhance tourists sense of identity by raising awareness of cultural roots and appreciation of traditional farming knowledge therefore agricultural heritage in the context of cultural and creative tourism enhances tourists experiences at the psychological and behavioral levels with the help of creative elements and forms tourists cultural identity second a high level of perceived authenticity did not moderate the relationship between creative performance and visitors novelty perception first the reason for this may be that due to the limited range of stakeholders we currently consult with and the fact that the process may require more stakeholders to reach a mediation decision second the result in the current scope of the study reflects that high perceived authenticity makes tourists pay more attention to the original cultural value of heritage and the novelty of tourists feeling of agriculture cultural creativity then fades as su et al pointed out in a highly productive modern society groups associated with chinese agriculture cultural heritage sites are less emotionally and functionally attached to agriculture than their traditional ancestors therefore when agricultural heritage shows high perceived authenticity based on the land the creative elements that it contains do not effectively attract visitors to the novel perception of agricultural heritage third a high level of perceived authenticity has a negative moderating effect on heritage knowledge transfer first although research for tourists has covered as much ground as possible current tourists have limited knowledge of heritage sites due to a short period of time therefore more stakeholders need to be researched in the future to further deepen the findings second to some extent the results of this study reflect an impact of the paradoxical relationship between creative performance and perceived authenticity on changes in tourists knowledge transfer the perceived authenticity of agricultural heritage involves authentic cultural expressions unique to agricultural heritage which is one of the characteristics that distinguish agricultural heritage from other forms of heritage tourism according to the regression results of authenticity in table 5 and figure 3 the higher the authenticity the more negative the coefficient in figure 3 and the flatter the slope in figure 3 reflecting the negative moderating effect of authenticity in the process of knowledge transfer by creative performance therefore when the perceived authenticity of an agricultural heritage site is too high in the scope of the current research the creative performance of heritage tourism cannot positively influence local tourists knowledge acquisition specifically when the perceived authenticity of the landscape of agricultural heritage sites is too high cropbased agricultural heritage sites are vulnerable to natural risks and therefore suffer from the seasonality of tourism it lacks adequate expressions of the value of agricultural heritage tourism and weakens the impact of creative tourism on knowledge transfer to tourists when the perceived authenticity of agricultural heritage tourism is too low creative tourism as a novel method of promotion is more likely to influence the process of agricultural heritage knowledge transfer to tourists theoretical contributions the first contribution of this study is the construction of a theoretical path for the formation of tourists cultural identity in agricultural heritage sites based on a creative tourism perspective previous studies have shown that factors such as tourists emotions residents perceptions of benefits and costs and local cuisine contribute to the formation of cultural identity in heritage tourism however few studies have explored the antecedents of the cultural identity of agricultural heritage in the context of creative tourism furthermore although some studies have focused on the role of creative performance in the cultural development of rural areas they imply the attractiveness of creative interaction of creative performance and perceived authenticity on knowledge transfer song et al 103389fpsyg2022968820 frontiers in psychology 12 frontiersinorg tourism in agricultural heritage to tourists but have not empirically explored the influence mechanism of creative performance on cultural identity and this paper fills this research gap importantly this study extends lius findings that creative performance in the context of traditional chinese culture influences tourists behavioral intentions this study makes a breakthrough by using multiple mediating and moderating mechanisms to emphasize the guiding role of creative performance in promoting the cultural identity of agricultural heritage tourists in addition this process is consistent with the social comparison process of social identity theory which verifies the reliability of its path implementation finally for the first time in agriculture heritage tourism we explore the relationship between creative performance and cultural identity the results not only enrich the research field of creative perspectives but also fill the gap between the integration of tourist identity issues in the field of giahs and the field of creative tourism the second contribution of this study is its clarifying that the theoretical path of creative performance on tourists cultural identity is a process related to psychological and behavioral mechanisms although many factors such as cultural memory and cultural learning contribute to the formation of combined traces of cultural identity in the field of cultural and creative tourism few studies have explored the mechanisms mediating the relationship between creative performance and cultural identity in terms of tourists psychological factors and behavioral factors separately this study extends the research on consumer psychology and organizational behaviors in addition the study results extend the research related to creative tourism of agricultural heritage farsani et al elucidated tourists attitudes toward creative tourism in agriculture heritage however unlike previous studies this study focuses on theoretical pathways rather than causal discussions of a single variable it emphasizes the complex path composition of the impact of the creative performance of agricultural heritage on the cultural identity of visitors meanwhile the multiple mediationregulation mechanisms of cultural tourism creative experience and tourists behavioral intention from huang and liu were applied in the field of agricultural cultural heritage tourism in a breakthrough in addition zhang et al found that cultural learning positively impacts cultural identity this study further emphasizes that the influence of cultural learning on cultural identity is caused by knowledge transfer and creative performance as preceding factors it provides a reference for exploring the relationship between psychological factors and the cultural identity of tourists more importantly social categorization and social identification stages in social identity theory are consistent with this process which provides theoretical support for this study finally the findings uncover the differential impact of perceived authenticity on the knowledge transfer of traditional farming culture in the creative tourism of agricultural heritage previous studies have shown that perceived authenticity positively affects visitors knowledge transfer behavior and it has a positive moderating effect between creative performance and changes in the cultural knowledge of visitors however few studies have demonstrated the impeding factors of perceived authenticity in the role of creativity and knowledge transfer and few studies have applied perceived authenticity to empirical research in the field of agricultural heritage tourism however this study emphasizes perceived authenticity as an important factor hindering the impact of creative performance on tourists knowledge transfer creatively extending perceived authenticity research to the field of agricultural heritage tourism and providing ideas for the future development of agricultural heritage cultural education more importantly the results validate min and zhangs views on balancing tradition and innovation in giahs and support the moderate development of creative tourism in giahs finally the study complements the three processes of social identity theory it highlights the hindering effect of authenticity on stimulus effect in the process of social comparison and provides a new research perspective for further research on cultural identity of agricultural heritage tourism management implications while the range of stakeholders consulted in this study was limited and management responses of different stakeholders may vary by context and level of knowledge future engagement processes may require additional stakeholders to reach mediated decisions however for the current scope of the research this study provides the following implications for the development and management of agricultural and cultural heritage sites first managers of agricultural heritage sites should clarify that the formation of tourists cultural identity requires an enhanced sense of creative experience in heritage tourism it requires the governments and managers of agricultural heritage sites to take creative performance as the starting point to create a cultural and creative tourism system for agricultural heritage for example the government should advocate attracting tourists through traditional cuisine and farming civilization unique to the heritage site to create products and services for tourists of heritage sites with creativity managers should also develop forms of creative tourism tailored to specific agricultural heritage sites for example for the ricetype agricultural heritage systems managers should develop cultural and creative services and products in the ricefish agricultural system and the ricefishduck agricultural system the development of creative forms of teabased agricultural heritage such as creative tea estates and tea cultural and creative products can help enhance the understanding of tourists identity with heritage sites second it is necessary to improve tourists heritage and cultural identity with the help of psychological and behavioral factors the management of heritage sites needs to allocate available resources wisely so that they could improve tourists awareness and knowledge education levels about agricultural heritage meanwhile they could enhance the heritage and protection of important cultural values of agricultural heritage by tourists examples of such applications include exhibitions of knowledge of farming cultures and ancient legends the promotion of the integration of agricultural heritage with new technologies to enhance tourists perception of cultural values of heritage the development of visual heritage tourism to awaken the interests of foreign tourists and the appeal to local tourists to preserve and pass on heritage to evoke a sense of mission in addition managers should pay attention to the dynamic development of cultures of agricultural heritage sites and integrate them as closely as possible with cultural and educational activities for example developing cultural landscapes or cultural and creative products based on agricultural history and creating educational lectures on agricultural heritage cultures can promote the heritage and development of agricultural heritage creative tourism in addition cultural scenes are displayed through natural scenery to educate and entertain and the artistic atmosphere is reinforced by idyllic rural scenery for example local scenic spots guide tourists to learn deeply about farming culture through the natural scenery and topography of heritage sites which in turn inspire them to explore the cultural and educational value of heritage and enhance their local identity with it third managers need to realize that enhancing the risk management of agricultural heritage sites is critical to the cultural experiences of visitors studies have shown that agricultural heritage sites suffer from tourism seasonality and that too high perceived authenticity can prevent the full expression of cultural tourism in heritage sites therefore heritage site managers can use a combination of static and dynamic approaches to avoid risks for agricultural landscapes vulnerable to natural factors for example the construction of agrarian museums such as agricultural technology and farming culture and static forms such as the opening of creative b bs in traditional villages help tourists shift their attention to heritagederived products and services when they are unable to perceive agricultural heritage dynamically due to seasonality in addition the risk management of agricultural heritage inheritors should be strengthened to avoid the risk of losing agricultural heritage skills and to promote a deeper understanding of agricultural culture among tourists for example they could hold master competitions to screen quality farming skills in visitor experiences and offer creative programs around female inheritors to enhance risk management for inheritors meanwhile they could increase visitors awareness of the value of heritage transmission limitations and recommendations for future research although this study proposes and extends thinking related to agricultural heritages cultural identity and creative tourism there are still some limitations first because the background of the participants and their knowledge or perception of tradition and authenticity may be limited the scope of stakeholder research is still limited although a certain degree of preresearch is conducted to try to facilitate prior agreement among stakeholders on the knowledge of relevant elements etc therefore future research processes may require additional stakeholders to reach mediation decisions or management insights second this study demonstrates the critical role of the creative performance of agricultural heritage on tourists cultural identity however tourists cultural identity with agricultural heritage may also be influenced by other emotional or cognitive factors such as place attachment value perceptions and community livelihoods therefore future research should determine the influences of emotional and value perception factors of interactions with residents or individual characteristics on tourists cultural identity third this study verifies the impact of creative performance on cultural identity from tourists perspectives regarding novelty perception and knowledge transfer however the relevant conclusions are based on questionnaire surveys and structural equation modeling analyses although this study used multiple mediatingregulatory mechanisms to clarify the antecedent paths of cultural identity further the robustness of the findings should be further explored in the future using qualitative interviews alternatively we should explore the theoretical path of cultural identity based on residents perspectives to improve the study of stakeholders attitudes toward agricultural heritage tourism finally the use of crosssectional surveys and selfreported data to examine the cascading mediating effects is a possible limitation of this study data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors 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

tourism in the globally important agricultural heritage system giahs is critical to the inheritance and innovation of excellent traditional farming cultures based on social identity theory this paper explored the process by which agricultural heritage systems creative performance influences tourists cultural identity through 406 questionnaires from chinese tourists the results indicate that creative performance affects tourists cultural identity through a dual perspective of knowledge transfer and novelty perception furthermore perceived authenticity acts as a moderator weakening the impact of creative performance on tourists knowledge transfer while perceived authenticity does not affect the process of tourists novelty perception this research provides a fresh perspective on the sustainable development of agricultural heritage tourism meanwhile it offers theoretical foundations and practical inspirations for the development of agricultural heritages creative tourism

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introduction a neighbourhood is a district of an urban city where neighbours live and come together through social and cultural networks for some a neighbourhood defines who they are in terms of social position and identity neighbourhoods can form boundaries as well as promote rich cultural diversity 1 2 3 social cohesion is defined as the presence of societal features such as trust networks support and societal norms 4 5 6 a neighbourhood with strong social cohesion can empower individuals within communities to support each other through residential bonds create coordinated actions and networks for a collective good 7 8 research has shown that neighbourhoods with higher levels of social cohesion can be beneficial to the wellbeing of their inhabitants 9 10 11 12 13 14 wellbeing is key to the creation strengths and limitations of this study ⇒ the study was able to examine multiple dimensions of subjective wellbeing with 639 residents in slum areas of delhi india ⇒ to the best of our knowledge this is the first study to evaluate the impact around neighbourhood cohesion and swb of residents that have been resettled compared with those who chose their informal settlement ⇒ crosssectional design implying that only correlations between neighbourhood social cohesion and swb were established causal associations could not be proven ⇒ results were subject to possible selection bias with regard to the colonies participating sanjay colony okhla phase ii and bhalswa resettlement colony were already known to the research team and therefore convenience sampling owing to our longterm relationship open access and maintenance of healthy and productive societies 15 16 high levels of wellbeing have been shown to result in better health and longevity 17 low levels of neighbourhood social cohesion and trust are associated with stress depression and anxiety 18 19 studies suggest that friendship support and advice are associated with wellbeing and that social cohesion relates positively to psychological health 20 21 22 23 24 25 26 the length of residency income and age of the individual have been shown to be closely associated with a feeling of positive neighbourhood cohesion 2 2733 some studies find no correlations 2 34 and others negative correlations concerning education level 30 32 research from around the world has demonstrated that maintaining wellbeing is important for those who are living in difficult circumstances 35 36 around onequarter of the worlds urban population live in informal slum and squatter settlements which typically are unauthorised 37 new delhi is currently the third largest megacity in the world and second to tokyo in asia with just over 32 million people living around and in new delhi 38 39 with a growth rate of 3 and 800 000 poor rural migrants arriving in the city every year looking for better economic opportunities forecasts suggest that in the next 5 years the population could outstrip tokyo making it asias biggest megacity 40 the delhi master plan divides the city into three categoriesplanned special and unplanned due to rapid population growth residents have bought and constructed houses on land which is not zoned in the master plan for residential purposes 41 42 43 44 in this paper we investigate similarities and differences in neighbourhood social cohesion and wellbeing for households living in two different settlement types in delhisanjay colony okhla phase ii a squatter settlement and bhalswa a resettlement colony squatter settlements are unauthorised occupations of vacant land mostly public with minimum access to civic services and amenities resettlement colonies are made up of families evicted from their original squatter settlement to plots allotted by the slum rehabilitation authority resettlement colonies reflect the systematic process of relocating poor residents to the periphery to facilitate the gentrification of urban spaces consequently they experience low levels of amenity provision by public agencies owing to scarcity of funds 42 4551 residents in resettlement colonies have expressed concerns around community cohesion studies of resettlement areas in india have found residents reporting greater social alienation their homes lacking both security of tenure and a socioeconomic livelihood base because resettlement sites are large distances from residents former homes 48 49 5256 residents started to live in bhalswa in 2000 having been evicted from 11 slum locations in and around delhi including nizamuddin dakshinpuri and rohini 57 we examine the relationships between subjective wellbeing and neighbourhood cohesion taking into consideration the socioeconomic backgrounds of the households as well as levels of trust in two different informal settlement types as neighbourhoods are bounded urban areas they offer an important opportunity to understand individuals and communitys perceptions within a finite region different neighbourhoods can be investigated explored and compared 58 59 60 61 we consider the association between neighbourhood social cohesion and wellbeing for residents living in different colony types one where the residents have chosen to make their home in a squatter colony and the other where squatter colonies have been demolished and the residents uprooted to reside in a resettlement colony in the present study we evaluate the psychometric properties of the neighbourhood cohesion index and the swb items initially through a pilot in bangalore india our findings may inform whether interventions such as promoting a sense of belonging respect and inclusion are required in specific neighbourhoods to promote community cohesion and potentially wellbeing they may also help in identifying potential policy problems as well as better understanding the drivers of swb 62 methods study design and setting this is a communitybased crosssectional study carried out with residents in two informal settlements sanjay colony okhla phase ii and bhalswa resettlement colony in new delhi india from 28 march to 9 april 2022 open access sample size calculation and sampling techniques sanjay colony and bhalswa were selected through convenience sampling owing to our longterm relationships with the communities in these areas sanjay colony okhla phase ii has a total population of 66 820 over an area of 199 km 2 with a population density of 33 659 people per km 2 63 bhalswa covers an area of 1038 km 2 with a population 102 701 and population density of 9892 people per km 2 64 households were selected by multistage random sampling stratified on the population and geographic area the sample size calculation was performed using n nx e 2 x and margin of error e √ x n n1 with x z 2 r where n is the population size r is the fraction of responses required and z is the critical value with the calculation based on the normal distribution this calculation gave a target sample size of 311 in sanjay colony and 328 in bhalswa at the 95 ci level for 51 53 margin of error with at least 80 power 65 in order to achieve the power calculation 660 households were approached in total 21 households did not agree to participate with an overall response rate of 97 94 and 99 in sanjay colony and bhalswa respectively measures neighbourhood cohesion index the nci is used in this research to measure social cohesion with a focus on neighbourhood networks and the degree of neighbourliness that is the emotional social support within the neighbourhood which includes visiting neighbours and friendships 66 67 higher mean total scores indicating a greater level of neighbourhood social cohesion 20 68 all items were measured on a 5point likert scale with 5 to 1 the total scores for nci were calculated by taking the average of the 18 items with 5 and 15 being reverse scored the nci measure can be divided into three subscale dimensions sense of community neighbourliness and attraction to neighbourhood 67 6971 it has been wellvalidated and used in a range of country settings with various communities 24 6870 72 73 subjective wellbeing subjective rather than objective wellbeing has been used in this study to explore the individuals internal subjective assessment of their own life as a whole based on cognitive judgments and affective reactions diener one of the leading scholars in swb research defines swb as how a person feels and thinks his or her life is desirable regardless of how others see it 74 this definition highlights the thinking and feeling dimensions of swb to gain an understanding of how an individuals perceived swb is associated with neighbourhood social cohesion four subjective measures of wellbeing were used these four subjective measures of wellbeing are hedonic wellbeing eudaemonic wellbeing evaluative wellbeing and freedom of choice 75 76 77 78 79 80 81 sociodemographic characteristics individuallevel characteristics include sociodemographics for neighbourhood characteristic we have settlement type patient and public involvement this research was done with public involvement and built on existing longterm relationships with the communities of sanjay colony okhla phase ii and bhalswa community representatives were informed of the purpose of the study and were consulted on the research instrument there was no patient involvement informed consent verbal informed consent was provided by participants who were willing to take part all participants were informed before the start of the household survey that participation was voluntary and anonymous with no personal identifiable data captured and the results would be kept strictly confidential and for research purposes only data were transferred and stored securely at newcastle university no incentives were provided for participation procedures the data reported in this article were collected from 311 residents in sanjay colony okhla phase ii and 328 residents in bhalswa these areas were chosen as they represent two different types of informal settlements sanjay colony okhla ii categorised by the delhi master plan as a slum and bhalswa categorised as a resettlement colony a team of 18 survey administrators under the supervision of a researcher from newcastle university collected the data indus information initiatives provided in country support a systematic household survey was carried out by administrators that were grouped into pairs and trained specifically for this project the main household wage earner was interviewed by the survey administrators in a random sample of households when the main household wage earner was not available a repeat visit was made at a time suitable to the resident where there was a nonresponse the team moved onto the next available initially a pilot was carried out with 150 residents in hawadigar colony karnataka india to test the crosscultural transferability of the survey hawadigar colony is an unplanned squatter settlement made up of 308 households four researchers working in pairs interviewed the main household wage earner in a random sample of households the psychometric properties of the nci and swb are reported in the results section data processing and analysis data were collected by the administrators who inputted in real time the responses into qualtrics during the household survey which were then exported into stata v17 for analysis initially descriptive statistical analysis was undertaken to obtain means and sd for the data statistical tests were then carried out to ascertain if any significant differences existed between the two communitys demographic variables independent ttests were used for continuous outcomes and χ 2 tests for dichotomous outcomes structural equation modelling was used to establish the construct validity of the nci and the swb measures the cronbachs alpha was used to measure the internal consistency of the nci for the swb internal reliability was considered through correlations between the nci and its subscores to understand the differences between residents in sanjay colony okhla phase ii and bhalswa individual items on both the nci and open access swb measures were analysed using the estimated average marginal components effect the acme is the average causal effect of changing the community variable from bhalswa to sanjay colony for a given resident while averaging over the other factors is given by τ ∑ ϵτ e yi yi ×pr where t ijl is an dimensional vector representing levels of all the factors except the factor l of the jth item answered by respondent i t ij denotes the levels of all factors for the remaining other than j and τ is the choice of pr the expectation is over a random sample of the respondents and item responses 82 a major advantage of this statistical method is that it is fully nonparametric and so does not require any functional choice probability assumptions results characteristics of participants we collected sociodemographic information from 328 residents in bhalswa and 311 from sanjay colony okhla phase ii between march and april 2022 the majority in both colonies were hindu belonging to the scheduled caste migrating from uttar pradesh however there were statistically significant differences between the two colonies with a higher proportion of muslims in bhalswa a higher proportion of general and backward caste in bhalswa and a higher proportion of migrants from up in sanjay colony for the 639 participants the mean number of years of education and the age of the main household wage earner were not statistically significantly different in the two colonies almost onethird of households in sanjay colony reported their main occupation as a selfemployed business owner whereas in bhalswa this was true for less than onefifth of households the average monthly income in sanjay colony was statistically significantly less at ₹16 68170 compared with bhalswa at ₹18 93598 monthly income was positively correlated with the household owning a refrigerator with a freezer washing machine and scootermotorcycle in both communities these wealth indicators show positive associations with monthly income those in sanjay colony were more likely to carry out employment within their own community compared with those in bhalswa where a statistically significant difference was found regarding wealth indicators only the ownership of a smartphone was more likely in sanjay than in bhalswa for scooter bicycle electricity refrigerator and washing machine bhalswa residents were statistically more likely to own these items than those in sanjay psychometric properties of the nci and swb measure pilot a pilot was carried out with 150 residents of hawadigar colony bangalore city karnataka india to test for reliability the composite reliability was good to establish the construct validity of the measures sem was undertaken in general good models should have root mean square error of approximation 006 and comparative fit index 09 the nci and swb measures both show good validity 83 84 current study the nci and swb in this present study show good composite reliability very good convergent validity of the nci is seen through correlations with its subscores of soc nei and attr for the swb internal reliability was considered through correlations between the nci for sanjay colony and bhalswa group level construct validity was established with values of cfi 094 and rmsea 005 for both sanjay colony and bhalswa reliability of the measures was also demonstrated by loadings on to each of the factors soc nei attr and wellbeing factor loadings greater than or equal to 03 are said to be salient and relate meaningfully to primary factors 84 85 86 neighbourhood cohesion index eight statistically significant differences were seen between the responses from residents in sanjay colony and bhalswa on the nci four in soc and two in each of the themes nei and attr as shown in figure 3 with additional details in online supplemental table 1 regarding the soc residents in sanjay colony were 93 percentage points more likely to believe their neighbours would help them in an emergency and 95 pp more likely to have a greater willingness to improve their neighbourhood than residents in bhalswa residents of sanjay colony were 102 pp more likely to feel a greater soc than those residents of bhalswa sanjay colony residents were 548 pp less likely to feel that their neighbours agree with them about what is important in life in the subscale neighbouring residents in sanjay colony were 476 pp less likely to invite neighbours to their home and 97 pp less likely to feel that neighbourhood friendships meant a great deal to them regarding attraction to the neighbourhood respondents from sanjay colony were 73 pp less likely to say they were attracted to living in the neighbourhood they were 225 pp more likely to have a feeling of belonging given that the base probability is 50 the effect size of this result is open access the most significant of all these results as it increases the base probability by 45 subjective wellbeing there were two statistically significant differences between the responses from residents in sanjay colony and bhalswa on the swb there was a 48 pp increased likelihood that residents in sanjay colony had a greater likelihood to feel more satisfied with life and a 48 pp increased likelihood of having greater perceived feelings of freedom of choice than residents in bhalswa for additional detail see online supplemental table 2 associations between nci and swb statistically significant positive correlations demonstrated modest associations between nci and swb in both sanjay colony and bhalswa in both communities there was a strong positive correlation between trust and neighbourhood cohesion however only in bhalswa was trust statistically significantly positively related to swb there was a statistically significant positive modest correlation with regard to the length of residence within the neighbourhood and the nci in both sanjay and bhalswa the longer a resident had lived in the community the greater the feeling of neighbourhood cohesion wellbeing was also statistically significantly correlated with employment in both communities only in bhalswa was there shown to be correlations with length of residency swb and trust for swb there was a negative modest correlation between the length of residency the longer the resident lived in the community the lower their level of swb for the level of trust there was a significant positive modest correlation with length of residency the longer a resident had lived in bhalswa the greater the level of trust interestingly regarding trust only in bhalswa was there a statistically significant correlation between employment and trust neither age nor education was found to be statistically significantly correlated with nci swb or trust in sanjay or bhalswa for additional detail see online supplemental table 3 discussion key findings this research considered two different informal settlement types in delhi india where both communities were built on unauthorised land with one spontaneously developed by individual families and the other planned by the government to reallocate slum dwellers away from the city we found that in both settlements residents feelings around community cohesion were associated with their subjective wellbeing that is a greater sense of satisfaction freedom happiness and purpose was felt by those residents that had rated more open access highly their sense of community attraction to their neighbourhood and neighbourliness when a community trusted their neighbours there was a greater feeling of cohesion the longer a resident lived in the community there was a greater sense of cohesion this could imply that residents who feel there is a greater sense of cohesion are more likely to remain in the neighbourhood those with higher incomes and those that undertook regular employment enjoyed higher levels of subjective wellbeing we found that neither age nor education influenced feelings around trust neighbourhood cohesion or subjective wellbeing those living in sanjay reported higher subjective wellbeing and were more likely to feel a sense of belonging to a whole community where they would help and be helped by their neighbours in an emergency however sanjay residents were less likely to be neighbourly with fewer friendships and less of an attraction to live in the neighbourhood part of the reason for this which we cannot substantiate may relate to the more cramped living conditions in sanjay in comparison to those in the planned resettlement community of bhalswa that sanjay residents reported higher subjective wellbeing than in bhalswa despite such factors may also indicate the independent and overriding value they place on having chosen where to live and not having been subject to forced relocationbut this needs additional research in bhalswa there was a greater feeling of neighbourliness and the longer the resident had lived in the community the greater level of trust in their neighbours even though residents did not express the sense of community belonging expressed in sanjay one explanation for this result could be that the shared feelings associated with the trauma of compulsory relocation allowed the development of strong bonds with immediate neighbours coping with the original sense of helplessnessand with longer terms of residency their trust in neighbours increased independent of their perception of the neighbourhood as a whole friendliness and supportiveness among neighbours could have remained independent of any sense of selfesteem or fulfilment within the neighbourhood our results showed however that the longer the resident had lived in bhalswa the greater the negative effect on their subjective wellbeing residents with poor subjective wellbeing may be those unable to leave owing to lower incomes and employment possibilities again a possible but unsubstantiated explanation for this finding may be the lasting negative impact on sense of belonging and wellbeing arising from the experience of forced relocation our findings are to some extent in line with the existing literature that reports associations between greater neighbourhood social cohesion and better subjective wellbeing 9 10 11 12 13 14 they show that a greater sense of community cohesion is associated with trust 6 as in other literature residents with the highest incomes expressed greater subjective wellbeing 27 28 33 interestingly income was only associated positively with trust and neighbourhood cohesion in bhalswa with regards to neighbourhood cohesion residents in bhalswa the resettlement colony were less likely to have a sense of belonging to their neighbourhood williams et al 56 agree stating that resettlement housing projects in india produce ghetto effects which inhibit feelings of belonging and processes of placemaking as in mahadevia et al 49 we found that residents in the resettlement colony of bhalswa were less likely to feel a sense of community and the desire to improve their neighbourhood owing to greater heterogeneity of the residents in contrast to the existing literature we found that education was not correlated with trust subjective wellbeing or neighbourhood cohesion blanchflower and oswald 87 in their study on wellbeing over time showed that education played a role independently of income and patel et al 88 found that higher education significantly decreased the odds of low subjective wellbeing in older adults in india limitations the first limitation of our study was its crosssectional design implying that only correlations between neighbourhood social cohesion and swb were established causal associations could not be demonstrated second the results were subject to possible selection bias regarding the participating colonies sanjay colony okhla phase ii and bhalswa resettlement colony were already well known to the research team we endeavoured to overcome this through the multistage random sampling of households third selfreported and subjective measurements might cause information bias fourth understanding the impact on swb that having chosen ones abode has in comparison to forced relocation requires a more ethnographic and immersive approach to understand the meanings that people attach to the experience of being subjected to compulsory resettlement finally associations between social cohesion and swb may vary between men and women one limitation of this study is that data were collected from the main household wage earner who in the indian context is typically male conclusion our analysis in this paper aims to contribute to debates concerning neighbourhood cohesion and swb for residents living in different informal settlement types in megacities gathering better local data allowed for a clearer understanding of the differences between residents of two types of slums both typically devoid of security of tenure and infrastructure but one on the periphery of the city detached from a socioeconomic livelihood base and where residents had been evicted from their original homes residents of resettlement colonies are forcefully relocated uprooted from established social and economic networks typically against their will additional research is required to understand the impact that this forced relocation may have on the sense of swb and personal agency this research should take into account issues of selection bias and requires a significant ethnographic component to explore the value that people attach to having chosen where they live competing interests none declared patient and public involvement patients andor the public were involved in the design or conduct or reporting or dissemination plans of this research refer to the methods section for further details patient consent for publication not applicable ethics approval this study involves human participants and was approved by the ethics committee of newcastle university and local community leaders approval through indus information initiatives a registered social research data collection organisation delhi india participants gave informed consent to participate in the study before taking part provenance and peer review not commissioned externally peer reviewed supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise data availability statement

objectives to evaluate the relationships between neighbourhood cohesion and subjective wellbeing swb in two different informal settlement types design crosssectional analysis of a communitybased survey setting communities in two districts sanjay colony okhla phase ii and bhalswa in delhi india participants 328 residents in bhalswa and 311 from sanjay colony measurements neighbourhood social cohesion scale measured on an 18point scale and the swb scale made up of four subjective measureshedonic eudaemonic evaluative and freedom of choice sociodemographic characteristics and trust were used as covariates results in both neighbourhood types there was a statistically significant positive bivariate correlation between neighbourhood cohesion and swb sanjay r0145 p 005 bhalswa r0264 p 001 trust and neighbourhood cohesion were strongly correlated sanjay r0618 p 001 bhalswa r0533 p 001 and the longer the resident had lived in the community the greater the feeling of neighbourhood cohesion sanjay r0157 p 001 bhalswa r0171 p 005 only in the resettlement colony bhalswa was swb negatively correlated with length of residency r0117 p 005 residents who chose their settlement type sanjay residents were 225 percentage points pp more likely to have a feeling of belonging to their neighbourhood than residents that had been resettled bhalswa cohens d effect size 045 sanjay residents had a greater likelihood to feel more satisfied with life 48 pp p 001 and having greater perceived freedom of choice 48 pp p 001 conclusions our findings contribute to the general knowledge about neighbourhood cohesion and swb within different informal settlement types in a megacity such as new delhi india interventions that promote sense of belonging satisfaction with life and freedom of choice have the potential to significantly improve peoples wellbeing

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introduction the covid19 pandemic has had profound effects on communities globally 1 since february 2021 this sarscov2 has engulfed the world with approximately 105 million confirmed cases and 22 million deaths 1 in australia by january 2021 over 28 000 confirmed cases and 908 deaths have been reported 2 as a result containment measures have included closure of or limited access to government and private offices schools shops parks and nonessential workplaces 3 this has directly and indirectly impacted peoples daily activities social events food availability dietary quality sleep cycle screen time employment access to recreational locations and financial security 4 5 6 7 8 recent studies have identified multiple aspects of life that have been influenced by the pandemic for instance a study of canadian families with young children found that covid19 restrictions adversely affected daily routines with reduced physical activity and increased screen time as well as an overall strengths and limitations of this study ► this is the first study to report on the role of ethnicity in perceived impacts and information sources of covid19 among mothers with young children in australia ► the study highlights the importance of taking ethnicity into account in providing appropriate health support for mothers with young child from various backgrounds during the covid19 pandemic ► the study could be limited by potential sample selection bias as a result of survey participants from an existing trial ► further qualitative research is required to understand why there were differences in sources used for information on covid19 and healthy lifestyle behaviours open access increased consumption of food and snacks 9 such changes triggered by stress eating working from home online home schooling and limited access to outdoor play areas are likely to lead to lower quality of life which in turn may lead to long lasting health problems 5 10 in addition to the impact on health behaviours covid19 restrictions also present unique stressors that have placed a burden on mental health 11 12 13 14 15 in examining the impacts of social restrictions and distancing measures a recent metaanalysis of 19 studies with 93 569 participants reported a higher prevalence of stress psychological distress depression anxiety and posttraumatic stress disorder during the pandemic when compared with previously estimated 1year prevalence rates prior to the pandemic 11 that review highlighted that more adverse psychological symptoms were exhibited among women people under 40 years and those with existing mental health illnesses unemployment and students 11 despite the rapid escalation and repercussions of the covid19 pandemic across all populations it has disproportionally affected disadvantaged and culturally and linguistically diverse communities according to recent provisional analyses covid19related death is significantly higher among cald communities than those of white ethnicity 16 17 this finding indicates that the influence of covid19 on cald communities can potentially exacerbate health inequalities in already vulnerable populations 18 the higher death rates from covid19 among cald populations may be partly due to factors such as lower education difficulty finding up to date information from trustworthy sources lack of accessibility of translated materials and language barriers to access health services 19 20 21 further within australia cald communities have lower levels of health literacy 22 it is therefore possible that these previously mentioned factors may influence the quality of health information cald communities receive about covid19 and their ability to respond appropriately an australian study also showed that people with inadequate health literacy and those who spoke a language other than english at home struggled to find and understand information on covid19 from government sources compared with those with adequate health literacy and who spoke english at home 23 in contrast a recent study highlighted government websites as one of the most used and trusted sources of covid19related information among people of white ethnicity 24 moreover the trust and choice of selected sources of information are influenced by several demographic factors such as ethnicity age religion education and political affiliation 24 25 to date there has been limited research examining the role of ethnicity related to the impacts of covid19 and accessing health information the aims of this study were to investigate perceived impacts means of communication with professionals and information sources related to covid19 among mothers with young children and further explore whether these impacts or information sources were associated with ethnicity methods study design we conducted a crosssectional survey of mothers with young children participating in an existing study 26 in sydney australia from march to october 2020 the mothers had participated in a longitudinal study since 2017 and the study protocol was published prior to the commencement of this trial 26 the recruitment process and first year outcomes of the original trial have been reported elsewhere 27 28 briefly the trial aimed to investigate effectiveness of an early childhood obesity prevention using telephone support or text messages this current study was part of the 3year followup survey patient and public involvement the survey participants were originally recruited to a longitudinal study 27 28 from antenatal clinics in eight hospitals of four local health districts in sydney for this current study the development of the research questions and outcome measures was partially informed by the intervention nurses through their telephone support consultations with the study participants as part of the original trial 28 the study participants played no role in the design of this study but their informed consent was sought not participating in this current study had no effect on their participation in the original study the summary results of this study will be disseminated to all the participants through mailouts or the website the study participants and project team members are acknowledged in the acknowledgements section inclusion and exclusion criteria for the original study women were eligible to participate if they were aged 16 years and over able to communicate in english had a mobile phone and lived in the recruitment areas of a local hospital women were excluded from the study if they had a severe medical condition or known major fetal anomalies based on medical advice survey respondents and data collection a total of 662 mothers remained in the existing trial when their children reached 3 years the survey was conducted by a marketing survey company using computerassisted telephone interviewing perceived covid19 impacts we measured the impacts that covid19 has had on families from four aspects including changes in eating physical activity and screen time behaviours mental health participating in research and whether the pandemic influenced their ways of receiving healthrelated information the mothers were asked to respond to five statements on whether their family ate more snacks fruit and vegetables had more screen time had more physical activity and were open access more likely to follow mealtime or bedtime routines during the covid19 pandemic we used a 5level likert scale strongly disagree disagree neither agree nor disagree agree and strongly agree the responses to each of the statements were further dichotomised into having more if they strongly agree or agree to the statement or no changes the patient health questionnaire4 was used to assess mothers mental health 29 the mothers were asked how often they were bothered by the following over the last 2 weeks nervous and anxious worrying depressed or hopeless little interest or pleasure in doing things mothers responded to each of the questions on a 4point scale 0 for not at all to 3 for nearly every day the phq4 total score ranges from 0 to 12 with categories of psychological distress being normal mild moderate and severe it was further dichotomised into psychological distress and none mothers were also asked how often they worried about family members and close friends on a 4point scale responses were dichotomised into worrying about family or no worry assessing the impact covid19 had on their research participation mothers were asked whether covid19 negatively affected their desire to participate in research mothers responded to the question on a 5level likert scale not at all a little bit moderately quite a bit and extremely we also dichotomised the responses into affecting research participation and no affect the mothers were asked whether the covid19 pandemic affected the way they receive and communicate healthrelated information with health professionals they were also asked how likely they would use the following modes to receive and communicate healthrelated information with health professionals face to face telephone short message service videoconference website social media and booklets or pamphlets mothers responded to each of the modes on a 5level likert scale unlikely possibly likely almost certain and certain the responses were categorised into yes and no with yes referring to likely almost certain or certain sources of health information for changing behaviours during covid19 pandemic we asked about sources of health information related to three areas specific to covid19 covid19related information changing food and beverage behaviour and changing physical activity from government officials health professionals family members social media or educators respectively the question allowed multiple responses mothers demographics mothers demographic information including their language spoken at home was collected at baseline using standard questions from the new south wales adult population health survey 30 all mothers demographic and socioeconomic information were categorised into groups statistical analysis statistical analyses were carried out using stata v13 all p values are two sided and statistical significance was set at the 5 level descriptive analysis was conducted to describe mothers baseline demographic characteristics for those who completed 3year survey pearsons χ 2 tests were conducted to examine the associations between mothers demographic characteristics and covid19 impact and sources of health information during covid19 pandemic number and percentage were reported multiple logistic regression models were built to investigate the associations between mothers language spoken at home and covid19 impact and sources of health information during covid19 pandemic to identify potential confounding factors mothers demographic variables that were significant in pearsons χ 2 tests with p 025 were entered in the multiple logistic regression models the least significant variables were progressively dropped until only those with p 005 remained variables dropped from the model were then entered into the model individually to assess confounding since the survey respondents were involved in an intervention trial their group allocation was also adjusted in the final model adjusted ors with 95 cis were then calculated as a measure of the association results of 662 mothers remaining in the followup study 537 completed the covid19 survey questions with a response rate of 81 table 1 shows demographic characteristics of the survey respondents with 45 of the mothers speaking a language other than english at home table 2 shows that the impacts on mental health were observed across the survey respondents with 26 reporting psychological distress and 59 worrying about their family there was no significant difference in psychological distress between mothers from englishspeaking or nonenglishspeaking backgrounds substantial proportions of mothers reported having more snacks and no increase in fruit and vegetable consumption in particular among englishspeaking mothers overall 77 of the mothers reported having more screen time while 60 reported no increase in physical activity with no significant differences found between englishspeaking and nonenglishspeaking mothers significantly higher proportions of englishspeaking mothers reported impacts of the covid19 restrictions on their mealtime or bedtime routines open access table 2 also shows 44 reported that covid19 affected the way they receive and communicate healthrelated information with health professionals especially those who spoke a language other than english with an aor they were less likely to use a facetoface service and more likely to use social media for healthrelated information table 3 shows the sources of covid19related information and information for changes in food and beverage consumption and physical activity behaviours during the covid19 pandemic for the covid19related information almost all of mothers relied on government officials followed by health professionals family members educators and social media however mothers who spoke a language other than english were more likely to rely on family members and social media less than half of the survey respondents reported accessing sources of information for changing physical activity from government officials and 27 reported accessing such information from health professionals however nonenglishspeaking mothers were more likely to rely on government officials or health professionals compared with englishspeaking mothers regarding information for changing food and beverages only about 20 reported accessing information from government officials or health professionals nonenglishspeaking mothers were more likely to rely on government officials or health professionals compared with englishspeaking mothers discussion this crosssectional survey conducted with mothers during the pandemic found that one in four reported having psychological distress with more than half of the respondents being worried about their family regardless of ethnicity the covid19 pandemic resulted in more snack consumption and more screen time it also affected the way mothers receive and communicate healthrelated information with health professionals especially those who spoke a language other than english nonenglishspeaking mothers were less likely to use a facetoface service and more likely to use family and social media for healthrelated information the survey also found that the majority of mothers relied on government officials and health professionals for covid19related information regardless of ethnicity impact of covid19 on mental health on average general mental distress among mothers with young child was moderate most reported feeling normal or having a mild degree of mental distress similar patterns were found among englishspeaking and nonenglishspeaking mothers the mental health status of our survey respondents appeared to be better than that of respondents of a survey that examined mental health status of the general australian population during the pandemic with responses from 5158 australian adults 31 a possible explanation could be due to the difference in data collection period that study collected data from 1 april 2020 to 4 april 2020 while lockdown restrictions were occurring in australia 32 our survey collected data from march till october 2020 which covered periods from lockdown to easing of restrictions in australia the varying results also could be explained by the different tools used for assessing mental health and the age range and gender of our study participants our findings are complementary to a previous study conducted in germany which showed similar psychological effects of the pandemic using the same phq4 tool analysis of the survey data collected from reported that the majority of respondents open access were concerned of the health consequences for their relatives the average depressive and anxiety phq4 score was mild among participants similar to our study additionally the study highlighted that women had a significantly higher phq4 score than men highlighting the susceptibility of women to mental illness 33 despite the low prevalence of mothers reporting mental distress in our current study it is intuitive that covid19 pandemic restrictions would increase mental distress as evidenced by previous literature on the negative influences of public health crises on mental health 11 12 13 14 15 more than half of our study participants reported worrying about their family members while government efforts to manage and eradicate covid19 continue our society will also need to continue maintaining physical distancing some social isolation and dealing with disruptions to life thus it is imperative to intervene to protect communities in particular those in highrisk groups such as women with young children 31 and other vulnerable communities such as nonenglishspeaking people where a greater effort to communicate well is needed specifically research needs to focus on better understanding from a cultural lens the cultural differences to help cald communities deal with the changing contexts related to covid19 and how they see the role of governments and health professionals to help cald communities interact with health systems 23 addressing this will increase the effectiveness of the covid19 response such as testing following physical isolation restrictions and the uptake of vaccinations to effectively and successful manage subsequent waves of the pandemic sources used for health information our study findings echo some previous studies in which it was also found that vulnerable populations are less likely to use facetoface services and more likely to turn to other sources for health information such as religious leaders or family members and community leaders who may be important in many cultures 22 24 social media is an additional platform that has been used substantially by many people including cald communities for healthrelated information 21 using social media from nonmedical or nongovernment sources may be of concern given the proliferation of readily available misinformation obtained via unreliable and unverified online social open access applications 34 35 recent evidence showed that twothirds of individuals encountered misinformation about covid19 on social media 36 an additional onethird mentioned obtaining false information from news media coverage 36 for instance in the usa misleading claims of a national lockdown fuelled panic buying of paper products and groceries resulting in food insecurity among vulnerable populations giving rise to mass hysteria and panic 37 while social media is highly used by populations of various backgrounds and can be a beneficial platform to share information there is a need to improve social media literacy skills more research needs to be conducted to identify relevant approaches to support cald communities and improve navigating through credible information on digital or social media platforms adverse psychosomatic outcomes are expected to increase especially among cald communities due to social isolation access barriers to health services discrimination and racism limited support networks low english proficiency and poor digital literacy 38 these circumstances can potentially exacerbate existing health inequities for these vulnerable groups thus perpetuating suboptimal healthseeking behaviours and poor engagement with healthcare professionals and the broader health system as identified in our study there is a cultural tendency to seek information from families religious leaders and media which highlights the importance of mitigating harm from digital infodemics and tailoring messages to community values 38 there is a clear case for government agencies to take a leadership role in communicating with cald communities using culturally appropriate methods in particular to increase the uptake of covid19 vaccinations in addition a crosssectional survey of pennsylvania adults found that covid19 knowledge correlates with using trusted news sources the study called for the use of government health websites as well as monitoring and correcting misinformation presented by other sources in order to maximise information dissemination and compliance with covid19related public health recommendations 39 this study found that during the pandemic the majority of people obtained covid19related information from government officials and health professionals but a much smaller proportion of mothers obtained health information for changing health behaviours from these sources this does not necessarily mean that mothers did not receive diet and physical activity information or advice from government officials or health professionals rather it may indicate that changing lifestyle open access behaviours was considered to be a low priority during the pandemic compared with navigating the various responses to covid19 another reason might be that the majority of the population in australia are less likely to have ever lived through a pandemic and therefore there is a sense of unfamiliarity in how to respond and react thus the government played a major role in the response including constant changes in social restriction laws requiring the population to follow information from government officials despite this good nutrition and regular physical activity contribute to improving immunity as such who released guidelines on diet during the covid19 pandemic stating that good nutrition is crucial for health particularly in times when the immune system might need to fight back 40 however there are currently very few culturallyappropriate programmes and resources that promote healthy eating and physical activity targeted at children aged under 5 years 41 government and various health agencies will need to continue developing culturally appropriate resources and healthrelated behavioural change support material to mitigate the likelihood of longterm impacts of covid19 on chronic disease status strength and limitations our survey is timely and specific to the impacts of covid19 during the pandemic mental health outcomes were measured with the phq4 which is a psychometrically valid instrument and has been demonstrated as a valid screening tool in general populations 29 with regard to the limitations our crosssectional survey design hindered causal inference the survey questions for perceived behaviour change and information sources as impacted by covid19 were newly developed for the current study given that no validated instruments were available at the time we initiated this study additionally our collection period ranged from march to october 2020 and within this period australia experienced a range of covid19 restrictions from full lockdown to eased restrictions to having varying levels of restrictions in place and in different states 32 we acknowledge that respondents behavioural data only represent their state on the date they completed the survey with limited generalisability further qualitative research is required to understand why there were differences in sources used for information on covid19 and healthy lifestyle behaviours conclusion the response to covid19 has impacted on mothers with young children in regard to their mental health means of communicating with health professionals and sources of health information mothers from cald communities were less likely to use a facetoface service and more likely to seek information from family members and social media appropriate health support for cald community needs to take these factors into account contributors lmw cr and lab conceived of the study lmw prepared the first draft of the manuscript hx conducted statistical analyses dj and lb contributed to literature review cr pp lab and st contributed to revising the manuscript critically all authors contributed to finalising the manuscript and approved the manuscript lmw and hx are the guarantors for this study disclaimer we declare that the funder played no role in the design and conduct of the study collection management analysis and interpretation of the data preparation review or approval of the manuscript and decision to submit the manuscript for publication competing interests none declared patient consent for publication not applicable ethics approval the trial was granted ethics approval by the ethics review committee of sydney local health district written informed consent was obtained from all study participants provenance and peer review not commissioned externally peer reviewed data availability statement data are available on reasonable request deidentified data and material can be available on request pending on ethics approval from dec 30 2021 to dec 30 2026 supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

objectives this study aimed to investigate perceived impacts ways of communication with professionals and information sources related to covid19 and explore whether these impacts or information sources were associated with ethnicity that is language spoken at home design a crosssectional study setting sydney australia during the period from march to october 2020 participants mothers of young children participating in an existing trial outcome measures mothers were asked to respond to a set of survey questions related to covid19 via telephone the questions included a mental health scale and how they communicated with health professionals and their information sources related to covid19 during the covid19 pandemic results of 537 mothers who completed the survey 81 response rate 45 reported they spoke a language other than english at home overall 136 26 reported experiencing mental distress 234 44 reported that covid19 affected the way they receive and communicate healthrelated information with health professionals especially for those from nonenglish speaking backgrounds with an adjusted odds ratio aor 158 95 ci 110 to 227 they were less likely to use a facetoface service aor 055 95 ci 037 to 080 and more likely to use social media aor 211 95 ci 140 to 317 for healthrelated information regarding sources of covid19related information mothers from nonenglishspeaking backgrounds were more likely to rely on family members aor 149 95 ci 101 to 219 and social media aor 334 95 ci 205 to 543 conclusions covid19 has significantly impacted mothers with young children in regard to their mental health means of communication with health professionals and sources of health information mothers from nonenglishspeaking communities were less likely to use a facetoface service and more likely to seek information from family members and social media appropriate health support for nonenglishspeaking community needs to take these factors into account trial registration number anzctr12618001571268 they

19681_0

and towards a new kind of inter or even transdisciplinary science based on complex adaptive theory 3 new ideas insights and phenomenon that emerge unexpectedly are fundamental to this new approach the parts of all kinds of different systems interact and organise themselves spontaneously into new unpredictable patterns and characteristics the consequence is that the overall system cannot be predicted or described based only its component parts emergence arises when selforganising components of a complex adaptive system interact these generate new unpredictable pathways as a consequence of this interactivity 4 often these patterns are fractal that is similar patterns tend to emerge at different levels of the system 5 work on complex adaptive system analysis from a range of different disciplines has culminated in new insights into emergent nonlinear behaviours of systems as diverse as evolution 6 organisations 7 and climate 8 interest in complexity theory is also increasing amongst health researchers especially in implementation science 9 evidencebased medicine has become central to modern healthcare policy and practice this is often interpreted through protocols and guidelines derived from systematic reviews of population level data and then applied to all those with particular conditionsclinical needs 10 david sackett one of the key architects of ebm framed ebm in a different way he and his colleagues saw ebm as an integration of multiple systems of knowledge values and expertise that together produce a unique optimal outcome for each clinical encounter evidencebased medicine is the integration of best research evidence with clinical expertise and patient value when these three elements are integrated clinicians and patients form alliance which optimises clinical outcomes and quality of life 11 salutogenesis the theory of salutogenesis was developed by aaron antonovsky 12 it conceptualises peoples capacity for wellbeing in terms of how they experience events the degree to which people see the world as meaningful manageable and comprehensible is characterised by their sense of coherence high soc tends to be associated with better health and social outcomes antonovskys theory relates to notions of human flourishing and a turn towards this kind of thinking can be seen in the united nations shift from a focus on survival alone towards thriving and transformation for women girls and adolescents 13 in this context childbirth becomes more than just a means of getting the baby out of the mothers body safely it becomes a potential space for positive transformation for mother and baby neurohormonally psychologically physically and emotionally throughout the lifecourse current norms in childbirth and related research there are hundreds of thousands of published studies in the area of pregnancy labour and birth the vast majority of these are focused on pathologies and the interventions designed to prevent them this would be an uninteresting observation if the field of investigation was a particular disease illness or adverse state indeed for women and babies who do have diseases or complications this type of research is critical for example the evidence on the efficacy of magnesium sulphate to prevent preeclampsia and to treat eclampsia 14 and the use of tranexamic acid for catastrophic haemorrhage 15 have saved many lives around the world however the large majority of the 130 million women who give birth annually do not require medical procedures or pharmacological agents to safely complete a process that has been shaped by complex adaptive evolutiona process that is critical to the survival of the human race in 1978 the alma alta agreement stated health is a state of complete physical mental and social wellbeing and not merely the absence of disease or infirmity 16 in terms of childbirth this has been reinforced by the following statements from an obstetrician and from the uk nice guidelines the nice guidelines were written 60 years after montgomery made the following comment i have stated on numerous occasions that there is no more need to interfere with the course of normally progressing labor than there is to tamper with good digestion normal respiration and adequate circulation 17 do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well in all stages of labour women who have left the normal care pathway because of the development of complications can return to it ifwhen the complication is resolved 18 despite this a search of pubmed undertaken on february 15 th 2020 using the term childbirth physiology to capture all articles on the physiology of childbirth only generated 17131 hits in contrast searching for studies of a specific procedure caesarean section generated 62945 hits this suggests that there is four times as much research taking place on one single surgical childbirth intervention than for the whole field of straightforward uncomplicated labour and birth rates of routine intervention in childbirth such as induction and augmentation of labour surgical birth and widespread routine use of antibiotics for mother and baby 19 are high and rising around the world in parallel inequalities in access to such treatments for marginalised poor rural andor ethnic minority groups are evident globally within and between countries 20 most global experts and agencies agree that there is an imbalance in maternity care around the world this can be characterised as too little too late for many marginalised poor andor rural women and babies and too much too soon for many urban women and neonates in even the poorest economies the inverse care law operates more marginalised women who need lifesaving interventions for them or for their babies are not getting them whereas wealthier women who do not need such interventions are getting too many of them this can lead to iatrogenic harm for them and their babies in the short and longer term 21 for example the usa has a very high rate of spending on interventions in normal pregnancy and birth 22 and caesarean sections are very common 23 however their national maternal mortality rate 174100000 is the highest among all highincome countries this is a higher rate than many middleincome countries 24 there is also intracountry variation in maternal mortality rates in the state of louisiana the rate has been cited at around 12100000 in contrast to california where the rate is 4100000 25 in europe according to europeristat caesarean section rates in 2015 ranged from 161 to 569 with no evidence that the highest rates are correlated with improved outcomes for mother and baby when compared to countries with the lowest rates 26 preterm birth and postpartum haemorrhage rates are also rising in europe and in other highincome countries 2728 these data suggest that while the current way of doing birth around the world has brought benefits to some women and babies it is also associated with harms for others this is particularly prevalent in privately funded health care systems or in countries where access to good health care education housing and womens rights are restricted 29 the drivers that generate this situation are complex intersectional and multifactorial under these conditions classical ways of framing and undertaking research in maternity care that assume that standardised drugs treatments or protocols that work at the population level will work for every individual in every context do not seem to be optimally effective an illustration of this is the assumption that universal hospitalisation for giving birth will inevitably reduce maternal and infant mortality and morbidity and will improve long term physical and psychological thriving this assumption has been only partially evident in practice indeed there is evidence from a number of highincome countries that hospitalisation of healthy women and babies without complications can increase iatrogenic damage for women and does not benefit their babies the increased use of induction augmentation and caesarean section contribute to these iatrogenic harms 30 31 32 some studies in this field have demonstrated longerterm epigenetic and microbial impacts associated with these interventions these have been linked to rises in autoimmune diseases such as type one diabetes and some childhood leukaemia types 33 34 35 balancing the benefits of nonintervention for physiologically normal childbirth with the need to intervene appropriately when pathology arises in the complex dynamic highly individual situation of labour could be termed a wicked problem such problems are defined as dilemmas in political and social planning that resist clear definitions defy traditional analysis approaches and refuse definitive resolution through predetermined solutions 36 intriguingly as an exemplar of the way in which wicked problems do not have simple right or wrong solutions a recent study of 64 facilities in ghana showed a complex set of relationships between maternal and neonatal mortality and factors such as geographic distance from facilities wealth and education these factors influence maternal and neonatal mortality in unexpected directions 37 wealthier women were more likely to attend hospital for birth but their outcomes were not better for them or their babies when compared to poorer women who did not attend facilities in fact the best outcomes were obtained for women who attended facilities that provided both effective emergency care for the minority who needed it and the capacity to protect physiological labour and birth for the majority of women and babies for whom this was appropriate further at the basic science level a recent study of the postnatal microbiome of babies compared babies born in hospital and at home who had completely straightforward births without procedures pharmacological agents or water birth the researchers found clear differences in the gut colonisation of the neonates born at home when compared to those born in hospital and concluded hospitalization may affect the microbiota of the vagina and initial colonization during labor and birth with effects that could persist in the intestinal microbiota of infants 1 month after birth 38 this suggests that physiological birth in a homecommunity environment is a critical contextual mediator of the biological adaptive processes of labour and birth the consequences of this both in the short and longterm are not yet fully understood implications for the cost birth action in recognition of the potential intrinsic value of physiological labour and birth as a catalyst for longterm wellbeing those collaborating on the cost birth action set out to reimagine the kinds of questions and investigations that could be asked and undertaken in the future the mix of academic and clinical disciplines policy makers service users and activists who were invited to join the action at the outset and who joined it subsequently worked to unsettle current scientific and normative ways of understanding and investigating this topic area the salutogenic approach taken by the action entailed examining how things go right as well as how they go wrong with an aim of increasing research on physiology as well as pathology the papers in this special collection are indicative not only of the inter and transdisciplinary insights that emerged from the interaction and multiple perspectives of over 120 people from 34 countries over the four years of working on the eu cost action they also illustrate the new kinds of questions that can be asked once those from different disciplines and perspectives spend time listening to each other the action worked across disciplines challenging assumptions and incorporating service users and activists experiences and knowledges the papers in this collection on neurophysiology address some of the basic science questions that still remain to be explored in the delicate neurohormonalpsychosocial dance that labour has evolved to be 3940 the investigation of thermal imaging as a basis for understanding how physiological labour works is an illustration of the synthesis of knowledge across clinical practice imaging science and service user engagement 4142 understanding how midwives work to facilitate physiological birth provides a window on techniques and practices that have heretofore been somewhat hidden 43 the examination of different oxytocin regimes across europe challenges assumptions that induction and augmentation guidelines are based on sound knowledge of physiological labour processes 44 finally the economic analysis of variations in caesarean rates illustrates how context influences data and their analysis and interpretation 45 conclusion members of the eu cost birth action engaged with childbirth from the perspectives of both complexity theory and salutogenesis the networks formed by the scientists academics clinicians service users activists and policy makers that were included in the programme have generated unexpected emergent insights that have led to new areas of enquiry that are ongoing the intention of this collection is to summarise and synthesis some of the research in this area and contribute to growing the evidence base in this critical but relatively neglected field of physiological labour and birth there was no data collected for this overview

in 2014 the eu funded a fouryear european cooperation in science and technology cost action to address the topic of childbirth the cost birth action was a crosseuropean network that brought together over 120 scientists practitioners activists and policy makers from 34 countries to work on intrapartum care the central aim was to advance the state of research and practice in a specific area of great clinical and social importance intrapartum care the action used inter and transdisciplinary approaches to address birth from multiple perspectives and drew on complexity theory and the concept of salutogenesis wellbeing this special collection presents six papers produced from the action and gives a sense of the range and depth of the work conducted the collection illustrates the knowledge that can be generated when a diverse group of people come together with a similar goals and perspectivesthe underpinning scientific framework of the action 1 was complexity theory applied through the lens of sacketts multisystem complex adaptive notion of ebm in contrast to most research in the intrapartum period it was also designed to explore childbirth from a salutogenic wellbeing perspective with a particular focus on the salutogenic concept of sense of coherencethe promise of classical enlightenment science has been that scientific method based on the idea that a causes b a linear hypothesis can be used to uncover what is true the belief underpinning this hypothesis is through scientific progress we will eventually know everything there is to know about the world 2 the academic and engineering discoveries resulting from this approach led to the marvels of the industrial revolution and a huge number of social and health care improvements however over the last thirty years or so there has been a significant move away from reliance on simple linear calculations undertaken in disciplinary silos

19682_0

background in december 2019 an outbreak of unusual pneumonia cases was reported in wuhan china 1 by january 11 2020 the etiologic agent was identified as sarscov2 and the clinical syndrome was named covid19 23 two months later on march 11 2020 the who declared covid19 a pandemic that had already reached 114 countries affecting 118000 people and causing 4291 deaths 4 on february 14 2020 the first african case was reported in egypt by april 2020 covid19 had already affected 10000 people in 52 african countries 5 dr matshidiso moeti the who regional director for africa asked then for a decentralized response which is tailored to the local context since then subsaharan countries have struggled to respond to the pandemic taking into account the particularities of their context 6 on the one hand the following factors may be considered positive and may have worked in their favor a lower risk of importation and transmission due to a lower flow of transport and trade 7 a younger demographic distribution 8 which is associated with lower mortality rates 9 the experience accumulated from other recent epidemic outbreaks 10 and other less obvious factors such as specific genetic variations and the continents climatic characteristics 11 on the other hand many other factors suggested greater vulnerability in african countries namely packed unregulated urban areas along with cultural practices that value social cohesion and social gatherings 612 higher levels of respiratory diseases 13 concomitance with immunocompromising conditions such as aids diabetes or malnutrition 14 weak healthcare structures that are too dependent on private or external financing 15 low human resources capacity lack of critical equipment and vulnerable supply chains 16 and other factors such as weak public administration infrastructure patchiness political instability and armed conflicts less educated populations who are more permeable to potentially harmful misinformation among others 12 given these particularities it seems necessary to carry out tailored actions that consider the specific context of different countries 17 in this regard an evaluation of the knowledge attitudes and practices regarding covid19 has proven useful to identify the most vulnerable communities to which health promoters should pay special attention 18 to the best of our knowledge no study of covid19 related kaps has been conducted in the republic of chad with an estimated population of 16 million 19 chad is among the most vulnerable countries when it comes to coping with covid19 11 it has an understaffed fragmented and uncoordinated health system 20 the country is characterized by a high rate of poverty and mortality a high burden of infectious diseases insufficient epidemiological surveillance and underdeveloped infrastructure 21 like other countries in the region chad declared a state of health emergency and adopted public health measures that included the mandatory use of masks contact tracing selfisolation or quarantine closures of worship spaces the prohibition of gatherings of more than 50 people closures of airports and public transport limitations authorities also made public health recommendations such as hand washing breathing practices and social distancing while preparing the health systems for specific diagnoses and treatments 2223 by december 11 2020 chad counted 1655 confirmed cases and 102 deaths 24 these relatively low figures need to be interpreted in the light of a low testing capacity and a fatality rate that goes over 61 25 additionally one must consider the social and economic impact along with other longstanding health issues such as malaria aids and tuberculosis as well as from recent outbreaks of measles and chikungunya that have affected the country 26 in this study we focused on the kaps regarding covid19 specifically in ndjamena the capital of chad our goal was to identify vulnerable social groups so as to inform policy makers in chad and thus contribute to the design of health strategies that consider populationspecific needs method study design and population this study was designed as a crosssectional survey using a convenience sampling technique a structured questionnaire and the consent form given to respondents were designed by a group of health professionals at the university hospital complex le bon samaritain ndjamena the study was conducted through may and august 2020 a period in which the government of chad had recently implemented numerous social distancing policies in efforts to mitigate the spread of sarscov2 22 the study population included individuals from ndjamena who understood french were 18 or older and could provide informed consent participation in this study was anonymous consensual and voluntary for which informed consent was provided by all prospective respondents measures the survey instrument used in this study was designed according to the recommendations for awareness and prevention of covid19 described by who guidelines 27 the questionnaire was drafted and validated by a group of health professionals before being used in the study health experts were asked to assess the instrument and make suggestions regarding the accuracy of the test in evaluating kaps relative to covid19 as well as the appropriateness of the questions based on the study population in a pilot study the questionnaire was administered by 10 health professionals to a sample of 18 people their opinions were used in reshaping the questionnaire into an easier and simpler instrument the final questionnaire designed for this study contained questions assessing sociodemographics sources of information as well as general knowledge attitudes and practices regarding covid19 sociodemographic variables included age gender marital status level of education occupation and work situation occupation was analyzed independently and was transformed into a dichotomous variable following the advice of local experts the knowledge section included 5 items surveying awareness of covid19 sources of information causes modes of transmission symptoms individuals at risk and preventive measures the attitudes section comprised 3 items including attitudes towards covid19 preventive measures feelings and adaptive measures towards the pandemic and perceptions towards the covid19 pandemic the practices section included 4 items such as adherence to government disease prevention orders use of face masks and the appropriate ways for coughing and sneezing statistical analysis data on demographic variables is presented using mean and standard deviations associations between variables were analyzed with ttests stata v 13 was used to carry out the statistical analysis results 2269 participants accepted and completed the survey the mean age of the participants was 3104 3848 were female 4614 were married 4561 were protestants and 4055 had vulnerable jobs more demographic characteristics of the participants are shown in table 1 knowledge questions regarding technical concepts such as what covid19 is or what typical symptoms it causes were mostly answered incorrectly only 371 answered correctly to both questions nevertheless the study population had greater knowledge regarding concrete aspects of the pandemic such as prevention measures and contagion probably due to the fact that communication campaigns extensively informed upon these topics hence only those 3 questions were further considered in the statistical analysis 356 participants did not answer any of those questions correctly 636 had one answer correct 792 had two answers correct and 485 answered all questions regarding knowledge correctly table 2 attitudes 784 participants were very concerned about the possibility of being infected 1844 were unsatisfiedvery unsatisfied with their social relationships after the pandemics began and 1553 thought that the pandemic was a disturbingvery disturbing issue practices 44 participants did not correctly answer questions surveying everyday actions to prevent the contagion 327 answered one question correctly 366 answered two correctly 688 answered three correctly and 844 answered all questions correctly table 2 social factors on knowledge attitudes and practices among the factors associated with kaps gender education and job vulnerability stand out regarding knowledge 1615 of women correctly answered all questions compared to 2464 of men 482 of people without education correctly answered all questions compared to 2138 of respondents with university education 1457 of people with vulnerable jobs correctly answered all questions compared to 2602 of people without this condition more results on knowledge based on social factors can be found in table 3 when analyzing attitudes some interesting features emerged gender did not significantly influence attitudes for which 2463 of women negatively assessed all questions exploring this dimension compared to 2378 of men education and work were associated to general attitudes as 1316 of people without education assessed the pandemic in a more positive way compared to 409 of university educated people 967 of people with vulnerable jobs assessed the pandemic in a more positive way compared to 504 of people without this condition more data on attitudes can be seen in table 4 finally when exploring the association between practices and the abovementioned social factors similar results were found 4941 of men follow all preventive measures compared to 3207 of women 1491 of people without education follow all the preventive measures compared to 4816 of university educated people 304 of people with vulnerable jobs do not respect any of the surveyed preventive measures compared to 119 of people without this condition table 5 presents complete information on practices based on social factors discussion the emergence of covid19 in china and its rapid global spread has resulted in the largest pandemic in recent times creating unprecedented public health challenges as one of the poorest countries in the world 28 the population of chad could be at greater risk of higher morbidity and mortality due to covid19 to the best of our knowledge this study is the first epidemiological survey aimed at assessing kaps of individuals regarding covid19 in chad collecting such information is necessary for the design and promotion of tailored public health measures the objective of this study was first to estimate the populations knowledge attitudes and practices relative to covid19 and second to identify vulnerable groups that require special attention from local authorities regarding knowledge our study reports a lower level of awareness compared to similar studies carried out worldwide greater knowledge about covid19 was found in american 29 asian 18 30 31 32 and african countries 33 34 35 36 37 38 for instance the great majority of nigerian respondents showed good levels of knowledge about covid19 which were significantly related to positive attitudes towards preventive measures 39 another study among ugandan health care workers showed that overall 69 had sufficient knowledge 21 had positive attitudes and 74 followed good practices relative to covid19 40 factors associated with knowledge were age and access to news media factors associated with good practices were age and level of education some discrepancies between our work and the abovementioned studies can be explained at least partially by substantial differences in the instruments used to assess kaps discrepancies could also be due to lower educational levels in chad compared to other african countries 28 in addition the majority of the chadian population has limited access to television social networks and the internet considering that media access should have a positive effect on levels of covid19 awareness 3941 results more similar to ours were found in a study of kaps among chronic disease patients in north west ethiopia 42 levels of poor knowledge and poor practices were 339 and 473 respectively age educational level rural residency and monthly income were significantly associated with poor knowledge levels being unmarried as well as illiteracy rural residency low income and poor knowledge were significantly related to poor practice levels as for attitudes our study shows that more than a third of the participants were very concerned about the possibility of being infected however an ethiopian study revealed that being infected with covid19 was highly threatening for nearly half of the study participants 42 on the other hand an american study reported that only 246 of respondents were highly worried about being infected with covid19 43 such notable differences could be explained by different sociosanitary contexts in each country people in highly developed countries may be more confident due to betterqualified health systems populations in african countries may tend to express more concern due to misinformation lack of confidence in political measures and a sense of unpreparedness 3639 it is worth noting that differences in how attitudes and risk perceptions were assessed can also make results difficult to compare in our study only 372 of participants answered all questions regarding practices toward covid19 correctly a similar prevalence of poor practices was found in an ethiopian study 38 although not in studies conducted in iran 44 and china 18 a binational african survey reported that the majority of respondents practiced selfisolation and socialdistancing but only 36 followed all health recommendations 36 similarly the majority of respondents in a nigerian survey reportedly followed precautionary measures including social distancing improving personal hygiene and wearing face masks during the lockdown period 39 these results sharply contrast from those found among sudanese residents who reported low levels of compliance with proper practices towards covid19 only 341 of those surveyed wore face masks and 579 avoided shaking hands in recent days 37 an ethiopian study showed that hand washing and avoidance of shaking hands were dominant practices older ages and unemployment negatively predicted hand washing and avoidance of handshaking 38 these results may reveal different levels of awareness and concern in study participants leading to variation in the application of actions and behaviors however such disparities might also be influenced by cultural diversity differences in outbreak phases within study areas as well as divergences in government recommendations and policies finally correlations between knowledge levels and attitudes towards covid19 on the one hand as well as preventive practices followed by the population on the other hand have been well established in various studies 1836 45 46 47 hence an effective starting point for preventive measures seems to be to increasing knowledge and awareness about the disease furthermore burström and tao reported that many of the potential risk factors for covid19 tend to cluster around the same individuals and areas 48 it is therefore important to identify vulnerable social groups for the design and implementation of effective preventive measures identifying vulnerable groups in order to control the spread of covid19 it is essential that public health officials know which groups are the most vulnerable 49 there can be a tendency in the field of health education and promotion to think of infectious diseases from a biomedical viewpoint as such prevention and treatment of infectious diseases can sometimes be perceived to be solely within the clinical domain yet the reality is that both nonclinical and clinical public health responses are required 50 not only physical vulnerability but also social vulnerability has been associated with increased risk of covid19 detection and death rates 51 therefore this pandemic confirms the call to redefine vulnerability in broader terms than strictly biological ones 52 vulnerable groups are those particularly exposed to a certain risk not only the elderly or patients with ill health and comorbidities are vulnerable to covid19 but also people from a gradient of socioeconomic groups that might struggle to cope financially mentally or physically with the crisis 52 the lancet continues as follows if vulnerable groups are not properly identified the consequences of this pandemic will be even more devastating although who guidance should be followed a onesizefitsall model will not be appropriate each country must continually assess which members of society are vulnerable to fairly support those at the highest risk in efforts to answer this call our study identifies particular social groups that are especially vulnerable as they face this pandemic according to our findings gender job conditions and educational level significantly affect our population regarding health risks associated with covid19 levels of kaps are lower in women with lower levels of education and more precarious jobs therefore health strategies designed by local authorities in chad should consider those variables to generate specific interventions focused on groups at the highest risk strengths and limitations according to the hdi chad ranks third among the least developed countries in the world 28 it is therefore a critical context that needs to be analyzed by following strict scientific methods that allow for evidencebased health measures very few epidemiological studies have been conducted in chad due to technical limitations lack of local conditions etc all of this has resulted in some kind of scientific isolation 1120 this study intends to fill this gap and brings the particular concerns of a subsaharan country to the global dialogue on health measures facing the covid19 pandemic the main limitation of this work is related to sample representativeness of chadian community inhabitants within ndjamena our study was dominated by respondents living in the city who were male single and who reached secondary education or higher therefore findings for this survey among uneducated and rural populations in chad might be quite different even if these figures are not representative of the chadian population 28 and these results may not be extrapolated to the general population a comparable gap has been described in other studies conducted in the region 3739 nevertheless despite this issue it was possible to carry out an analysis comparing social groups with different characteristics identifying some groups from the surveyed population for whom measures against covid19 should be reinforced conclusion this study provides a comprehensive assessment of kap levels observed from residents of ndjamena chad with regards to covid19 given that a high level of awareness has been shown to be a positive predictor of success in curtailing covid19 the vulnerable population would require special attention efforts toward assessing kap levels of underprivileged and vulnerable populations as well as the dissemination of health education among these groups should be intensified considering the unique factors observed in different groups of the chadian population would constitute a holistic and viable approach toward facing covid19 authors contribution grtd ydk jpkr fdm jn rm rr fd mt and jpo contributed to project conception and did the data acquisition and analysis grtd and rl did the statistical analysis cgv did the literature review mb rl cgv wrote the manuscript and grtd critically revised the successive drafts all authors read and approved the final manuscript

the first african covid19 case was reported in egypt in february 2020 since then subsaharan countries have struggled to respond to the pandemic among them chad is characterized by a high rate of poverty and mortality a high burden of infectious diseases insufficient epidemiological surveillance and underdeveloped infrastructure in this study we explore the knowledge attitudes and practices kaps regarding covid19 within the chadian population to determine whether there are more vulnerable groups of the population that require greater attention from authorities this study was designed as a crosssectional survey conducted in ndjamena chad using a convenience sampling technique that included 2269 participants the study was conducted in may and august 2020 questions regarding technical concepts were answered incorrectly by most participants 8365 the population had better knowledge about concrete aspects of the pandemics such as prevention measures and contagion regarding attitudes 3455 participants were very concerned about the possibility of being infected 8127 were unsatisfiedvery unsatisfied with their social relationships after the pandemic began and 6844 thought that the pandemic was a disturbingvery disturbing issue as for practices 4941 of men followed all preventive measures compared to 3207 of women and 304 of people with vulnerable jobs did not respect any of preventive measures compared to 119 of people without this condition gender job conditions and educational level impact kaps within the chadian population it is suggested that local authorities in chad should consider these variables when developing health strategiescovid19 • chad • africa • public health • knowledge • attitude • practices carlos gómezvírseda

19683_0

introduction villages are areas that have more traditional characteristics than urban areas so it makes villages a very potential asset of every country to make villages more developed it is necessary to develop the community through educational activities community independence is a condition that is characterized by the ability to think decide and do something that is deemed appropriate in order to solve the problems faced by using the capabilities possessed society must be able to develop in the context of education this is stated in the 1990 world declaration with the theme education for all in jomtien thailand the declaration aims to develop the concept of a community learning center in other words society can develop if there are learning activities that come from by and for the community itself independence also includes various aspects especially the capabilities of each member of the community learning refers to a conscious and deliberate activity that brings several reasons for efforts to develop community members as human resources there are several characteristics of the case being studied the case also served as the reason why the research was conducted informants were selected using snowball sampling according to snowball sampling is a sampling technique to collect data from key informants in this technique key informants can provide information developed according to the instructions given the researcher only conveys the criteria needed as a requirement to be used as a sample the informants in this study were the managers of the giri mulya study group community the data were collected through observation and interviews on the role of giri mulya study group community in increasing community empowerment researchers as research instruments should at least have the capacity to be sensitive to the environment and predict what is important to support research adapt to the situation to collect various data pay attention to all forms of response and consider that each situation is assessed as a whole and can be used as a material to support the findings prioritize the feelings to explore social situations and considering that the process of exploration requires human interaction and analyze the data and interpret the findings obtained determination of data sources in this study is carried out purposively where the number of data sources depends on the consideration of the completeness of the information or data needed or to obtain certain information data source collection can be repeated until the level of reduction completeness or saturation is achieved nasution in stated that there will be no additional meaningful new information obtained even from a new informant the collection of data sources in this study was based on several criteria including problems previously faced by the people of munggugebang village the learning process in the giri mulya study group community encouragement in carrying out community empowerment processes in munggugebang village community management and the role of the giri mulya study group community in increasing community empowerment informants or resource persons in this study are the managers of the giri mulya learning community and people living in munggugebang village benjeng district gresik regency this present study focused on the process and impacts of the giri mulya learning community in empowering the munggugebang village community secondary data for this study were obtained through observation of the empowerment process in the village those data were then used to support the findings of primary data the data collection procedure is the most important and strategic process in research with the right procedure information that is in accordance with the main purpose of the research may be obtained in carrying out research researchers must know the data collection procedures used thus providing information related to the research objectives data collection procedures used by researchers in this study were interviews and observation qualitative research is different from quantitative research qualitative research is rooted in a natural setting as a whole relies on humans as research tools u tilizes qualitative methods conducts data analysis inductively directs its research objectives to an attempt to find theory from the basics is descriptive emphasizes process rather than results limits studies with focuses has a set of criteria to check the validity of the data is tentative in terms of research design and the research results are agreed upon by two parties namely researchers and the research subject in addition creswell in explains that in qualitative research data analysis is an attempt by researchers to thoroughly interpret data either in the form of text or images therefore researchers must really prepare the data so that they can be analyzed understood presented and interpreted this study used the qualitative approach so that data analysis activities were carried out interactively and continuously until they were complete and the data were saturated in qualitative data analysis an indication of data saturation is shown by no more data or new information being obtained the data analysis activity used in this study is based on miles and hubermans theory which includes data reduction data presentation conclusion drawing and verification data presentation or data display is one of the stages of qualitative data analysis techniques it is an activity of compiling data in a systematic and easy way to be easily understood thus providing the possibility of drawing conclusions the data presentation in research can be in the form of narrative text or field notes matrices network graphs and charts after the presentation the data will be combined and arranged in a coherent and easily accessible form thus making it easier to see what is happening in the field however whether the conclusions drawn are correct or not need to be reanalyzed the essence of data collection and analysis is to make us get some conclusions that are relevant to our research problem and achieve the project objectives this is a fairly demanding and creative process that requires a lot of thinking process perception and careful care to build logical arguments all previous work will be devalued if we do not sufficiently draw on the implications of our analysis and take advantage of the insights it provides we really need to make it clear how the results of the analysis provide evidence for new insights into our chosen subject and respond to specific research problems that were presented at the outset of the study this study went through three stages to obtain data through a qualitative approach the stages include preresearch research implementation and postresearch stage 1 preresearch stage as an initial stage of research researchers needed to develop a research concept by conducting a preliminary study aimed at determining the topic and focus of research based on problems that were related to increasing the empowerment of the munggugebang village community collecting information and references from various relevant sources related to the research focus and topic collecting reference materials related to previous research that was relevant to the research topic developing research proposals and instruments preparing a research permit and submitting it to the intended research location and determining the research informants research implementation stage the research implementation stage is a stage for researchers to carry out research in accordance with the intended research location namely munggugebang village gresik regency at this stage researchers conducted research on the role of the giri mulya learning community in increasing community empowerment this stage is essential to collect valid data in the implementation process data collection was carried out through two techniques namely interviews and observations data collection was carried out simultaneously with the data analysis process postresearch stage the postresearch stage is the last in the research in this stage the researchers compiled the recorded data obtained from the interview and observation process the recorded data were then analyzed based on the interactive model by miles and huberman this model includes some stages namely data reduction data presentation conclusion drawing and verification meanwhile to test the validity of the data triangulation of sources and techniques on all the findings obtained during the research process was done the type of approach used in this study was the qualitative descriptive approach research employing this type of approach describes or makes a systematic description of the facts in this present study the researchers also functioned as an important instrument of the process as a whole researchers were involved in the continuous experience with informants to obtain information by paying attention to and exploring phenomena that occurred in the field to be interpreted and given meaning to be then adapted to the research objective of examining the role of the giri mulya learning community in increasing community empowerment in this study the main data source was the results of interviews with the giri mulya study group community manager and the community who were involved in learning activities according to qualitative research is a description of the social situation obtained from the results of research through various data sources which are then narrated in this regard the data collection techniques used in this study include 1 indepth interview this indepth interview method was carried out with the managers of the giri mulya study group community and the munggugebang village society who were involved in the learning activities it aimed to collect data about the increase in empowerment activity conducted by giri mulya study group community participatory observation in this study researchers used direct observation by referring to the observation guidelines for the phenomena of the subjects studied the subject was the munggugebang village society the purpose of this observation is to collect data on the role of the giri mulya study group in increasing empowerment activities the data collection instruments used were interview guidelines and observation guidelines during the data collection process a recording device and field notes were also used the data analysis technique is based on miles and huberman interactive analysis which consists of several stages including data reduction which was done by making a summary category coding making reflection notes and data sorting data display and data verification and conclusion drawing the conclusions that had been made previously were still temporary if strong supporting evidence was found at the next stage of data collection there would be an adjustment initial conclusions that were supported by valid and consistent evidence were considered credible thus the result of the verification was a complete comprehensive and accurate conclusion result and discussion munggugebang village community condition munggugebang village is located in benjeng district gresik regency most parts of the benjeng subdistrict are rice fields yards gardens residential areas and small and medium businesses the majority of the residents are farmers so they are still heavily dependent on crops according to government regulation republik indonesia nomor 78 tahun 2014 tentang percepatan pembangunan daerah tertinggal nd an underdeveloped area is a district where the area and its people are less developed than other regions on a national scale the people of munggugebang village show a lack of social empowerment the indicators of community empowerment by soeharto in are presented as follows 1 the awareness and desire to change 2 the ability to increase capacity to gain access 3 the ability to face obstacles 4 the ability to build cooperation and solidarity the above parameters are used to see the condition of an area related to the ability to develop the potential to be empowered by people from or outside the community through these parameters munggugebang village is considered not to have the ability to develop potential munggugebang village has lack human resources development this then has an impact on other problems such as poverty and the fulfillment of basic infrastructure needs such as educational facilities this issue is caused by the lack of public awareness of the potential of human resources one of the potentials that can be utilized by the people of munggugebang village is a youth organization that may become hr drivers as well as agents of change in the village unfortunately the youth organization is somehow unnoticed and as a result the village is less empowered than other regions in essence underdeveloped areas have great resource potential but they are not utilized optimally this condition leads to a strong dependence on other regions in munggugebang village there are many natural and human resources that have not been developed optimally because the community relatively has lack competence and income according to limited knowledge and income can be factors that hinder village development there are mainly two types of village potentials the first is physical potential which includes land water climate geographical environment livestock and other natural resources second the nonphysical potential that is shown by the community interactions social institutions educational institutions and village social organizations that include village officials and civil servants the village youth organization is one of the potentials of the munggugebang village community according to the potential is the power and ability to be developed in order to improve social welfare however the people in the village do not pay any attention to the youth organization although it functions as a forum to develop and empower the village youth can make a contribution to community development efforts but they can also become a burden on society if they do not empower themselves and become a group of unemployed thus there is a need to socialize the importance of the organization in addition to the problems above people in munggugebang village have lack of insight and experience in creating and managing programs to access local resources this can happen due to a lack of information and socialization on the role of youth organizations in developing villages and their communities the youth organization in copyright © 2022 jppm issn 23551615 issn 24772992 munggugebang village was not active in the local peoples productivity and welfare in addition the youth organization management also lacks the ability to plan programs that are in accordance with the real needs of their citizens these problems urgently need to be solved in order to make it contribute collectively to the village government and related institutions learning in the giri mulya study group community in order to optimally utilize the potential of human resources in munggugebang village the local government and village youth organization established a learning group community called giri mulya study group based on the results of interviews and observations it was shown that first the giri mulya study group community succeeded in increasing the empowerment efforts for the munggugebang village community second the philosophy of constructivism pedagogy education adopted by the giri mulya study group community was the zpd education concept with the socialcultural constructivist theory by vygotsky where learners improve their potentials and abilities so that they develop as learning progresses third the learning outcomes were related to the ability of the munggugebang village community to empower the village independently and adjust developments at last the factors supporting the success of the giri mulya study group community was the community enthusiasm it could encourage other communities to participate in learning activities meanwhile the internal inhibiting factors included the study group participants that did not quite understand the concept of learning so learning could not run optimally the external factors were related to the lack of assistance in providing encouragement to the learning community giri mulya study group community is a forum for the community to obtain proper education and health development facilities the study group provides programs for all residents from children at an early age to the elderly this activity is very helpful for the people of munggugebang village who previously had difficulties in accessing education and health facilities giri mulya study group community specifically provides services related to educational problems for children from an early age to elementary school age the study group also conducted health checks for the elderly however the focus is the effort to empower the munggugebang village community by providing learning activities that help children get educational guidance so as to help produce a capable and skilled generation as an effort to empower the village in the future today the learning process in the giri mulya study group community shows a good impact on the efforts of empowering munggugebang village children in the village are now provided with more insight they have been able to develop their literacy communication skills and the ability to understand digital developments giri mulya study group community was established based on the philosophy of constructivism pedagogical education by vygotsky according to glasersfeld in constructivism is a philosophy that emphasizes that our knowledge is our own construction bettencourt in points out that knowledge is not a description of the existing world of reality but it is always the result of a cognitive construction of reality through ones activities believing in this philosophy the managers of giri mulya study group community seek to create lifelong learners who are active in developing their imaginations and ideas to be poured into learning so that children will have constructive reflexive thinking when viewed from the educational practice in indonesia the concept of constructivism education has not been realized properly because the education unit level curriculum and 2013 curriculum systems which offer a free learning process to educational units which include teachers and students do not optimally implement the constructivism education both curricula aim to shape the competence of learning citizens according to their needs and interests however the implementation of the learning system did not completely fail conceptually it meant that the government was trying to bring education based on constructivist learning the theory used in the learning activities done by giri mulya study group community is a socialcultural constructivist by lev vygotsky based on this theory children can only learn by being directly involved in meaningful activities with people who are more knowledgeable in this case it is not only teachers but anyone who is able to provide knowledge to children through these interactions children will be able to improve their understanding and knowledge and can help form other peoples understanding in the future the implementation of this theory in giri mulya study group community is aimed at making children able to socially understand the conditions that occur in the village through interacting with other communities both parents and peers and then construct problemsolving solutions related to the problems being faced the proximal development zone applied to the giri mulya study group community needs to be interpreted using the scaffolding method which views the proximal development zone as a scaffold or a kind of buffer area or a stepping stone to reach a higher level of development the concept of the zone of proximal development proposed by vygotsky is considered very suitable for the conditions of the people of munggugebang village therefore its application to residents in the giri mulya study group community can serve as a stepping stone in empowering the community in general according to vygotsky the level of development of an individual can be divided into two the first level is actual development while the second level of development is potential development the actual development is shown by how a person completes his tasks and solves various problems independently meanwhile the potential development is shown in a persons ability to complete tasks and solve various problems when guided by adults or when collaborating with more intelligent peers the gap between the actual development and the potential development is called the zone of proximal development the concept of constructivism learning by vygotsky also suggests several main concepts in learning the concepts highlight that development and learning are interdependent or interrelated development and learning are contextdependent or cannot be separated from a social context and participation in social activities is a fundamental form of learning those learning concepts are very much in line with the expectations of the munggugebang village community of making the residents more empowered thus children will experience the development of constructivism pedagogy to be used to constructively overcome problems that occur in the environment based on their knowledge and experience community empowerment process in munggugebang village robbins chatterjee canda in state that empowerment is a process done by individuals and groups to gain power access to resources and gain control over their lives munggugebang village is undergoing an empowerment process so that it can develop into an independent village has power over its territory has access to resources and has control over the sustainability of life in the village in order to realize the concepts giri mulya study group community shares knowledge with residents regarding social issues that are currently happening including that they are less empowered than other areas the community empowerment process carried out through giri mulya study group community does not only rely on managers and educators but also requires participation from the community in order to be in a more empowered and independent state people who want to take part in learning activities in the giri mulya study group community need to understand what the goals of the study group community program are if a family wants their child to participate in the study group the parents should not just leave their child alone they must also recognize what learning processes that their child will go through the involvement of parents in their childrens learning is to perpetuate the knowledge transfer process that occurs in the learning environment so that it remains well constructed even though they are at home mardikanto soebianto in stated that community empowerment is an effort to increase the social level of a society who are in poverty and underdevelopment condition in addition community empowerment is a process where the community especially those who are poor in resources women and other neglected groups are supported to be able to improve their welfare independently based on this description it can be concluded that community empowerment is an effort to provide power or reinforcement to the community by providing encouragement motivation and facilities to develop certain potentials and improve societys welfare independently according to mardikanto the purpose of empowerment includes various efforts as follows education improvement empowerment must be able to produce better education that encourages lifelong learning accessibility improvement with the growth and development of lifelong learning it is hoped that it will improve its accessibility to sources of informationinnovation action repair by improving education and improving accessibility with a better variety of resources it is hoped that better actions will be available institutional improvement by improving the quality of activitiesactions taken it is hoped that institutional improvements will be made including the development of business partnership networks business improvement improvement in the aspects of education accessibility action and institutions are expected to improve the efforts made revenue improvement with the improvement of the business carried out it is hoped that it will be able to increase the income of families and the community in general environmental improvement income improvement is expected to improve the environment because environmental damage is often caused by poverty life improvement the level of income and improved environmental conditions are expected to improve the conditions of every family and community 9 community improvement better living conditions supported by a better environment are expected to lead to better community life giri mulya study group community is an effort to carry out the community empowerment process through the empowerment and family welfare movement measured based on the empowerment strategy the strategies are further described below possibility based on the researchers point of view and the results of interviews on the development of existing potential by conducting training to improve skills socialization is done so people can change their mindset and perspective about the potential benefits however there are many obstacles that must be faced such as limited budget lack of support from related opds and local officials and lack of human resources due to age limits educational background and habits reinforcement public knowledge is influenced by cadres who disseminate information about various information such as the importance of education health etc information received by the community is influenced by the knowledge that they have how the cadres deliver the information and the cadres approach to the community therefore it is hoped that the study group can change peoples perspectives mindsets and habits especially in this millennial era it is hoped that cadres possess ict competency protection people commonly have limited knowledge of crimes that target us and criminal acts existing in society the implementation of family resilience has not run optimally because there is no place for community consultation on the one hand support from local officials is not always available support there is a lack of guidance and no counseling service for the community thus people in the village cannot immediately solve their problems the community is expected to get training in packaging clean and halal food products its people especially housewives should be more productive maintenance whether or not the chairperson is active greatly affects the performance of its management this also leads to frequent changes of tppkk administrators for various reasons moreover the lack of response from the local government causes tppkk movement to have no progress a good management and organizational culture must be owned by pkk movement because if it doesnt work well effective and efficient goals will not be achieved results of giri mulya learning community development in improving society the development of giri mulya study group community had a positive impact on community empowerment in munggugebang village the success of this empowerment was initiated not only by giri mulya study group community but also by all parties involved in the empowerment process from managers educators residents and parents to local youths who helped develop this community it is true that collaboration among elements of society can be a significant impetus in carrying out an empowerment process developing human potential as well as socialisation values and skills must be carried out through educational activities the implementation of educational practices is directed at the efforts to uphold humanistic values into a solution to this global phenomenon conclusion the sustainability of education in giri mulya study group community is the most basic effort in empowering an area in this case the countryside munggugebang village community lacks human resources that can help advance the village development this has an impact on other problems such as meeting basic infrastructure needs and educational facilities thus the giri mulya study group community has become the center of attention in efforts to empower munggugebang village community because of the existence of learning activities that help children get educational guidance and help the munggugebang village community be capable and skilled in some areas munggugebang village is undergoing an empowerment process so that it can develop into an independent village has power over its territory has access to resources and has control over the sustainability of life in the village in order to achieve this empowerment giri mulya study group community tries to provide learning to residents regarding social issues that are currently happening in the village including the lack of empowerment when compared to the other villages

this study examined community needs for community empowerment oriented to regional potential the empowerment was conducted by giri mulya study group community using the communitybased community resource management process this community is a form of a development strategy and community empowerment that contributes to controlling and managing productive resources this research employed the qualitative research method while the approach used in this research was the case study approach the research informants were selected using the snowball sampling technique and data were collected through observation and indepth interviews giri mulya study group community development had a positive impact on community empowerment in munggugebang village cooperation that existed among elements of society can be a significant impetus to carry out an empowerment process sustainability of education in the giri mulya study group community is the most basic effort in empowering an area in this case rural areas

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introduction physical activity has important physical emotional and social benefits for children 1 2 3 helping children develop the foundation for healthy pa habits is critical for health promotion and disease prevention in childhood and beyond 4 5 6 7 physically active children have healthier cardiovascular profiles leaner body frames and higher peak bone mass than physically inactive children 45 in addition to regulating body weight and improving body composition pa improves childrens psychological and social wellbeing 45 despite the welldocumented benefits of pa preschoolage childrens pa levels have declined over the past decades with approximately 50 of children in this age group in the united states not getting the recommended 180 min of pa daily 89 furthermore racialethnic minority children are less likely to meet the daily pa recommendations than white children 910 additionally physical inactivity is even a greater problem among racialethnic minority children in the us 10 11 12 13 and latino immigrant children have the highest prevalence of physical inactivity 14 parents play a unique and central role in influencing their childrens behaviors including their pa habits 1 2 3 and this influence is particularly important during the habitforming years of early childhood 11516 existing scientific evidence suggests that one way in which parents influence their childrens pa levels and behaviors is through their parenting practices 2317 parenting practices are the specific sets of behaviors that characterize parents interactions with their children and the beliefs and attitudes that underpin these interactions 18 19 20 21 pa parenting practices describe what parents do to encourage or facilitate their childrens pa such as providing logistic support for pa encouraging their children to be physically active monitoring and setting limits for sedentary behaviors modeling pa behaviors etc 2 20 21 22 23 24 moreover evidence indicates that some parenting practices such as having rules and restrictions psychological control etc may unintentionally discourage or inhibit childrens pa 32223 the social contextual model 25 an adaptation of the socioecological model integrates social class and culture to the different levels of the sem 26 including intrapersonal or individual factors interpersonal factors organizational factors and environmental factors the social contextual model emphasizes the expression of cultural pathways that may influenceimpact behaviors and explicitly inform the design of health promotion interventions 25 the social context cultural norms and values influence parental beliefs attitudes and practices toward child rearing thus parenting practices may vary across ethnic groups 2728 research is needed to understand how culture influences parenting practices so interventions can best address these practices brazilians are a rapidly increasing latino immigrant group in the us yet little research has examined factors influencing pa levels and behaviors of brazilian children growing up in immigrant families 29 30 31 this information is needed to develop culturally sensitive interventions tailored to this population therefore the purpose of this qualitative study was to explore pa parenting practices used by brazilian immigrant mothers of preschoolaged children methods this study was conducted in two cities located in massachusetts somerville and everett the present qualitative study was part of a larger ongoing mixedmethods research study with brazilian families living in the greater boston area examining parenting styles and parenting practices related to the risk of childhood obesity 29303233 focus group discussions were used to gain an indepth understanding of parenting practices of brazilianborn immigrant mothers living in the us that may promote or prevent their preschoolaged children from being physically active in addition the guide explored mothers information seeking about pa and screen time and beliefs and practices related to sleep and bedtime routines of their preschoolaged children these results are presented elsewhere 2930 fgds are valuable techniques for working in diverse cultural settings as they yield rich information 34 as the synergistic effects of the group settings elicit ideas and discussion that may not arise in individual interviews 34 this study received ethical approval from the university of massachusettsboston ethics board data collection a native brazilianportuguese speaker trained in qualitative research methods moderated all fgds in portuguese using a semistructured discussion guide that was developed based on previous systematic reviews of parenting practices 21617 and explored participants views and experiences about 1 how parents encourage or facilitate their preschoolage children to be physically active and 2 how parents may unintentionally discourage or inhibit their preschoolage children from being physically active in addition the guide explored mothers information seeking about pa and screen time and beliefs and practices related to sleep and bedtime routines of their preschoolaged children these results are presented elsewhere 2930 the guide was piloted in a fgd with a small group of brazilian immigrant mothers and then refined prior to use data from the pilot fgd were not included in the present study table 1 presents a sample of questions and prompts used in the fgds before each fgd the moderator explained in portuguese the studys purpose fgd procedures study confidentiality and obtained written informed consent from all participants before each fgd participants were asked to think about their preschoolaged children when participating in the discussion a trained bilingual research assistant took notes during all fgds which were audiorecorded and lasted between 6080 minutes the moderator and research assistant met for about 15 minutes after each fgd to identify new and review recurring themes which were entered into a grid that was used to closely follow emerging themes and to determine when data saturation was reached at the end of each fgd participants completed a brief selfadministered questionnaire in portuguese that assessed education marital status access to health care services including participation in governmentsponsored health and nutrition programs etc country of origin length of time living in the us and acculturation which was assessed via the short acculturation scale for hispanics a 12item measure scale validated for use in latinos including mexican americans cuban americans puerto ricans dominicans and central and south americans the sash assesses language use media use and ethnic social relations 36 and items are measured on a scale of 15 and an acculturation score was computed by averaging across the 12 items data analysis the qualitative data was analyzed using thematic analysis an iterative multistep process of coding data in phases to create meaningful patterns 37 first a professional transcriptionist and native brazilian speaker transcribed all audio recordings verbatim in portuguese second two experienced qualitative researchers and native portuguese speakers read several transcripts numerous times to become familiar with the content and generate initial codes 3437 third the two researchers manually coded all transcripts independently but met regularly to discuss coding and to identify and resolve coding disagreements 37 fourth coded text describing similar ideas were grouped and sorted to identify emergent themes and describe what types things that you do to make sure or encourage your child to be physically active describe things that you do that you think might discourage your child to be physically active describe barriers that you face in making sure that your child is physically active when at home � probes space time household obligations neighborhood safety knowledge of how physically active your child should be influence of other people in the household describe barriers that you face in making sure that your child does not spend too much time sedentary time such as watching tv andor videos or playing video games at home � probes lack of household rules space time other obligations that keep you from having time to take your child out to play subthemes finally salient text passages were extracted and translated into english as illustrative quotes for emergent themes although a thematic approach was used for the initial data analyses and the codebook did not include an a priori determined list of parenting approaches it was evident during analysis that the selfdescribed strategies were amenable to categorization based on wellrecognized types of parenting practices 231617222338 therefore in a second phase of the data analyses identified themes were sorted and grouped based on pa parenting practices identified in prior systematic reviews and studies 231617222338 in addition descriptive statistics and frequencies were calculated for data collected in the sociodemographic survey using microsoft excel 2008 results seven fgds were conducted before saturation was reached with no new themes or subthemes emerging during the final group mothers participating in this study were 26 to 41 years old the majority was married had graduated from high school owned their own housecleaning business and had two children approximately half reported a family income of 40000 or less which is considered lowincome for a family of four in the us while the rest reported an annual income between 40000 60000 which is considered to be a lowmiddle income participants were originally from three main regions of brazil eg the southeast the south the midwest with the majority being from the state of minas gerais in the southeast region in addition the majority spoke portuguese at home watched television programs in portuguese and reported that the majority of their friends were brazilians mothers had lived in the us for an average of 67 years and their mean acculturation score was 143 indicating that they identified more closely with brazilian culture than with that of the us identified themes were classified into three domains 1 parenting practices that may encourage or facilitate childrens pa 2 parenting practices that may discourage or inhibit childrens pa and 3 social contextual factors affecting pa parenting practices although mothers with children aged 25 years were purposively recruited to participate in the study most mothers discussed their pa parenting practices within the context of the entire family including older children and fathers domain 1 parenting practices that encourage or facilitate childrens physical activity analyses identified seven parenting practices within this domain these parenting practices included 1 modeling pa 2 engaging and being involved in pa with child 3 providing logistic support 4 encouraging praising and providing motivational support 5 watching supervising and teaching children how to engage in pa 6 monitoring and setting limits to childs screen time and 7 prompting child to be physically active modeling physical activity across all fgd all but one mother spoke of the importance of parents serving as pa role models and of this modeling having a positive influence on childrens pa for example mothers spoke of taking walks with their children using exercising equipment at home etc and felt that these activities were important for exposing their children to pa as one mother explained the most important thing a parent can do is to be a good model and set a good example we cant expect children to be active if the parents are not active so i think the parents need to set a good example and be active themselves and the children will learn from them will want to imitate them parents fgd 2 mother 12 engaging and being involved in physical activity almost all mothers spoke of the importance of parents being actively engaged and involved in their preschoolage childrens pa and that this practice positively influenced childrens pa levels and behaviors for example mothers spoke of the importance of parents being active playing sports such as soccer baseball etc with their children and that this fostered their childrens enjoyment of and desire to be physically active one mother mentioned parents who play with their children play soccer go for a walk thats important to be active together i think if a parent is involved and playing with their children taking them to play soccer ride a bike that helps children being active fgd 5 mother 28 furthermore many mothers reported that their husbands or partners participated in more pa with their preschoolage children especially with boys than they did this is illustrated on the following statements providing logistic support about twothirds of mothers spoke of enrolling their preschool children in sports classes taking children to the park buying active toys providing transportation and that viewed these practices as important for promoting pa among their preschoolaged children as one mother reported the ymca near our house offers some classes physical activity and sports for young children i enrolled my son 5 year old in an all sports class and he loved it he is now doing soccer fgd 1 mother 4 moreover some mothers spoke of their network of friends positively influencing their childrens pa by their provision of informational andor logistic support for example mothers mentioned that having friends tell them about pa classes and organized sports classes motivated them to enroll their own children in similar activities as one mother explained i enrolled my son 5 years old in a karate class he also is taking swimming lessons at the ymca my nextdoor neighbor and me take turns taking the kids to swim lessons its really helpful because sometimes i need to get home later from work and we help each other that way fgd 6 mother 27 likewise some mothers reported that having close friends with young children motivated them to get together and take their children to parks and playgrounds for example one mother described sometimes i am home and a friend will text or call me and say do you want to go to the park with the kids having a friend mother who also has children about the same age make it easier for everyone the kids play and we mothers talk its just makes it better to have company and you feel like getting out with the kids more fgd 3 mother 17 encouraging praising and providing motivational support the majority of mothers spoke of offering their child motivational support by encouraging and praising their children while they are physically active mothers felt that this encouraged their children to continue to be physically active for example i think its important for parents to be supportive and encourage their children to keep trying to motivate them to learn and to try and learn new things humm to improve i am a big supporter of my son he plays soccer and i always watching him play cheering saying good job do it again thats great he loves when i say you played so well you are the best number 1 laughs fgd 4 mother 19 moreover several mothers mentioned encouraging their young childrens participation in organized sports as one mother described my son 8 years old always loved playing soccer since he was little he would have a soccer ball with him all the time we enrolled him in a little soccer league and he plays all year around last year his team won the town tournament and he got a trophy for the player who scored the most goals we were so proud of him we now have a shelf in his room that we say are for his soccer trophies we want him to continue to play soccer who knows whats in his future laughs fgd 3 mother 13 furthermore more than half of the mothers spoke of being proud of their children when they participated in organized sports or physical activities such as soccer games swimming dance classes etc they felt that their pride furthered their childrens motivation to be physically active as one mother explained my daughter took swimming lessons at the ymca and her teacher told me the ymca had a swim team and that i should consider enrolling her daughter this is her second year swimming with the team and she loves it my husband and i take her to all the meets and we cheer for her she feels so proud when she wins and we are even more proud than she is i feel that us parents showing them how proud we are and motivating them to keep doing it is really important especially when they are young now she wants to swim team even during the summer fgd 3 mother 15 watching supervising and teaching children how to engage in physical activity more than half of the mothers spoke of watching and supervising their children engage in pa and that they felt this promoted their children to be active several mothers reported supervising their children playing at local parks and playgrounds as the following quote illustrates i take my kids to the park and playground when the weather is nice my little one is learning to ride her bike without the wheels and its safer for her to ride her bike in the park there is a safe paved area in the park and i can walk by her side and help her fgd 2 mother 11 some mothers also spoke of teaching their kids different types of pa such as such as swinging climbing a tree riding a bicycle etc one mother described one day we were at this nice park near a friends house and there were a lot of trees my son was trying to climb a tree but couldnt really do it his friends were used to climbing that tree he was so upset so i took my shoes off and showed him how to climb the tree back in brazil we grew up climbing trees and it was so nice to see how happy he was after he was able to climb the tree he kept climbing up and down he was so proud of himself fgd 7 mother 35 in addition some mothers expressed joy and feeling gratified at being able to help their children learn new activities and that this inspired their continued guidance in encouraging their children to participate in these activities and offered children new opportunities in pa as one mother described i grew up climbing trees and one day we were at the playground near our house and my daughter was trying to climb a small tree but couldnt do it she was really upset because all the other kids could do so i helped her and she kept trying and now every time we go to that playground she runs to the tree to show me that she knows how to do it by herself it makes me so happy to see how proud shes of herself we grew up climbing trees brazil fgd 6 mother 27 monitoring and setting limits to setting childs sedentary time several mothers spoke of monitoring and setting limits to their childrens screen time which mothers perceived as positively influencing their children not to be physically inactive one mother reported i think parents need to be vigilant and make sure the kids are not on their electronics too much at our house i tell my kids you can watch tv or play in your ipad for one hour thats it when one hour is up they need to find something else to do its not easy but as parents we have a responsibility to teach them children fgd 2 mother 9 prompting child to be physically active some mothers mentioned prompting their preschoolage children to be physically active especially when they thought their children had too much screen time this is illustrated in the following quotes when i see the kids have been inside the house for too long watching cartoons on their ipads i tell them to go outside and play if you let them they will stay on their ipads all day so i tell them come on lets go outside lets go for a walk fgd 1 mother 4 sometimes the kids are inside the house and not doing much so i see the weather is nice outside and i tell them ok go outside go play outside the weather is nice its not good to be inside the house the whole day so go play outside fgd 5 mother 28 domain 2 parenting practices that discourage or inhibit childrens physical activity analyses identified four parenting practices within this domain these parenting practices were 1 modeling of sedentary behaviors 2 having rules and restrictions due to safetyand weatherrelated concerns 3 limiting childs outdoor time due to parental time constraints and 4 restricting childs outdoor and play time as punishment these parenting practices are presented below with selected illustrative quotes modeling sedentary behavior as mentioned earlier the vast majority of mothers spoke of the importance of parents being role models for pa and almost all mentioned parents modeling of sedentary behaviors as negatively influencing childrens pa and increasing their sedentary time and contributing to the development of sedentary habits one mother described children watch and copy what their parents and other adults do the good habits and the bad ones too so if we as parents are always online the kids see that and do the same the other day i told my daughter you need to put your ipad away do you know what she told me its not fair if i have to put my ipad away then you need to put your phone away shes only 4years old they know they watch what we do we need to set a good example fgd 7 mother 36 having rules and restrictions due to safetyand weatherrelated concerns many mothers reported having rules and restrictions such as not allowing children play outside without an adult due to safety or traffic concerns mothers acknowledged that these rules and restrictions reduced their childrens pa these are illustrated in the following comments we live in a busy street so i dont let the kids play outside or ride their bikes on the sidewalk because i dont think its safe people drive their cars really fast and i worry about the kids being hit by a car i dont think its safe fgd 7 mother 33 our street has a lot of traffic and its hard to let the kids play outside my son likes to ride his bike on the sidewalk but i get nervous because the streets are narrow and cars drive really fast so i only let him ride his bike in the park fgd 3 mother 13 furthermore more than half of the mothers stated that weather concerns sometimes made them limit their childrens time outdoors which they recognized may negatively impact their childrens pa mothers also reported their children spend more time outdoors and were more active during the warmer months one mother explained in the winter its hard to get the kids outside to play it gets cold and dark early so the kids spend more time indoors my kids are more active during the summer when the weather is nice and after so many months of winter we all want to be outside fgd 4 mother 22 some mothers did acknowledge that their children would probably like to play outside during the cold months but that they themselves did not like being outside during the cold weather as they were not used to it one mother explained my kids dont really mind the cold weather they like playing outside in the snow sledding they are growing up with the cold weather and used with the cold weather but i cannot get used to it i dont like the winter and prefer not being outside when its cold i grew up with warm weather all year around i just cant get used to the cold weather fgd 4 mother 18 limiting childrens time outdoors due to parents limited time about half of the mothers reported that their children engaged in sedentary activities indoors due to their time constraints because of work obligations or household chores some mothers spoke of getting home after a long day at work and still having to do household chores and said that it is often easier for them to keep the children indoors instead of taking them outside to play so they can get things done around the house others explained that they were tired when they come home from work and do not always have the energy to take their children out to a park playground or outdoors to play for example one mother explained sometimes i dont have time to go out with the kids by the time i get home from work need to prepare dinner do some household chores it gets dark and late for the kids to go outside and play so the kids stay in the house playing fgd 2 mother 8 restricting childs outdoor and play time as punishment a couple of mothers spoke of making children stay inside giving time outs and not allowing children to play outdoors as punishment for what they perceived as bad behavior this practice was classified as inhibiting young childrens pa sometimes a parent needs to make a child sit down and take a break to calm down and i think that could be a way to keep a child from playing and being active like my son sometimes he just gets too hyper and out of control so i tell him please sit down just quiet down for a few minutes then you can play again he just needs a break sometimes fgd 6 mother 28 domain 3 social contextual factors influencing parenting practices although not the focus of the fgds analyses determined that social contextual factors influenced mothers pa parenting practices and in turn childrens pa some mothers spoke about not being able to provide child with opportunities for pa and active play due to financial constraints and limited space furthermore some mothers mentioned that limited resources kept them from enrolling their children in organized sports activities one mother said id like to enroll the little ones children in some classes but sometimes its expensive and the classes time are not good for my schedule when the kids are older its easier you can drop them off for soccer and pick them up but the little ones you need to stay with them fgd 3 mother 16 moreover as mentioned earlier a number of mothers reported having limited space where their children could play safely and that this inhibited their childrens pa one mother stated we live in an apartment building so we dont have a place for the kids to go out and play outside unless my husband or me are free and can take them out the kids pretty much stay inside fgd 4 mother 20 discussion this study contributes to the scant literature examining pa parenting practices of brazilian immigrant mothers a rapidly increasing latino immigrant subgroup in the us 39 analyses identified a number of parenting practices that may encourage or facilitate childrens pa that occurred at the interpersonallevel and that appeared to be influenced by social contextual factors although parenting practices that may discourage or inhibit childrens pa were identified at the interpersonal level these practices appeared to be influenced by both environmental and social contextual factors that affect the daytoday lives of brazilian immigrant families for example mothers reported implementing rules and restrictions due to safety and weatherrelated concerns lacking resources to enroll their children in sports or pa classes etc these findings suggest that culturally appropriate parentingand familybased interventions designed to increase preschoolaged childrens pa should consider the social context of brazilian immigrant families daily life for example these interventions could use a familytailored approach that helps parents develop parenting skills to facilitate and encourage pa for their preschoolaged children moreover developed interventions could provide tailored content to help parents overcome specific contextual barriers experienced by brazilian immigrant families 4041 parental modeling was the most commonly cited parenting practice and was viewed by mothers in this study as both encouraging and discouraging childrens pa mothers explained that children often mimic their parents behavior for the better and for the worse these findings concur with previous research suggesting the positive and negative influences of parental modeling on childrens pa and sedentary behaviors 102238 42 43 44 furthermore the majority of mothers in this study reported that parental engagement and involvement in childrens pa encouraged children to be more physically active which concurs with previous research conducted among other racialethnic groups in the us 4546 these findings combined with mothers awareness of both positive and negative influences of parental modeling on childrens pa are noteworthy and can be used to inform intervention messages additionally mothers identified providing logistic support offering verbal encouragement praise and motivational support supervising watching and teaching the child to engage in various types of pa and prompting child to be physically active as parenting practices that encourage or facilitate preschoolage childrens pa these findings are consistent with prior studies demonstrating the positive influence of these parenting practices on childrens pa 31722233847 evidence from research with hispanic parents shows that logistic support can positively impact childrens pa 48 49 50 51 similarly previous studies conducted with hispanic parents have determined that positive reinforcement as measured by a parents praising of the child being physically active is positively associated with childrens pa 1322 likewise parental verbal encouragement of pa positively influences child pa 4551 moreover studies conducted with parents in canada us and hong kong have shown that parents believe that supervising and teaching children how to engage in pa is an important strategy that positively influences childrens pa 162238 mothers participating in this study also spoke of monitoring and limiting childs screen time as a strategy to decrease childrens sedentary time and promote childrens pa current evidence on the associations between parenting practices and child screen viewing is mixed with some studies showing a positive influence of this practice on childrens pa while others show a negative association 52 53 54 55 56 57 current research suggests that the association between parenting practice of setting limits and childs screen time varies depending on the type of screen time and the frequency of limit setting 5358 these findings suggest that interventions designed to promote pa among children in brazilian immigrant families should also focus on helping parents develop skills needed to limit screen time although mothers participating in this study reported a number of parenting practices that may encourage or facilitate their childrens pa they also spoke of parenting practices that have been shown in prior research to discourage or inhibit their young childrens pa 47 59 60 61 62 63 64 as mentioned previously mothers felt that that parental modeling of sedentary behavior may inhibit pa additionally mothers in this study reported having rules and restrictions due to safetyand weatherrelated concerns that limited their childrens outdoor time and active play this finding is similar to that of prior research conducted with other latino ethnic groups 59606364 furthermore consistent with prior research a lack of time and lack of safe space for child to play outdoors and lack of resources were identified as limiting childrens pa 1022476566 these findings are important and suggest modifiable pa parenting practices that can be addressed in culturally sensitive interventions designed to promote pa in preschoolage children of brazilian immigrant families living in the us although more research is needed these findings suggest potential targets for interventions designed to promote pa among preschoolaged children of brazilian immigrant families living in the us nonetheless additional qualitative research with brazilian immigrant fathers and brazilian parents from other communities across the us should be considered although the study sample included approximately 51 of participants with household income under us 40000 parents of lower socioeconomic status should also be considered furthermore future research should also consider employing objective measures to assess pa parenting practices brazilian immigrant parents use to promote pa these studies could employ crosssectional or longitudinal study designs to assess the associations between pa parenting practices and preschoolage childrens pa limitations study findings should be considered in light of some limitations findings are based on a nonrandom purposeful and a relatively small sample of lowincome brazilianborn immigrant mothers in two cities in ma which limits generalizability participating mothers might have had a heightened interest and awareness regarding the focus group topics moreover the use of snowball sampling to recruit participants might have resulted in the recruitment of study participants who share similar beliefs and practices related to pa thus further research is needed to increase generalizability and to explore whether results apply to a broader group of brazilian immigrants finally the present study included only mothers and this is a limitation given the increasing evidence suggesting the importance of including both parents in child health promotion and obesity prevention research and interventions 1024384255 future research can address these limitations by exploring pa parenting practices used by brazilian mothers and fathers from other communities across the usa selecting a larger sample size and employing multiple datacollection methods including both qualitative and quantitative methods conclusions the present study provides new information on pa parenting practices of brazilianborn immigrant mothers of preschoolaged children living in the us that encourage andor discourage childrens pa although additional research is needed studys findings may provide important targets to consider when designing interventions to promote pa among preschoolaged children of brazilian immigrant families and can inform specific intervention components and strategies for this particular ethnic group future research should further explore pa parenting practices of brazilian immigrant parents including quantifying pa parenting practices that encourage and discourage pa as well as examining the influence of fathers pa parenting practices on young childrens pa this information is needed to identify factors amenable to interventions and to design culturally appropriate parenting and familybased interventions targeting the home environment of brazilian children of immigrant families and designed to meet the specific needs of this ethnic group data cannot be shared publicly because of informed consent agreement included in institutional review board application due to vulnerability of immigration status of study population deidentified data are available from the university of massachusetts boston irb ethics committee for researchers who meet the criteria for access to confidential data supporting information s1 table socioeconomic and demographic characteristics of the sample sedsampleponedocx

brazilians are a rapidly increasing latino immigrant group in the united states us yet little research has examined factors influencing physical activity pa levels and behaviors of children growing up in brazilian immigrant families this information is needed to develop culturally sensitive interventions tailored to this population therefore this qualitative study explored pa parenting practices used by brazilian immigrant mothers living in the us thirtyseven brazilian immigrant mothers with at least one child between the ages of 2 and 5 years participated in 1of 7 focus group discussions thematic analysis identified seven parenting practices that mothers employ that may encourage or facilitate physical activity their preschoolaged childrens pa including 1 modeling pa 2 engaging and being physically active with child 3 providing logistic support 4 encouraging praising and offering motivational support 5 watching supervising and teaching children how to engage in pa 6 monitoring and setting limits to childs screen time and 7 prompting child to be physically active in addition analysis identified four parenting practices that may discourage or inhibit childrens pa including 1 modeling of sedentary behaviors 2 having rules and restrictions due to safetyand weatherrelated concerns 3 limiting childs outdoor time due to parental time constraints and 4 restricting childs outdoor and play time as punishment furthermore analyses demonstrated that social contextual factors eg income housing neighborhood safety etc influence mothers pa parenting practices and consequently their childrens pa this is the first qualitative study to our knowledge to explore pa parenting practices of brazilianborn immigrant mothers living in the us future research should further explore pa parenting practices of brazilian immigrant parents including quantifying pa parenting practices that encourage and discourage pa as well as examining the influence of fathers pa parenting practices on young childrens pa

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i introduction the associations between raceethnicity and oral health outcomes are well documented while some oral health research has considered race and ethnicity in addition to poverty and select other variables little work has examined race and ethnicity in a broader contextone that permits assessing the effect of raceethnicity on oral health and oral health care when social economic racial educational political and behavioral factors that affect … health care issues are considered the purpose of this article is to examine more plainly how raceethnicity relates to oral health care access and outcomes for children taking into account other social determinants of health which influence among other things access and outcomes specifically we used a large nationally representative survey to assess the independent association of raceethnicity on oral health status and oral health care while simultaneously considering child familyand communitylevel characteristics ii methods conceptual foundation the basis of this analysis is our conceptual model detailing a multilevel approach to understanding childrens oral health this model has been used with the outcome of parentreported young childrens oral health status although not with a focus on racial and ethnic disparities thus it is adapted accordingly here to reflect at the center of the model that the focus is on oral health disparities some of the conceptual factors in the theoretical model were not measured in the dataset so they were not included in the modeling data source data are from the 2007 national survey of childrens health conducted by cdcs national center for health statistics in brief the nsch was conducted from april 2007 to july 2008 using randomdigitdialing to identify households with children nsch sampling weights account for households without telephones or wirelessonly in each household one child was randomly selected as the subject of an indepth health interview the respondent was the adult in the household most knowledgeable about the childs health interviews were completed in english spanish and four asian languages the overall weighted response rate was 467 the survey methodology is described in detail elsewhere the analyses were restricted to respondents with complete data for raceethnicity income files from cdc using multipleimputation methodology were used in all analyses to account for the 93 of respondents missing income data respondents missing data for any other variable of interest were excluded from the analysis dependent and independent variables for dependent variables we selected a global measure of oral health status and two sentinel indicators of access to oral health care parents report of childs oral health status was dichotomized access indicators were parents report of whether the child had at least one preventive dental visit in the past year as a measure of access to preventive care and parents report of delayed dental care or unmet need in the past year as a measure of difficulty in accessing the dental system overall each outcome was analyzed separately independent variables shown in table 1 included data from the nsch on child family and neighborhoodlevel factors augmented with statelevel contextual data from other sources see table 1 footnotes for state data sources in an effort to capture a range of the social determinants of health race and ethnicity were reported by parents analytic groups were hispanic nonhispanic black nonhispanic white nonhispanic other and nonhispanic multiracial for parsimony and to reduce multicollinearity indices were constructed where multiple questionnaire items captured similar underlying constructs these included parental coping social capital positive neighborhood attributes and negative neighborhood attributes analytic plan this analysis included children 217 years children at least two years old were selected as their primary teeth should have started to erupt by age 1 and thus should have had dental care within the prior year and the american academy of pediatric dentistry preliminary analyses were conducted for two age groups as some of the questions for younger children are different than for older children reflecting their different activities these two analyses did not show marked differences and so for ease of understanding and applicability we analyze children together as a whole adjusting for age our goal was to develop a model that could be generalized to the child population and not limited to a specific age group since only one child per household was sampled and households were not geocoded to the neighborhood level the family and neighborhood levels were not distinguishable from the child level and could not be modeled statistically therefore our model represents four conceptual levels but only two statistical levels with external geographic variables all measured at the state level our analysis first summarized the study sample using sudaan incorporating sampling weights to estimate nationally representative point prevalences for each outcome by raceethnicity adjustments for the complex sample survey design were also incorporated to produce valid chisquare tests of differences between estimates we then used a modelbased approach for complex survey analysis this allowed us to estimate models with variables from individualto statelevels using sas proc glimmix this approach fits generalized linear mixed models with logit link to estimate adjusted odds ratios and 95 confidence intervals the modeling process entailed fitting singledomain models for the child family and community domains shown in table 1 the full model included all variables significant at the 005 level in any singledomain model for each outcome variables not significant at the 005 level were eliminated from the full model finally we added the statelevel contextual variables to each model keeping those significant at the 005 level significant variables for each outcome are detailed in the footnotes in table 3 results from each imputation were aggregated using the sas procedure mianalyze to obtain standard errors that account for variation across imputed data sets multicollinearity was examined but no instances were observed sample sizes were reduced in the multivariable models due to missing data on covariates by 95 40 and 74 the impact of bias due to missing data was evaluated by comparing to models with nonmissing observations results were consistent between the two approaches indicating the results were robust to missing data our goal was to assess the association of raceethnicity while controlling for other factors to facilitate this goal outcomes were initially modeled with only a raceethnicity indicator variable these analyses provide an unadjusted assessment of the relationship of raceethnicity with each outcome then we tested a series of models in model 2 raceethnicity and poverty status were tested together this model estimates racial ethnic impact while controlling for poverty status in model 3 health insurance status a key predictor of health care utilization was added information on dental insurance was not available model 4 includes the remainder of the childlevel variables as well as the familylevel factors model 5 includes all the significant factors from table 1 we tested interaction as described by altman and bland to determine if the aor in each model was significantly different from the aor in the previous model in those cases where cis overlapped results unadjusted results for racialethnic disparities only 88 of children were described by their parents as being in fair or poor oral health however that report varied among racialethnic groups children of hispanic descent had the highest percentage of reported fair or poor oral health this rate is markedly higher than that for nonhispanic whites nonhispanic blacks nonhispanic multiracial and nonhispanic other race each group except nonhispanic multiracial children has rates of being in fair or poor oral health significantly higher than those for nonhispanic whites overall 174 of children had not received a preventive dental care visit in the past year again children receiving no care in the past year were disproportionately children of color with highest prevalence found in hispanic children as compared to nonhispanic whites nonhispanic blacks nonhispanic multiracial or nonhispanic other both nonhispanic black and hispanic children were significantly more likely than nonhispanic white children to lack a preventive dental visit in the prior year only 31 of children were reported to have had a delay in care or unmet need for oral health care in the past year there were no significant differences by raceethnicity adjusted results for racialethnic disparities one of our major goals was to examine the extent to which the racialethnic disparities shown in table 2 are attributable to other factors included in our conceptual model we assessed the independent association of raceethnicity on oral health outcomes using four multivariable models for simplicity of presentation we only present results for hispanics and nonhispanic blacks as these were the two racialethnic groups that showed the greatest disparities in table 2 relative to nonhispanic whites in the first section of table 3 we present the bivariable results for raceethnicity for the three outcomes shown above in table 2 but here in the form of unadjusted ors with nonhispanic white as the reference group in the first multivariable model we examine raceethnicity adjusted for poverty status these results shown in the second group of columns in table 3 demonstrate that the effect size of raceethnicity as indicated by the adjusted odds ratios attenuates when poverty status is simultaneously considered for instance the unadjusted or for having fairpoor oral health for hispanics as compared to nonhispanic whites was 43 but that decreased by almost half after adjusting for poverty status for nonhispanic blacks the initial or was not quite as high but adjusting for poverty status also attenuated the aor by almost half to 14 when additional factors are included in the model the effect sizes for raceethnicity further attenuated adding health insurance in model 3 slightly decreased raceethnicity disparities to aors 24 for nonhispanic blacks and to 13 for hispanics but the changes between models were not significantly different with all the individualand familylevel factors the aors decreased further although more for hispanics than nonhispanic blacks to 17 and 12 respectively in the full model adjusting for all significant child familyand communitylevel variables from table 1 the apparent disparity seen by raceethnicity from the unadjusted model was markedly reduced down to aors of 16 for hispanics and 12 for nonhispanic blacks these estimates were not significantly different from those for model 4 a similar pattern of attenuation in racialethnic disparities is shown for not having a preventive dental care visit in the prior year but with more marked results in the unadjusted analysis hispanic children had almost twice the odds of nonhispanic white children for not having a preventive dental visit in the past year nonhispanic black children had a less dramatic but still significantly higher or versus nonhispanic whites at 14 however as additional child familyand communitylevel variables were added aors for hispanics decreased with added factors in models 2 3 and 4 each subsequent model showed a statistically significant decrease in the aor as compared to the previous model thus each model explains more of the apparent racialethnic difference than the previous one for nonhispanic blacks even just including income was sufficient to eliminate the aor differences from nonhispanic whites for the hispanic children the aor of having no preventive dental visits was no different compared to their nonhispanic white counterparts by model 4 this pattern of attenuation of disparities is repeated again with our third outcome parents report of delayed dental care or unmet oral health need in the past year on an unadjusted basis hispanics and nonhispanic blacks had higher odds of delayed care or unmet needs than nonhispanic whites but these disparities attenuated as additional factors were included in the model specifically a decrement was seen with adjustment for income at which point there is no difference from nonhispanic whites for nonhispanic blacks in the full model neither hispanics nor nonhispanic blacks experienced an elevated risk of having not received preventive care in fact when all variables are included in the full model nonhispanic black children were significantly less likely than nonhispanic whites to report delayed dental care or unmet oral health needs during the past year iii discussion the medical literature contains myriad studies showing poverty and other factors in part explain the impact of race on outcomes such as cancer incidence childhood asthma and overall mortality moreover kaufman and colleagues describe in detail how confounding can bias interpretation of data toward the conclusion of independent racialethnic group effects similar findings have been shown for adults oral health in childrens oral health yu and colleagues demonstrated a diminution of the effect of raceethnicity on receipt of preventive dental care when limited other factors were considered dietrich and colleagues saw a similar decrease in the odds ratios of disparities in fair or poor oral health with inclusion of six adjustment factors our study builds on their work by considering additional outcomes a much larger set of child family community and contextual factors which represent social determinants of health and economic racial educational political and behavioral factors it also uses multiple models to show the progression of impact our findings indicate that racialethnic disparities in childrens oral health care and oral health status while clearly present are primarily attributed to other factors associated with raceethnicity one of the main contributions of our study was to see the additional impact of incorporating a broader set of individual family and neighborhoodstate factors in the analysis of racialethnic disparities we found that no single factor accounts for the observed raceethnic disparities in oral health outcomes rather it is the combination of raceethnicity family income and insurance which accounts for the majority of the apparent raceethnic difference with additional explanation derived from incorporating other individual family and neighborhoodstate factors thus to a large degree racialethnic disparities in oral health care and oral health status are not intrinsically about race or ethnicity although of course there are components that do relate directly to appearances of raceethnicity such as discrimination or reduced opportunities the most important of these factors appears to be socioeconomic status here represented by family income in relation to the federal poverty level but we found that other factors contributed to further attenuation of racialethnic disparities many of the external factors we examined are mutable whereas raceethnicity is not innovative interventions that focus on these external factors may have a reasonable chance for success in reducing childrens oral health disparities these approaches could include communitybased interventions and engagement health promotion and prevention initiatives integration of oral health with other health activities and other approaches which address the childs context through education as well as policy at the local state and national levels contextual changes can have wideranging impact targeted interventions aimed at the factors that underlie racial and ethnic disparities can positively impact a broad range of health issues beyond solely oral health for instance interventions directed at both parent and child which improve access to healthy foods and healthpromoting activities can also decrease obesity and diabetes programs promoting personal family and broader contextual characteristics can reduce drug use in adolescents and improve oral health overall just as these characteristics were found in our work to be associated with less racialethnic disparity similar downstream beneficial effects may accrue from interventions targeted at factors underlying racialethnic differences in oral health interventions which could positively affect other health conditions as well by addressing social determinants of health while valuable because the breadth and depth that the nsch offers there are limitations as with any crosssectional survey data the validity of survey results depends on low sampling and nonsampling errors nsch employs several methods to reduce such errors with crosssectional data one cannot infer causality hence our results should be viewed as correlative and provisional in addition there are factors in our conceptual model which were not included in our empirical analysis either because they were not available or for concerns of overspecifying the models even when including as many factors as we did there may still be other factors which would add to understanding childrens oral health disparities such as literacy or health financing it is perhaps surprising that little difference was seen in delayed care or unmet need we attribute this to the fact that these questions were asked combined when we would expect there to be differences in the way each question would be answered there may also be cultural socioeconomic and age differences in when an oral health issue is perceived to be a problem for which care has been delayed or there is an unmet need the modest differences in this outcome disappear or reverse in the case of blacks when other variables are considered that our oral health status dependent variable is a subjective measure of parents report of childs status which might be subject to bias merits additional discussion while survey subjects did not have an objective exam data support the correlation of this subjective measure with medical and mental health studies have shown that general health and oral health are correlated in particular perceived medical health can predict selfreported oral health status further parents subjective assessment of their childrens oral health correlates with objective dental findings there may be further question of variation in selfreport by raceethnicity or other characteristics in adults answering selfreport questions in spanish there was a higher rate of fairpoor response than would be expected if they answered in english this has been seen in other studies with adults although attenuated with cultural and contextual factors this may in part stem from translating the word fair in english to regular in spanish in a study done of parental assessment of preschool childrens oral health differences by raceethnicity found in bivariable analysis lost their statistical significance after regression analysis controlled for other factors in adolescents parental report is somewhat less reliable weyant et al did find parents of black adolescents had increased odds of reporting their child to have fairpoor oral health of note given that there are differences in oral health by raceethnicity parents perception of their own oral health as poor was significantly related to perception of their childs oral health as poor there are other factors by which parental selfreport varies such as marital status this was accounted for in our model at the family level iv conclusion oral health disparities by race and ethnicity are apparent but not explained in past descriptive analyses in a more thorough analytical approach when child family communityand statelevel factors are considered racialethnic disparities diminish considerably or even reverse this analysis demonstrates racialethnic disparities in childrens oral health status and access are attributable largely to child family community and state factors associated with raceethnicity rather than to something intrinsic to race ethnicity it also shows the additive value of including a more comprehensive set of variables from individualto statelevel in the analysis of disparities incorporating these factors in future research can help to elucidate pathways to more effectively target and reduce racial and ethnic disparities in oral health and health care outcomes moreover future analyses could look at these factors using structural equation modeling to try to tease out direct and indirect effects it is not until the role of mutable sociocultural factors influence on health is fully recognized that the field will be able to design more holistic interventions that truly improve the health of the most vulnerable racial and ethnic groups based on our analysis addressing the disadvantaged circumstances experienced by racial and ethnic minority children their families and communities will foster the goal of eliminating childrens oral health disparities re race and ethnicity nh nonhispanic or odds ratio aor adjusted or lci lower 95 confidence interval uci upper 95 confidence interval 1 variables included for fair or poor oral health status family poverty status insurance status age gender receipt of preventive dental care dental visit in last year medical home highest education in household family structure household size physical health of parents parental coping with child raising use of tobacco products language spoken at home index of perceived neighborhood support index of positive neighborhood attributes index of negative neighborhood attributes percent persons receiving fluoridated water 2 variables included for no preventive care in past year family poverty status insurance status age gender receipt of preventive medical care medical home highest education in household family structure household size physical health of parents use of tobacco products language spoken at home index of perceived neighborhood support index of positive neighborhood attributes dentists per 100000 3 variables included for delayed care or unmet need in past year family poverty status insurance status age medical home highest education in household family structure use of tobacco products language spoken at home index of perceived neighborhood support index of positive neighborhood attributes index of negative neighborhood attributes sealant 2 surfaces abbreviations

objectiveassess the extent apparent racialethnic disparities in childrens oral health and oral health care are explained by factors other than raceethnicitynational survey of childrens health for children 217 years n82020 outcomes included parental reports of childs oral health status receipt of preventive dental care and delayed dental careunmet need modelbased survey data analysis examined racialethnic disparities controlling for other child family and communitystate contextual factors resultsunadjusted results show large oral health disparities by raceethnicity compared to nonhispanic whites hispanics and nonhispanic blacks were markedly more likely to be reported in only fairpoor oral health odds ratios ors 95 confidence intervals 43 4046 22 2024 respectively lack preventive care ors 19 1820 14 1315 and experience delayed careunmet need ors 15 1317 14 1315 adjusting for child family and communitystate factors reduced or eliminated racialethnic disparities adjusted ors aors for hispanics and nonhispanic blacks attenuated for fairpoor oral health to 16 1518 and 12 1114 respectively adjustment eliminated disparities in each group for lacking preventive care aors 10 0911 11 1112 and in hispanics for delayed careunmet need aor 10 among nonhispanic blacks adjustment reversed the disparity for delayed care unmet need

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health promotion in coping with covid19 a virtual culture circle experience promoção da saúde no enfrentamento da covid19 experiência de um círculo de cultura virtual promoción de la salud del enfrentamiento a la covid19 experiencia de un círculo de cultura virtual experience report jeane barros de souza i orcid 0000000205129765 ivonete teresinha schülter buss heidemann ii orcid 0000000162161633 aline massaroli i orcid 0000000347795579 daniela savi geremia i orcid 0000000322597429 i universidade federal da fronteira sul chapecó santa catarina brazil ii universidade federal de santa catarina florianópolis santa catarina brazil introduction 2019 ended with unexpected news a new virus appeared within the chinese territory which entered the year 2020 causing the infection of an increasing number of people worldwide it has been termed severe acute respiratory syndrome coronavirus 2 sarscov2 causes the disease called coronavirus disease 2019 known by the abbreviation covid19 the number that makes up the name of the disease is related to the fact that the first notification to the world health organization took place in december 2019 in january 2020 china witnessed the uncontrolled increase in the spread of sars cov2 registering an expressive number of individuals who developed covid19 who presented symptoms such as mild respiratory conditions to severe acute respiratory syndrome the latter requiring intensive care beds and ventilatory support through mechanical ventilation during this period the worlds attention turned to china to follow the development of the disease and the implemented control measures within a few days cases of covid19 began to appear in different countries which were initially related to a contact with the chinese territory the rapid spread of covid19 to countries other than china was influenced by the globalization process which is characterized as a phenomenon that promotes the articulation and interaction of the world through political cultural social and economic issues making the environment increasingly more complex and dynamic this globalization process facilitates and intensifies the communication and movement of individuals throughout the globe it is conducive to human development but it has shown the world that this type of relationship and mobility also entails danger in view of the records of dissemination of covid19 which quickly surpassed the borders of countries and continents with the advancement of cases of community transmission of the virus in different countries that is when the source of the infection cannot be identified the who classified covid19 as a pandemic in march 2020 which is when a disease is present on five continents circulating in a large number of countries with the declaration of a pandemic worldwide discussions on what would be the most effective measures for the control and prevention of the disease intensified with a consensus for the hygiene of hands surfaces and environments respiratory etiquette additional specific precautionary measures along with the standard precautions in health services nonsharing of personal objects detection and isolation of suspected and confirmed cases in addition to other nonpharmacological measures among the nonpharmacological measures social distancing isolation and quarantine stand out social distance is indicated for everyone and establishes that individuals must maintain a minimum distance of 2 meters between them considered a safe distance so that contamination does not occur isolation is indicated for symptomatic or asymptomatic cases with a suspicion or confirmation of the disease to reduce the contact of these suspected cases with healthy individuals and avoid transmission quarantine is determined by the health administrator of a given territory based on the analysis of the epidemiological profile and capacity of health services to respond to the epidemic in order to reduce the circulation of people and thus slow down the speed of transmission of the disease and the number of sick individuals needing assistance in a hospital and in intensive care beds this measure becomes even more important in cases of diseases such as covid19 which does not have a specific vaccine or medication for its treatment in brazil such action is regulated by ordinance no 356 of march 11 2020 with the advance of community transmission of sarscov2 and the significant increase in the number of covid19 cases several brazilian cities and states declared quarantine for its entire population it was recommended that people stay at home schools and shops were closed only services considered essential were allowed to keep functioning abruptly restricting the relationships that individuals kept in their daily life whether it be in their work friendship family or religious spheres among others this quarantine movement caused sudden changes in societys life habits and profoundly transformed the routine of individuals and families living in the same house adding to this turmoil is the restriction of wide social contact and the distancing of several interpersonal relationships which were previously frequent such changes have the potential to cause different feelings and reactions within individuals and families depending on the way they receive process and cope with the situation directly influencing mental health the psychological impacts of quarantine have been studied for some time considering that in other periods in history this action has already been instituted in different places for the control of other transmissible diseases among the main effects on the mental health of individuals who experience quarantine the negatives stand out such as symptoms of posttraumatic stress confusion anger boredom frustration anxiety insomnia irritability depressed mood and fear of being infected the development of these are influenced by the duration of the quarantine the access to essential supplies as well as the persons previous state of mental health based on this evidence actions were also identified to minimize the negative effects of quarantine on the mental health of individuals such as making social withdrawal periods as short as possible providing essential supplies providing quality information for people to understand the measures that are being implemented in addition to strategies to reduce boredom and promote communication between individuals as for the last action we can emphasize the importance of the internet and of technological resources which promote the connection and approximation between geographically distant people in fact it can be seen that people have expanded the use of technologies to get closer to each other and maintain relationships with their families meanwhile seeking to reflect on the repercussions of quarantine researchers with experience in the use of paulo freires culture circle have used this in a virtual way as an extension action by a public university in southern brazil to establish a connection with some brazilian families in order to promote health through dialogue enabling the sharing of experiences objective to report the experience of a virtual culture circle with brazilian families as a means to offer a space that promotes health in facing covid19 methods organization of the virtual culture circle the experience was based on paulo freires research itinerary which has a liberating pedagogical proposal takes place through horizontal dialogue and consists of three dialectic and interconnected moments thematic research encoding and decoding critical unveiling these stages take place in a space called the culture circle in which each participant brings their own experiences and knowledge and individuals are active in their learning involving the participation of all there is a mediator who develops group interaction to achieve collective knowledge and develop intervention actions due to the need for quarantine it became inevitable to establish the culture circle through virtual means for this purpose the zoom® application was used through the cell phone camera which enabled the families to participate in an interactive way even though each one was at home in order to carry out the culture circle and maintain a close relationship between those involved it was decided to first invite a family from the social strata of the authors to facilitate the interaction and deepen the discussions since then this family has invited other people from its family circle among brothers parents brothersinlaw grandparents and friends to join the virtual culture circle so that seven brazilian families were involved in this process totaling the participation of 21 individuals aged between 10 and 82 years the seven families reported being middle class and residing in different places in the national territory being two in são paulo two in rio de janeiro two in santa catarina and one in goiás the vcc was held on march 26 2020 during the quarantine period with the duration of two and a half hours mediated by a nurse doctor experienced in conducting this type of approach it should be noted that on the day before the commencement of the vcc families were instructed on the use of the application and a test was carried out to verify the connection with everyone involved in the process adjusting the cell phones microphone and camera as well as defining the location within the residence where families would remain during the activity to provide comfort and allow all members to be seen and heard by the participants in the activity in addition each family was asked to have readied a large piece of paper and pens to be used at the meeting at first the proposal was presented to the participants with an explanation of the work methodology that would be developed at the vcc the stages of the research itinerary were carried out through the analogy of the construction of a house which depends on all its structures to remain assembled then a puzzle was organized to carry out the construction of the house adapted by the authors in a playful way with an aim of making the discussion about coping with covid19 more concrete creative interactive and dialogical as shown in figure 1 the house was continuously built during the reflections remaining physically in the residence of the vcc mediator who constantly sought the support and interaction of the families in the mission of assembling the puzzle thematic research was compared to the fundamentals of the house to instigate dialogue it was asked what are the repercussions of the covid19 pandemic on your life the families dialogued widely and elected two themes for discussion at the vcc initiating the construction of the house 1 quarantine weaknesses 2 quarantine potentials for the coding and decoding stage the walls and roof were built through discussions mediated by two guiding questions what are the weaknesses of experiencing quarantine what are the potentials of experiencing quarantine based on these guiding questions the families in dialogue at the vcc codified and decoded the generating themes being asked to write the weaknesses of the quarantine experience on one side of the paper and on the other side to register the potentialities that the quarantine provided the families presented and discussed their perceptions with the group giving rise to new significant themes that expressed the situation experienced at the moment and while sharing the mediator wrote down the main reflections as shown in figure 2 to validate these records the mediator read all the notes to the vcc participants encouraging reflection again on the themes the last stage of the research itinerary is the critical unveiling which took place in an actionreflectionaction process of the investigated themes in which families were invited to express the meaning of experiencing the vcc at that moment they built the doors and windows of the house in the perspective that they represent the internal and external environments of a residence as was made possible by the participants of the circle that is they were able to look at themselves and subsequently at of health promotion in coping with covid19 a virtual culture circle experience souza jb heidmann itsb massaroli a geremia ds connection with them the playful during the educational process activates the interaction and the construction of knowledge together enhancing the protagonism of those involved in the activity and the exercise of autonomy with expression of feelings and ideas in the experience reported here the representation of the house was chosen because it allows the reflection of the situation of the participating families who were quarantined in their homes during the period of the vcc this made the discussion more concrete creative interactive dialogical close to the reality of the participants as well as making it possible to carry out all the phases of paulo freires itinerary in a single meeting in this context the vcc presents itself as a soft technology for care being an innovative and creative strategy that emerged due to the impositions and limitations brought by covid19 as it enabled the dialogue between families that were distant allowing social approximation reflection and learning in an agile way and with scarce resources in a pandemic period the use of soft technologies in the field of nursing has gained prominence with the opportunity to develop them in favor of the growth of the profession they are produced in the work process condensing the relationships of subjectivity interaction generating welcoming bonding and autonomy in the meetings between health professionals and individuals who need care therefore as a suggestion the development of welcoming opportunities for individuals through the vcc is emphasized to promote health these spaces must prioritize the exchange of knowledge and provide dialogue empowerment and hope for individuals families communities both nationally and worldwide in this regard nursing stands out as a potential strategy for dialogue between communities and health care being able to act in their territory through intersectoral actions mainly in primary health care thus seeking to promote health in its broadest sense study limitations this experience was limited by the fact that it was the authors first experience in the development of the culture circle through the virtual environment being that future opportunities could be conducted with greater tranquility and security providing new perspectives on this strategy contributions to the field of nursing health or policies based on the successful experience reported by the researchers this work represents an innovation in the way of developing the culture circle as it allows to extrapolate the limits of the presence of all participants within the same physical space expanding the opportunities for using this methodological strategy as a soft technology for care in addition it enables the practice of listening with acceptance the exchange of experiences and information to be instruments for promoting health and wellbeing in families even if geographically distant therefore the accomplishment of the vcc based on paulo freires referential emerged as a methodological and assistance tool for nursing and through liberating dialogic actions it allowed the development of humane comprehensive and welcoming care given the need for social restriction their externalized and built group reflections to then resignify the discussions held and empower themselves internally and mutually strengthening and transforming themselves for the mental health of the whole family in the quarantine experience caused by covid19 from the development of this vcc a matrix research project was organized to understand the perception of brazilians about coping and the repercussions of covid19 in their lives it was approved by the research ethics committee virtual culture circle a tool to promote health in times of covid19 through the vcc dialogues debates were raised about the daily experiences of quarantine thus the criticalreflective thinking of the participants was widely shared and the virtual meeting became a dynamic learning space which made it possible to reflect on the existential situations in coping with covid19 participating families exchanged knowledge during the vcc being that when room is made for listening to the needs of individuals with an opportunity to exchange experiences and information allowing everyone to share their problems and together seek solutions such actions make it also an instrument for health promotion in the community in addition the participants requested other similar moments to further the discussions that emerge when facing covid19 and this shows that they intensely enjoyed participating in this space which provided health for those involved and shared experiences the fact is that physical isolation is necessary in the context of the pandemic but not social isolation that is it is necessary to stimulate the social interaction of individuals and family members through electronic devices that promote communication interaction and health just as it was done in this experiment it can be seen that in general researchers and scientists have actively been seeking information regarding covid19 in order to achieve greater possibilities for the cure of affected individuals and the prevention of new cases which is healthy and extremely relevant in the current situation however attention is drawn to researchers and health professionals so they can also look at individuals families and communities facing the current situation seeking strategies to promote health in times of pandemic as it is believed that the repercussions of this moment of crisis will extend over a long period of time in the way of life of both the individuals and the communities in this scenario it is necessary to transpose the current biomedical model and promote health as a benefit and a right of every citizen being that the conceptions and practices regarding illness can hinder the possibilities of doing health based on the ways of being and living in society it is worth remembering that the concept of health promotion resulted from the ottawa charter of 1986 defining how the process of qualifying individuals and communities to act to improve their quality of life considering the importance of social determinants of health furthermore for the culture circle to be virtual or presential to become a healthpromoting space it is suggested that the mediator organize a creative and playful strategy to cover the stages of the freirean itinerary in order to get closer to the reality of the participants in a concrete way establishing a greater of health promotion in coping with covid19 a virtual culture circle experience souza jb heidmann itsb massaroli a geremia ds final considerations the vcc supported by paulo freires theoreticalphilosophicalpolitical assumptions provided a space for embrace and horizontal dialogue promoting participants health by enabling a feeling of trust construction of knowledge freedom of expression love hope this allowed us to critically reflect on life and its consequences becoming aware of its existence with a reelaboration of the knowledge of its reality in the experience of the quarantine generated by covid19 it can be seen that the development of the vcc was a fruitful strategy as it favored the approach of the participants without the need of physical contact enabling the integration of geographically distant people this innovative vcc execution presents itself as a potential to promote the health of individuals and of collectivity in times of pandemic as well as for the realization of an actionparticipant research with the involvement of individuals regardless of their geographic location it is also suggested to carry out studies that can deepen the possible characteristics of differing in both strategies the inperson culture circle and the vcc

objective to report the experience of a virtual culture circle with brazilian families about coping with covid19 as a space that promotes health during the pandemic method experience resulting from an extension action the virtual culture circle was held based on paulo freires research itinerary it counted with the participation of seven families from different locations in brazil during the dialogues a house was built the foundation represented the thematic research walls and roof coding and decoding doors and windows the critical unveiling results the actionreflectionaction process favored the approach and integration of the participants of the culture circle despite the geographical distance it is an innovative strategy for empowerment and health promotion final considerations the virtual culture circle constituted a soft technology for health care and can be explored as a tool for promoting health especially in scenarios where facetoface meetings are an impossibility

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introduction during the previous decade or so the popularity of distance education programs has increased substantially through distance learning educators have the ability to offer lowcost courses and programs to individuals spread across vast geographic regions often allowing users to learn at their own pace the flexibility and convenience of such online courses is especially important for working professionals who are required to pursue continuing education trainings but at the same time face decreasing travel budgets and increasing workloads that afford them less time away from their daily work duties traditionally continuing education and other similar professional trainings have been offered through facetoface instruction by extension agentsspecialists and other subject matter experts however because online trainings have the potential to increase the geographic scope of audiences as well as reduce costs for both instructors and participants there is growing momentum to shift from the traditional facetoface format to more online education in extension effective distance education programs are not simply facetoface programs put online so students have opportunities to apply concepts they learn to real world situations adult learners in particular prefer learning environments that incorporate problem solving with opportunities to incorporate both new knowledge and past experiences engaging in higherorder thinking for this reason a hybrid approach that blends facetoface and online formats can be very well suited for adult extension audiences when implemented correctly distance learning can yield positive results despite the often reduced participantparticipant and participantinstructor interactions characteristic of traditional facetoface environments in fact even though facetoface courses may be preferred by some participants a multimediarich and highly interactive online learning environment can lead to achievement levels comparable to or above traditional instruction hybrid courses can provide benefits over strictly facetoface learning because participants are able to work through foundational content ahead of time at their own pace and then revisit that content as often as they choose this in turn leads to more meaningful engagement in facetoface discussions and activities flipped classrooms where lectures are presented online followed by inperson sessions that involve active learning activities to promote student engagement can lead to improved understanding of course material extension has been adopted as training required for promotion among entrylevel land managers by several counties in florida until 2011 all nata workshops were offered as 3day facetoface trainings at remote locations that provided settings relevant to workshop material during 20092011 participant enrollment dropped significantly due to numerous factors such as increased government travel restrictions budget cuts and the inability to leave regular work duties for extended periods of time because a large proportion of potential participants were facing similar challenges we decided to adopt a hybrid format for our trainings beginning in 2012 our goal was to create workshops that offered the flexibility and convenience of an online program that also facilitated the networking and handson learning that come with inperson trainings by 2014 all four core workshops had been converted to a hybrid format at which time we surveyed participants to gain an understanding of how they perceived this change in workshop structure as well as the quality of their learning experience methods traditional workshops from 2000 to 2011 the four core workshops offered by nata occurred as 3day inperson trainings and were generally offered once per year the entirety of each workshop was held at a remote site with rustic accommodations such as a state park the material for each facetoface workshop was taught through a variety of methods workshop participants engaged in group activities collected data on field trips around the training site listened to presentations from guest instructors who were experts in their field and presented their results from casestudy exercises to each other participants were also provided with a takehome binder that contained worksheets copies of all lecture presentations and additional resources that we felt might be beneficial for postworkshop learning workshop conversion we decided that all four core workshops would be converted to a hybrid format but recognized that it would not be appropriate for each training to be structured exactly the same way in order to keep with the 24 instructional hours of the traditional workshop formats we adopted a 2day online1day inperson approach for two workshops and a 1day online2day inperson approach for the other two each workshops format was determined based on the amount of lecture material presented and the amount of field material that could not to be replicated online the online material was presented asynchronously for each workshop through coursesites by blackboard a free online learning platform this allowed users to access and work through the material at times convenient for them and at their own pace the length of the online portion of each workshop depended on how much material was presented generally 4 8 weeks workshop content was divided into modules each of which contained interactive video presentations ungraded selfassessment quizzes and optional readings and resources additionally some modules also contained assignments that were not graded but were required to be submitted to earn workshop credit assignments were designed to substitute for activities that would have been done in groups at the facetoface workshops giving participants an opportunity to apply the concepts and information learned surveys in 2010 before conversion to the hybrid delivery format an electronic survey was sent to individuals who had completed a traditional nata workshop within the previous 5 years the survey included 18 questions on topics such as which factors respondents considered when deciding to enroll in a workshop what benefits they most desired in a workshop what benefits they actually gained by participating in a workshop how relevant the workshop material was to their job whether they had learned new skills at the workshop how useful the workshop information was and how often they use the techniques or skills learned at the workshop in their job survey participants were also asked which format of workshop they preferred and which factors would prevent them from attending future nata workshops in 2014 a similar electronic survey was sent to workshop participants who had completed at least one of the converted hybrid workshops during 20122014 this survey asked the same 18 questions with the same question wordings and answer choices as the 2010 survey but to understand how the incorporation of the hybrid teaching model associated with participant satisfaction questions were added that addressed participants perceived experience with the hybrid workshops the additional questions were 5category likerttype ranging from 1 to 5 that corresponded to the technology acceptance model a threeitem scale measured participants perceived ease of use of the online system a sixitem scale assessed their perceived usefulness of the hybrid workshop format a threeitem scale evaluated the flexibility provided by the hybrid format and a fouritem scale evaluated participants overall satisfaction results and discussion the 2010 survey had a response rate of 256 although fairly low this response rate is considered adequate for deriving reliable results from online surveys the majority of respondents identified the primary focus of their job at the time of the survey as land management biology outreacheducation park ranger or ecology research the number of years respondents had been employed in a natural resource management field ranged from 1 32 and most respondents identified their current employer as a state agency county government or a private company the 2014 survey had a response rate of 443 the majority of respondents identified the primary focus of their job at the time of the survey as land management volunteer coordination biology and outreacheducation the number of years respondents had been employed in a natural resource management field ranged from 1 22 and predominant employers shifted to municipalities state agencies and county governments participant perceptions of the program 2010 versus 2014 decision to enroll we asked one ranking question with six answer choices regarding the most important factors considered when deciding whether to enroll in a workshop and found little change in responses between 2010 and 2014 in both years the top three factors were how closely the topic relates to my job responsibilities my personal interest in the topic and whether or not my boss thinks i should attend in both years respondents found three other factors to be of lesser importance the number of days the workshop will keep me from my daily responsibilities the location of the workshop and the reviews ive heard from previous workshop participants the consistency in responses suggests that during both periods investigated our workshop topics aligned well with managers job responsibilities managers interests and priorities of their supervisors we asked one ranking question with six answer choices regarding the importance of various factors in preventing enrollment in additional nata workshops the top three hurdles were the same in both 2010 and 2014 but the rank order changed with high registration costs ranking the highest in 2010 and time away from the job in 2014 both years all other factors were deemed less important the consistency of highranking challenges to enrollment between survey periods indicates that our conversion from a fully inperson approach to the hybrid format was apt benefits desired and benefits gained we asked one question with five answer choices regarding what benefit participants most hoped to gain and found no change in responses between 2010 and 2014 the three benefits most desired were ranked the same during both years we also asked one question with five answer choices regarding what benefits participants actually gained and this time found a shift in response between 2010 and 2014 specifically understanding of a particular topic was rated the highest desired benefit both years it was the third highest benefit gained in 2010 but was the highest benefit gained in 2014 in 2010 there was a mismatch between the benefits desired and the benefits gained whereas this discrepancy was less apparent in 2014 this suggests that nata was doing a better job in 2014 of meeting participants expectations in comparison to 2010 relevance we asked one question to assess how useful the information covered during the workshop attended was for meeting participants current job responsibilities and received similar feedback both years the majority of respondents indicated the information was extremely useful with a lesser percentage indicating the information was somewhat useful a small minority indicating the information was marginally useful and no one indicating the information was not at all useful either year these responses suggest nata has been consistently helping participants learn information useful to their jobs with a slight increase in usefulness between 2010 and 2014 we also asked one question about how often new knowledge gained during workshops was put to use on the job and found a slight change between years in 2010 12 of respondents reported using information very often 37 often 43 occasionally 6 rarely and 2 never similarly 7 of respondents reported using information very often in 2014 45 often 39 occasionally 10 rarely and 0 never this confirms that although there were some changes in the primary focus of the jobs of survey respondents between the two points in time surveys were conducted the information covered by nata was and continues to be relevant to resource managers jobs satisfaction we asked one question regarding overall satisfaction with workshops and had similar responses both years in 2010 71 of respondents indicated they were completely satisfied 25 somewhat satisfied 1 neither satisfied nor dissatisfied 3 dissatisfied and 0 completely dissatisfied in comparison although a lower percentage of respondents were completely satisfied in 2014 61 were somewhat satisfied and 0 reported being neither satisfied nor dissatisfied dissatisfied or completely dissatisfied in other words although there was a drop in participants who were completely satisfied with the course there were no neutral or negative ratings to nata in 2014 we asked one question with four answer options regarding preferences among workshop formats there was a clear shift in preference to incorporation of an online learning format between surveys it is noteworthy that the format used in 2010 was preferred in 2010 and that the format used in 2014 is preferred in 2014 we cannot speculate whether this reflects a preference for the format participants are most familiar with versus a true change in acceptance of online learning platforms over time regardless it is clear that the workshop format currently in place is preferred at the current time participant perceptions of the hybrid approach 2014 respondents reported high perceived ease of use of the online system high usefulness of teaching strategies employed high flexibility and high satisfaction satisfaction with the workshop was most closely correlated with perceived flexibility and perceived usefulness corroborating previous research due to increased flexibility and accessibility distance learning is becoming more common in extension and outreach education programs our experience indicated that workshop participants were satisfied with the hybrid workshop format because it provided flexibility while enabling them to learn information relevant to their job responsibilities our survey results indicated the hybrid workshop format is doing an even better job of providing the most highly desired benefits than did the traditional facetoface learning environment we used for 11 years because time spent away from daily job duties was cited as the biggest hurdle to enrolling in additional training opportunities in 2014 the hybrid workshop format seems to be a viable alternative to our traditional facetoface trainings it should be acknowledged that there are costs of transitioning away from a facetoface workshop although survey results showed mostly positive impressions of the hybrid format results do indicate that there was a drop in the proportion of participants who were completely satisfied with the workshop likely some participants might not feel as strongly about a workshop that has less connection with instructors and other participants and time in the field the hybrid workshop is more efficiently doing its job of providing a valuable learning opportunity for professionals but it might not evoke as strong a feeling of satisfaction as the facetoface workshop format however as an increasing number of extension programs are moving in the direction of offering at least a portion of their trainings online we expect that with time there will be a shift in participant satisfaction that better aligns with this hybrid format the market for online training is large and expected to continue expanding due to technological advances growing acceptance among endusers and improved understanding among educators of how to make the best use of new technology hybrid trainings may well be the best approach to reach adult extension audiences across large regions at reduced costs to both participants and instructors

a recent shift in desires among working professionals from traditional learning environments to distance education has emerged due to reductions in travel and training budgets to accommodate this the natural areas training academy replaced traditionally formatted workshops with a hybrid approach surveys of participants before and after this change indicate that a traditional inperson format was preferred in the past but a hybrid format is preferred now respondents indicated the new format is more effective at providing highly desired benefits than the traditional facetoface approach these findings have implications for many extension programs targeting working professionals across large geographic areasmodernizing training options for natural areas managers joe 53 5

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and shoelace tying and gross motor skills 1 this disorder which affects 56 of schoolaged children 23 interferes with youths higherorder cognitive functions such as executive function and academic performance 45 furthermore dcd can affect various aspects related to individuals physical health and psychosocial wellbeing 6 7 8 some of these effects seem to be pervasive and enduring during subsequent years 3 for example it has been suggested that in more than half of children with dcd problems persist into adolescence and adulthood 23 however intervention studies have mainly focused on typically developing children so far and little attention has been paid to the effects of motor interventions on motor proficiency of adolescents with dcd 9 according to the international classification of function disability and health for children and youth framework 10 motor interventions are categorized into three types based on the aims that an intervention follows body function structureoriented interventions where an activity or intervention is designed to improve body functions and considered to underlie the identified functional problems activityoriented interventions where the activity is designed to improve performance in that activity and participationoriented interventions where an activity or intervention is designed to increase participation in that activity regardless of the aim that an intervention follows there is a clear gap in the scientific knowledge regarding how adolescents with dcd respond to motor interventions as an exception bonney et al 12 compared the effects of two different types of interventions on mp and activities of daily life in adolescents with dcd they found that both types of interventions were effective in improving several outcome measures difficulties in coordinating motor actions in individuals with dcd have been mainly attributed to impaired postural control sensorymotor integration muscular strength speed and agility 13 14 15 therefore it is important to apply interventions that target these factors in this regard studies suggest that regular practice of martial arts improves childrens postural control and balance abilities as an important component of mp 1617 a recent review showed that regardless of the individuals age of commencement of practice martial arts can improve balance muscular strength and cognitive function of healthy adults 18 it has also been found that karate and judo athletes have faster reaction times than nonathletes 19 these benefits were also observed in children with dcd and an improvement in sensory organization and standing balance has been observed after a taekwondo intervention 20 moreover studies suggest that an increase in isokinetic knee muscle strength at 180º and static singleleg standing balance in dcd children can be obtained after 3 months of intensive taekwondo practice 21 considering that karate requires a high level of coordination for executing precise techniques under static and dynamic conditions in this study the research team were interested in examining the effects of karatedo on mp in adolescents with dcd 22 because karate practice also requires a high level of motor and functional abilities involving speed strength 23 and precise control over executed movements 24 25 26 a recent study has revealed that prolonged karate training can result in superior functional balance in adolescents suggesting that moderate karatekata training would be a good alternative in rehabilitation programs 27 although several studies have been conducted to uncover the effects of karatedo interventions on motor performance most of the previous studies have focused only on the effects of interventions on balance performance and few studies addressed the effects of karatedo interventions on motor proficiency especially in adolescents with dcd in addition the ecological perspective in contrast to the maturational perspective assumes that all changes in human motor behavior are not attributable to human body systems with other factors such as the environment significantly contributing to manifesting behavior thus both the body and the environment are important when a researcher attempts to understand the effects of a particular intervention on motor outcomes the socioeconomic status of a family is an environmental factor that is known to influence mp 21 22 23 24 25 26 hardy et al 28 in a study using 6917 students found that girls with low ses were twice as likely to be less competent in locomotor skills when compared with high ses peers 27 klein et al 29 also found that children and adolescents with a higher ses exhibit a higher mp than their peers with a lower ses background 30 it has also been demonstrated that high ses children exhibit superior fine and gross mp compared to middleand lowses children 21 however a recent study has reported that the effect of ses on motor scores is neglectable 31 in the existing literature few studies have tried to find out if ses impacts the mp levels of adolescents with dcd valentini et al 32 found that 910 yearold children with probable dcd and at risk of dcd exhibit an inferior performance in balance and manual dexterity tasks more importantly in that study ses was found to be the strongest predictor of motor outcomes and low ses was associated with significantly poorer mp 33 considering the discrepancy in the mp levels of children with different ses it is reasonable to expect that ses modulates the effects of motor interventions in sum the current knowledge regarding the effects of motor interventions on motor performance in adolescents with dcd is highly limited in addition while several studies suggest that ses impacts childrens mp few studies have attempted to investigate the effect of environmental factors including ses on the performance of adolescents with dcd therefore in this study the research team aimed to investigate the effects of an 8week karate intervention on the mp in adolescents with dcd and highlow ses as studies suggest that martial arts including karate may improve factors such as balance performance 30 muscular strength endurance speed and agility the research team hypothesized that these factors would improve following our karate intervention and that the rate of improvement would vary depending on the level of participants ses the research team further hypothesized that the karate intervention would result in adolescents with dcd exhibiting an improved performance in measures such as fine motor precision and manual dexterity the later hypothesis is based on several studies which suggest that cognitive factors such as executive function selective attention and reaction time improve following karate practice 1831 methods measures demographic information and physical activity basic demographic information was acquired through individual interviews with each of the participants these interviews were conducted by the fourth author based on previously designed and validated questions 38 such questions were related to age general health disease record disorder previous sports background and time of menarche the international physical activity questionnaire was used to measure the level of physical activity 39 this questionnaire which was completed by each participant uses the information obtained to report the level of energy expenditure of each individual in metabolic equivalents minutes per day ses questionnaire when measuring the socioeconomic background of a family the persian version of a ses questionnaire was used 34 which consisted of four components relating to income economic class education and housing status along with a total of six demographic questions and five general questions after a full explanation of the questionnaire and the data confidentiality protocol of the questionnaire each participants parentguardian filled out a paper questionnaire in the school and parents and guardians were asked to fill out the questionnaire in 15 min using a likert scale for investment income education social class and housing prices for consistency of communitybased criteria for ses and family background participants were considered low ses if the total score of the parents answers to the questionnaire was between 5 to 8 and high ses if the total score was between 22 to 25 the validity and reliability of the questionnaire were confirmed by 12 experts supported by a cronbachs alpha of 083 40 botmpsf2 test the short version of the bruininksoseretsky test of motor proficiency second edition 41 was completed for evaluation of the mp of adolescents in preand posttesting phases by the fourth author who had expertise in motor development this validated measurement tool assesses fine motor precision fine motor integration manual dexterity upper limb coordination bilateral coordination balance strength speed and agility and provides a single overall motor composite score to meet the requirements of the testing protocol the test was administered in a calm atmosphere in the school gym with dimensions of 10 m × 30 m the time for taking the botmpsf2 was approximately 15 min per participant the botmpsf2 was previously validated against the long version of the original battery for people aged 4 to 21 and the usefulness of this tool was confirmed for the motor assessment development and evaluation of motor intervention programs 41 the botmpsf2 subtest scores are ageadjusted scaled scores possessing a mean of 15 and a standard deviation of 5 whereas the bot2 composite scores are standard scores with a mean of 100 and a standard deviation of 15 scaled scores were converted into standard scores the reliability of the botmpsf2 was reported to be between 089 and 090 42 procedure the intervention program used in this study was adopted from the published karatedo guide 43 the karatedo intervention was conducted by an expert karatedo instructor who was an official coach of the karate federation the karatedo intervention involves performing the kihon and heian shodan kata each session of intervention program targeted the development of balance coordination and strength for a total of 75 min including a 45min episode of the karatedo martial activity each session included 30 min for the warmup and cooldown exercises in the early sessions of the intervention the exercises and activities were taught in a simple and direct pedagogical manner the exercises were performed in smaller groups with the instructor in order to enhance the fluidity of the sessions at the initial stages of learning new movements all participants were required to slow down and control their movements advancing the practice of resident gestures was static to dynamic movements also the periods of rest between each workout to the next exercise were considered the intervention lasted for 8 weeks statistical analysis the results of fine motor precision fine motor integration manual dexterity upper limb coordination bilateral coordination balance speed agility and strength tests were recorded on two occasions during the preand postassessment stages scaled scores from the individual 8 items of the botmpsf were obtained and the total scores were calculated for further analysis repeated measures analyses of variance were conducted to examine the effect of the karatedo intervention on the mp of highand lowses groups the η 2 p values were reported for the effect size and considered small for η 2 p 06 moderate for η 2 p 06 and η 2 p 14 and large for η 2 p 14 44 the typical assumptions of anova including data normality as well as sphericity and homogeneity of variance were checked by boxplot and qq plot all participants completed the intervention and the data obtained at preand postassessments were submitted to statistical analysis the analyses were conducted using spss version 230 with the significance level being set at p ≤ 0 05 result the information on the participants demographic characteristics and the values for body mass index are provided in table 2 there were no differences in the baseline mp performances between highand lowregroups effect of intervention on motor proficiency the results of a 2 × 2 repeated measures anova as presented in table 3 revealed that there were significant main effects for time across all eight subscale scores and the total mp score the interaction between group and time was significant for fine motor integration manual dexterity bilateral coordination balance strength and the total mp score posthoc analyses using bonferroni adjustments revealed that while there were no differences between low and high ses scores at the baseline the high ses group improved more significantly in fine motor integration manual dexterity bilateral coordination balance strength and the total mp than low our ses group for more details see the additional file 1 discussion the purpose of this study was to investigate the effect of a karatedo intervention program on the mp of adolescent girls with dcd at highlow ses to this end we investigated the effect of karatedo training for 16 sessions in 8 weeks confirming one of the study hypotheses karatedo intervention was found to significantly improve the mp of both highand lowses groups over time this finding is consistent with a line of research which suggests that martial arts can improve the mp of children and adolescent youth with dcd 202145 moreover our findings extend the literature base as to the authors studies found that active video game interventions are effective in improving balance 46 and general skill training may improve strength or endurance 47 these studies along with our findings suggest that activityoriented interventions are generally effective in improving body functions 11 activityoriented interventions including sportrelated interventions are generally more costeffective than interventions directed to body functions and structures because the latter usually needs relatively expensive training devices a good avenue for research in dcd is to investigate whether activityoriented interventions can improve body functions and structures at a comparable or even a superior level to interventions targeting body functions and structures interestingly the current study observed that following the karatedo intervention body functions improved while improvements in balance muscular strength and bilateral coordination are to be expected after a karate intervention it may be challenging to explain why factors such as fine motor integration and manual dexterity have improved in this study there is a need for providing further direct evidence however these findings may be explained from cognitive and neural perspectives it has been shown that cognitive functions such as executive functions attention and reaction time improve following karatedo practices furthermore some studies suggest that karate improves motor control due to the microstructure of white matter in the cerebellum and m1 48 further studies however are needed to arrive at robust conclusions as to how cognitive and neural factors contribute to the mp improvements in adolescents with dcd who have engaged in karate practice as mentioned earlier female adolescents with dcd at highses group had an increased likelihood of demonstrating significantly better improvements in overall mp over time when compared to the lowses group along similar lines a research by tine and butler 49 reported that children at low ses are susceptible to additional benefits in acutebased aerobic exercises involving selective attention golos et al 50 also found increased intervention effects in both cognitive and motor skills of boys at low ses the inconsistency in these findings may be attributable to the difference in the age range of participants in our study and the above studies while ses in adolescence appears to have a significant moderating role in the effectiveness of motor interventions its function may be different between children and adolescents during the period of maturation adolescents of lower ses background appear to consistently experience more stressful and less cognitively stimulating situations at the home environment when compared to their highses peers 51 52 53 54 in addition studies show that ses is positively associated with motor competence 55 for example it has been shown that children and adolescents with low ses are less competent in fine and gross motor skills as well as stability performance when compared with high ses peers 282956 it is evident from the present study findings that ses has a significant role in adolescents response to activityoriented interventions the analyses of the subcomponent scores revealed that the two ses groups significantly differed in manual dexterity bilateral coordination and strength manual dexterity is one of the main components of finemotor skills and in previous studies it has been found that social disadvantage may have a persistent detrimental effect on this skill over time 57 regarding the motor coordination prätorius and milani 58 have further shown that children with lower social backgrounds are at an increased likelihood of coordination impairments and these abilities have not changed significantly within the last 25 years such pieces of evidence can help explain the current research findings in terms of lowses this study has several limitations that lead to recommendations for future studies due to the limited number of adolescent participants with dcd at highlow ses a generalization of the results to other young people should be made with caution in addition while the researcher who collected participants data was an experienced motor development evaluator she was not blind to the groups division which may have led to some unintentional effects on our collected data future studies are required to consider such potential limitations the study is only limited to adolescent girls with dcd and as a result the research team failed to include adolescent boy counterparts as it has been shown that there are gender differences in mp in individuals with dcd future studies using both genders are required in order to determine the effects of ses as an environmental factor it is recommended to study the longterm effect of motor development interventions across different age groups with other developmental disorders conclusion due to the limited research in the field of cognitive and motor functioning in adolescents with dcd and high low ses it is expected that the current findings can be used to facilitate lowcost interventions that can be implemented in schools such findings have the potential to provide motor development opportunities for adolescents with dcd especially those possessing high ses abbreviations competing interests the authors declare that they have no competing interests

background there is not a general consensus on the best type of intervention to improve the motor proficiency mp of adolescents with developmental coordination disorder dcd considering the effect of socioeconomic status ses in relation to the mp of adolescents with dcd it is necessary to examine this issue further the purpose of this study was to investigate the effect of karatedo interventions on the mp of adolescents with dcd from highlow ses methods participants included 16 adolescent girls 12 to 13 years old with dcd and their classification into high low ses groups was done by using appropriate previously validated questionnaire a short form of the bruininksoseretsky test of motor proficiency second edition bot2 was used to assess fine motor precision fine motor integration manual dexterity upper limb coordination bilateral coordination balance strength speed agility and overall mp level of the participants both highlowses groups completed a specifically prescribed karatedo intervention program for 8 consecutive weeks 3 sessions per week with each session lasting for 75 min results from this 8week intervention showed that the pattern of change in manual dexterity bilateral coordination strength and the total mp score improved over time in both groups with varied socioeconomic backgrounds specifically the highses group performed significantly better than their lowses counterparts during the 8week karatedo intervention p 005 conclusions following participants completion of the karatedo intervention the existence of significant changes in the mp of adolescents with dcd at highlow ses confirmed our hypothesis compared to the lowses group adolescents with high ses displayed superior mp following the intervention it seems that karate kata training serves as a good alternative for rehabilitation mp programs however an important issue concerning social infrastructure is to create a suitable exercise environment for adolescents at lower ses until the ses achievement gap in female adolescent mp is stable future work is warranted to discover more practical and meaningful interventions

19689_0

introduction for most refugees the decision to flee means to temporarily or permanently leave behind close family members in their countries of origin the separation from the nuclear family is particularly challenging as it can have farreaching consequences for refugees in many areas of life between february 24 2022 and december 2022 more than one million ukrainian refugees were registered in germany an initial analysis on refugee patterns of ukrainian refugees in germany has detected that the legal situation in ukraine since russias invasion with the general mobilisation and the travel ban for men of military age precisely causes such separations of nuclear families however the current influx of ukrainian refugees differs from previous refugee cohorts while previous refugees to western europe eg from syria from 2013 to 2016 tended to be mainly young men with their families or single men the demographic composition of the ukrainians is different the group of ukrainian refugees mainly consists of women their children and a larger amount of older people moreover there are substantial gender differences in the family constellations very few male respondents from ukraine reported to have arrived in germany without their partner whereas a large share of women arrived without their partner or that they were single only every fifth woman from ukraine came to germany with their partner and about every third woman was spatially separated from her partner due to the flight from previous literature we know that longer involuntary separations from the partner do not only have negative effects on mental health and wellbeing of the separated partners and other family members spatial separation also limits the chances of getting by in the destination country eg social integration or participation in the labour market the situation is further exacerbated by the fact that about half of the refugee women from ukraine have minor children in germany indicating that many of the refugee women are at least temporary lone mothers research has also shown that especially female refugees and in particular singleparenting mothers are in disadvantaged positions in the past decades growing attention has been paid to gendered migration patterns and the role of the extended household as the behavior of migrant women cannot be fully understood without considering their family situation and their roles within them for example women often have to additionally fulfill the role of a caregiver but may be less familiar with administrative or financial issues than men international migration let alone in the context of forced migration may change gendered patterns in families also across generations involuntary separations usually go along with mental stress and the intention to reunite the partnership or family as fast as possible familymigration patterns or reunification patterns are gendered and depend on the legal conditions for migration which in itself are not genderneutral and thus may reproduce genderrole patterns moreover family migration is one of the quantitatively most important drivers of chain migration recent research has pointed out that policy should be more focused on realising the unity of refugee families in order to improve wellbeing therefore robust evidence on reunion potentials possible determinants and barriers is essential for targeted policy interventions however the quantity of such chain migration processes is very difficult to accurately predict the best data available in early processes of fleeing are reunification intentions here research has already shown that mobility intentions are a rather good predictor of future behavior hence knowledge about such intentions allows to estimate such potentials for further immigration and also possible determinants and barriers yet regarding the group of ukrainian refugees little is known about their intentions to reunite with their family members in germany therefore our paper aims at exploring such intentions for family reunion in germany we focus specifically on female refugees our study pursues the following research questions what are the patterns of intentions for family reunion in germany with respect to partner andor children which factors are related to ukrainian refugee womens desire to reunite with their partner andor children in germany previous literature on migrant family reunion intentions and refugee mobility behavior suggests that a number of factors may be at play first these are sociodemographic factors such as age family structure and education here we would expect a relationship between the desire to reunite with the partner andor children in germany and a younger age a higher educational level and the presence of children in germany second the different regions in ukraine vary in the extents they had been and still are affected by the war while regions in the east and the south and the capital kiev are most affected and report the highest numbers of victims loss and damage regions in the west of the country have been to date much less affected by direct violent acts of the war previous research on the relation between experiences of violence and flight mobility points to a significant association to mobility behavior therefore we assume that refugees originating from regions more affected by the war and its violence state a stronger intention to reunite with family members third the intention to permanently settle in germany are also supposed to be strongly related to partner reunion intentions data method and sample the data we use comes from the iabbibfredabamfsoep survey on ukrainian refugees in germany the survey is a probabilitybased sample relying on two administrative registers in germany the central register of foreigners and the population register einwohnermeldereg 2 ister emr which are regularly used in similar studies the combination of both registers allowed for the construction of a highquality sampling base within a short time frame for the sampling of ukrainian refugees in germany a twostage procedure was implemented on the first stage 100 cities and counties across the 16 federal states in germany have been randomly drawn considering daily updated information on the regional distribution of ukrainian refugees registered in the azr the emr was utilised in the second stage in particular a gross sample of 48000 ukrainian nationals aged between 18 and 70 years who first registered in germany not earlier than february 24 2022 was drawn the iabbibfredabamfsoep survey on ukrainian refugees in germany was realised based on a sequential pushtoweb mixedmode design a similar design was previously used for other spatially mobile populations in germany within the framework of the german emigration and remigration panel study or in large general population surveys such as freda the german family demography panel study this design combines the advantages of postal registerbased recruitment with those of an online survey the questionnaire covered a selected range of topics such as education employment individual financial situation in ukraine and germany participation in integration measures family situation and social contacts accommodation needs and intention to stay in germany as well as the health situation of respondents and their children a total of 11763 persons took part in the survey of whom 9525 persons participated online and 2238 persons by letter post resulting in an overall response rate of about 25 percent which is comparable to studies with similar research designs or target groups the survey lasted a median time of 197 minutes comparisons of the distribution of key demographic characteristics of respondents with the distribution of all ukrainian refugees registered in the azr between february 24 2022 and september 30 2022 revealed little evidence of systematic bias in the sampling indicating a high quality of the survey data remaining differences were additionally compensated by a weighting procedure eg accounting for the selective survey participation willingness hence overall information provided by the iabbibfredabamfsoep survey on ukrainian refugees in germany can be generalised to ukrainian nationals who fled to germany during the initial months of the war the data can thus be used to provide reliable evidence for this group in our analyses we focus on female refugees from ukraine in germany with our data we are able to reconstruct the crossborder family household constellation of 8604 women aged 18 to 70 years about 23 percent of them arrived together with their partner in germany while 42 percent were single with our approach we are especially interested in the women who are spatially separated from their partner this subsample consists of 3606 women in a first step we show a descriptive overview on the sociodemographic characteristics of these partnered women who came to germany alone and compare these to those who arrived together with their partner and to single women then we zoom in the group of temporarily separated women and focus on family reunion intentions by relying on the question do you plan to bring your partner to germany the answer categories were i cannot answer i do not want to answer yes and no note due to small case numbers in the categories i cannot answer and i do not want to answer were combined in one category for the multivariable analyses we recategorised the answers on intentions into a dichotomous variable distinguishing between all respondents who said yes and all others including those who could not or did not want to answer we carry out a binary logistic regression which models the relationship between a binary outcome variable and some predictor variables it estimates the probability of the outcome belonging to a particular category compared to a reference category we display the results as odds ratios with values below zero indicating smaller odds as compared to the reference and values above 0 indicating higher odds the analyses are presented within stepwise approach beginning with sociodemographics adding region of origin and context of reception and finally intentions to stay in germany results table 1 shows the family constellation of all refugee women in our sample we find that women who arrived without their partner to germany and who have minor children are the biggest group with about 24 percent about 12 percent of the sample are those who arrived with partner and minor children and 14 percent are lone mothers third countries do not play a large role in crossborder constellations of refugee women asked about the location of their partner at the time of the interview 95 percent of the women who were separated from their partner indicated ukraine about 5 percent mentioned another country including a small number in poland table 2 compares the characteristics of women who arrived without their partner in germany to those that arrived with a partner and single ukrainian women with about 68 percent the share of those who arrived with minor children is higher among the spatially separated mothers than among those who arrived with their partner while the sociodemographic patterns of these three groups do not vary substantially their intentions to stay in germany and or to return to ukraine differ significantly across these groups the share of women who said that they intend to stay in germany until the end of the war is the most frequently chosen answer in each group but it is highest within the group of temporarily separated women compared to 30 percent in the group of women who arrived with their partner and 31 percent single women in line with that finding among the women who arrived together with their partner with about 30 percent we found the largest share of those who intended to stay in germany forever this corresponds to 25 percent among single women and only 16 percent among the women spatially separated from their partner it also becomes apparent that uncertainty plays a role within each of the groups as a bit less than 30 percent stated that they dont know how long they intend to stay in germany the answers to the question about return intentions to ukraine produced a largely corresponding pattern between 17 and 20 percent of the women stated that they dont know also validating the notion of uncertainty about 44 percent of the women spatially separated from their partner wanted to return to ukraine but 38 percent indicated not to of the partnered women only 29 percent wanted to move back to ukraine and 53 percent did not want to return at all 3 regarding their intention to family reunion 46 percent of the women spatially separated from their partner said that they intend to bring their partner to germany regarding children in all three groups of women less than 5 percent indicated that they intend to bring children to germany in the majority of cases this would be only one child only few women indicated two or more children table 3 displays the results of the stepwise multivariable analyses model 1 accounting for sociodemographic factors shows that the intentions to bring the partner to germany decreases by age and are higher among refugee women originating from the regions in the east and south of ukraine and crimea the presence of minor children and the family status are not statistically significantly related to reunion intentions model 2 additionally controls for the context of reception in germany refugees who arrived to the eastern part are less likely to intent family reunion in germany importantly however the inclusion of region of living and employment situation hardly affects the relations between the variables included in the first step model 3 additionally accounts for the intention to stay in germany while this does hardly affect the results of the other variables the intentions to stay prove themselves as strongest predictor of family reunion intentions those who plan to stay in germany forever are three times more likely to wish to bring their partner to germany as compared to those who assume that they may stay for a couple of years women who said that they want to stay till the end of the war were also less likely to say that they wanted to bring their partner to germany note the results were basically similar when we used the variable of return intentions instead of intentions to stay and by this corroborate the robustness of our findings however as return and stay intentions are highly correlated we do not use both variables in the presented model conclusion our paper provides an indepth description on family and household structures of ukrainian refugees in germany and an explorative overview of the factors involved in the intention to reunite families in the destination county we used a large representative dataset of refugees who arrived in germany in the first months of the russian invasion in 2022 these ukrainians have specific sociodemographic patterns compared to other migrant groups the majority of adult refugees are 4 female and many of them are either single or spatially separated from their partner around half of the female refugees live with children or adolescents in the age groups younger than 50 years this share is even higher caused by gendered patterns of flight from ukraine a large share of refugee women are lone mothers which is different compared to previous refugee migrations to germany within an overall vulnerable population this group deserves attention because they are faced with more adverse conditions and higher risks than refugees in general eg with respect to physical and mental health social participation and economic circumstances additionally migration theories focus much on voluntary and economic migration while less is known about the perpetuation of migration and familymigration patterns in contexts of forced migration against the background of this specific situation of many separated couples and families with children we analysed womens plans to reunite with their partner and children in germany for children we found that only about up to 5 percent of the women in our sample intended to bring one child to germany only few of them two or more children about 10 percent stated that they did not intend family reunion with children in germany these numbers seem to be rather low compared to other migrant groups yet we think that they provide valuable estimates of further family migration with respect to children because the overall number of children in ukraine is lower compared eg to that in the middle east region and many of the mothers arrived already with their minor and adult children that were legally allowed to migrate in line with that interpretation the majority of the refugee women in our sample said they do not have children living abroad with respect to the partner the situation is different the legal situation of family reunifications may appear more restricted or unclear the individual journeys may be illegal more dangerous and therefore in many cases family reunion intentions may even be impossible to realize yet less than half of the women who were separated from their partner by their flight said that they plan a family reunion in germany with a more finegrained view such reunification intentions appear to be stronger when minor children are in germany as well which separates the children also from their fathers moreover reunion intentions are higher in younger ages and among those from regions which are largely affected by the war at the same time settlement intentions matter even more in a way that those who wish to stay in germany forever as well intend to reunify with their partner in germany overall our findings suggest that the intentions of family reunion do not only depend on individual attributes but also on developments in both countries the intensity length and locality of the war in ukraine and the situation and social participation which refugee women have or anticipate to have in germany both may change in the course of the next months and years perhaps the longer the war lasts and the longer female ukrainian refugees live in germany their intention for family reunion may increase evidence from previous studies suggests that family reunion is also associated with refugees wellbeing their social integration and intention to stay the adaptation process including learning the german language and labour market participation of adults as well as day care and school enrolment of children may contribute to the intention to have a family reunion in germany at the same time different scenarios appear likely with individuals struggling with the loss of their former life causing refugees to return to their home country in future the panel structure within the framework of the bibfreda survey on ukrainian refugees and by this the data of the forthcoming waves will allow us to investigate the developments in the intentions to stay to return and of family reunion over time moreover it will be possible to link these intentions to real behavior because further waves of data collection will follow within the next years therefore in future studies we may be able to not only rely on crosssectional data from the first weeks after the refugees arrival in germany but also to rely on additional information eg on integration processes in germany as well as data on onward migration and crossborder networks and activities to sum up our study provides first quantitative insights on the family structure and family reunion intentions of ukrainian refugees in the first half year after their flight to germany based on unique representative data our analyses show the factors associated with a high desire in this group to reunify their families in germany the high share of women many of them de facto lone mothers and children of the ukrainian refugee population suggests that tailored policies eg child care fullday school language courses employment counselling housing mental health services need to be tailored for their specific situation

since the outbreak of the russian invasion of ukraine about one million people have fled to germany in 2022 due to the genderspecific policies for staying and leaving ukraine the sociodemographic composition of the refugees differs markedly from previous refugee migrations to western europe and from forms of voluntary migration in particular it stands out that about three quarters of the adult refugees arriving in germany were women our paper explores systematically the family constellations of the ukrainians who have fled their country and analyses their familyreunion intentions we use representative data from the first wave of the ukrainian refugees in germany iabbibfredabamfsoepsurvey about 11000 refugees aged 18 to 70 years participated in the survey only about 23 percent of the women arrived together with their partner in germany another 42 percent were single women and 35 percent of the women arrived without their partner descriptive analyses reveal ambiguity and uncertainty regarding their stay and family reunion multivariable analyses reveal that among these spatially separated women intentions for family reunion in germany are particularly high in constellations where the partner lives in more waraffected regions and when the respondents express their intention to stay in germany

19690_0

introduction population aging spawns many significant influences in a society understanding the role of the aging process has become an important issue for both politicians and scholars all around the world many variables can be used to explain health inequalities and it can also operate at various geographic scales the increase in the older population is normally a symbol of living standards and health care improvements however different countries exhibit different patterns take china as an example over 38 years from 1980 to 2018 the life expectancy in china increased by 153 percent when compared with 1950 life expectancy increased by 903 percent 1 the dramatic increase of life expectancy has been driven by three aspects rapid economic growth leading to improvement of living standards and wealth accumulation the baby boom in 1950s and the one child policy in 1980s leading to the growth of older people and the decrease of fertility rate furthermore the improvement in health and longevity of people in china which varies greatly by regions the longest life expectancy in shanghai is 8026 years old while the number is 6817 in xizang 23 the geographic disparities among provinces result in health inequalities in china developed countries are getting older after getting rich whereas china is getting older while getting rich 4 with the negative conditions of poverty and inadequate health care resources china is encountering intense population pressures which can lead to social and financial burdens for people and influence the sustainability of society research suggests that peoples demographic characteristics contribute to the improvement of life expectancy 5 gender interacts with health on many dimensions that produce different outcomes with respect to physical and social contact the most wellknown knowledge is that women live longer than men while they are likely to suffer from elevated morbidity rates research shows that people with lower educational levels report worse health and are likely to die earlier than welleducated people 6 it is because welleducated people will have better financial status and they are likely to have a better sense of selfcontrol compared to less educated people also the relationship between socioeconomic status and health is one of the most widely reported phenomena in the health literature it is well recognized that people with higher ses are healthier than people in lower ses 7 generally there is a positive correlation between income and health outcomes 8 a considerable body of incomehealth related research suggested that better health favors higherincome groups 9 10 11 increasing income inequality affects the health status of the population overall 12 the adverse health impact of income is even worse for older people than for younger groups 13 other characteristics addressing ses include martial status and living arrangements it has been demonstrated that being divorced or widowed is associated with poorer health because of marriage protection and selection effects 14 as people grow older they tend to benefit more from the impacts of marriage married adults are healthier than their unmarried counterparts one of the reasons is that marriage financially strengthens family capacity another mechanism is the marriage selection effect that healthier individuals are more likely to marry and stay married 15 an international comparison on life course adversity and physical performance of older people in four countries showed that older people living alone are associated with low physical performance 16 people living alone are associated with worse health outcomes more research has been conducted to gain more insights into health inequalities as a function of access to health resources 17 people who are able to access wellequipped community or health care centres are likely to report better health outcomes 18 19 20 21 22 health inequalities not only occur between different countries but also occur for population groups within a country most research on health inequalities has been carried out in englishspeaking countries because of the shorter period of economic development and the rapid aging process research on health inequalities is relatively limited in china and there is even less research on older people for instance gender and health inequalities research is conducted with an assumption that individuals are situated within certain social cultural and political contexts the health advantage or disadvantage for females that can be characterized in western industrial countries does not necessarily apply to other countries in china due to the increased population in baby booming in 1950s and the long history of advocacy for the rights of males over females in chinese culture it is interesting to explore if health inequalities are more or less marked between females and males among the older population with regard to the key virtues of filial piety and dutiful payment it suggests that older parents should be taken care of by their adult children and live with their children due to the rapid urbanization process and the migration of the labor force to cities parents cannot live with their children but the influence of the living arrangements on older peoples health is changed and unknown what is more unlike western countries the chinese household registration system is a dual system within this system urban residents enjoy a range of social economic and cultural benefits whereas rural residents do not receive the same benefits 14 this system is closely associated with the social security system that excludes rural residentsmigrant workers from the citywide social security system 23 despite the remarkable research in health outcomes over the past decades there is a limited amount of research on health inequalities in china which deserves more attention chinese health inequalities have their own characteristics where a comprehensive study is urgently needed it is necessary to find out whether the wellestablished health inequality assumptions work in the same way in china or not based on the date from the chinese statistical year book 2018 spatial analysis was applied to identify the spatial clustering of life expectancy and to describe the geographic distribution of health inequalities in china in order to investigate the determinants of health inequalities of older people in china demographic and ses variables were selected from the 2010 population census of the peoples republic of china and the china statistical year book of environment 2010 correlation analysis was conducted to study the relationships between older peoples health status and healthrelated variables materials and methods this study is a descriptive analysis at the national level in china data for this study come from the 2010 population census of the peoples republic of china 1 the chinese statistical year book 2018 2 and the china statistical year book of environment 2010 3 these nationallevel statistics cover all people residing in the territory of the peoples republic of china including 31 provinces autonomous regions and municipalities that have data we do not have data for hong kong macau and taiwan therefore they are excluded from the study the general file is made up of questions that reflect the populations demographic characteristics ses health care utilization characteristics as well as peoples geographic characteristics table 1 summarizes all variables selected from the previous three datasets dependent variable variables health inequalities life expectancy independent variables variables demographic characteristics percentage of older people percentage of younger old percentage of older old percentage of male older percentage of female older ses characteristics income inequalities percentage of people live on minimum living allowances old dependency ratio percentage of illiterate population percentage of divorced and widowed percentage of people with married status ratio between one person and more ratio between one generation and more health care accessibility percentage of hospitals percentage of health care centers health care centers per 1000 population geographic characteristics percentage of nonagriculture hukou all variables selected from the three datasets reflecting characteristics of older people national surveys cover 31 provinces autonomous regions and municipalities that are directly under the central government in china excluding hong kong macau and taiwan based on the date from the chinese statistical year book 2018 spatial analysis was applied to identify the spatial clustering of life expectancy and to describe the geographic distribution of health inequalities in china life expectancy was selected form the chinese statistical year book is an annual statistical which reflects comprehensively the economic and social development of china it covers the key statistical data for the local levels of province in 2018 the use of the latest date of the chinese statistical year book 2018 helps us understand the current situation of life expectancy of older people in china in this research life expectancy is chosen as the dependent variable measured as the average number of years of life expectancy for both females and males in each province life expectancy is understood as the expected number of years to be lived on the average by a particular population at a particular time 24 for a more detailed understanding of how life expectancy is calculated in order to investigate the determinants of health inequalities of older people in china demographic and ses variables were selected from the 2010 population census of the peoples republic of china and the china statistical year book of environment 2010 china conducted the 6th national population census with the participation of 13 billion people of all nationalities the 2010 population census covers all people residing in the territory of the peoples republic of china and the chinese citizens residing outside but not permanently settled down in locations beyond the territory of the peoples republic of china at the census reference time excluding residents of hong kong macao and taiwan and foreigners temporarily staying in the territory of the peoples republic of china territory here refers to the territory of the customs two types of questionnaires were used for the 2010 population census the short form contains items that reflect the basic situation of the population while the long form includes all short form items plus other items such as economic activities marriage and family fertility and housing the china statistical yearbook on environment 2010 was prepared jointly by the national bureau of statistics ministry of ecology and environment and other ministries it is an annual statistics publication with comprehensive data in 2010 and selected data series in major years at the national and provincial levels reflecting various aspects of chinas environmental development variables that reflect older peoples demographic characteristics and ses are selected form those two databases correlation analysis was conducted to study the relationships between older peoples health status and healthrelated variables because this research is a secondary analysis of data by the national bureau of statistics which is available to the public without identifiable information an ethics review of the data collection method is therefore not required the date can be found at the 6th national population census was conducted in 2010 in order to match the census data we selected the china statistical yearbook on environment for the year 2010 in terms of demographic characteristics of older population the percentage of older people indicates the population distribution of older people to the total population in each province the percentage of older old and younger old reflects the age distribution of older people in each province with respect to gender the percentage of female older persons and the percentage of male older persons show the gender distribution in each province it is the ratio between femalemale older people and total population in each province two variables are used to study older peoples income status income inequalities and the percentage of people who live on minimum living allowances the ratio between older people with high income and low income is defined as a general estimate of income inequalities in each province the degree of income inequalities reflects if the income is equally distributed among older people the increased income inequality affects the health status of the population negatively the percentage of people who live on minimum living allowances is a variable of the distribution of absolute wealth of older people in each province the old dependency ratio is calculated as the ratio between the number of older people and the number of workingage people of each geographic unit it is used to reflect the relative financial support for older people a high dependency ratio represents people of working age who face a greater burden in supporting the aging population which can be shifted to reflect the increased needs associated with older people older peoples educational status is measured by the percentage of illiterate people in each province the ratio between older people who cannot read and older population in each province in this research marital status is measured by two indicators the percentage of divorced and widowed is the ratio between divorced or windowed older people and total older population in each province unlike western countries being single is not quite the fashion in chinese culture especially for older people the amount of unmarried older people is very small for this reason we do not have a particular variable for single older people the percentage of people with married status is the ratio between married older people and total older population regarding the living arrangements for older people the ratio between one person and more is used to describe if older people live alone or not it is the ratio between older people who live alone or live with more than one person in addition the ratio between older people living along and living with more than one person is used to describe if older people are physically isolated from their children the percentage of hospitals and health care centers are variables that reflect health care accessibility in each province it is the ratio between the number of hospitals in each province to the total number of hospitals in china the number of health care centers per 1000 population is used as a measure of health care accessibility in each province it is the ratio between the number of health care centers in each province to the number of health care centers in china for most older people in china they tend to stay home and are taken care by their families in this case hospitals and health care centers are only places where older people can get professional medical assistance also we do not have the data for the number of people who visit doctors or take medicine the percentage of hospitals and health care centers and the percentage of health care centers per 1000 population are the most suitable variables to reflect the situation of the health care access that older people have in this research the percentage of nonagricultural hukou is an important variable to reflect the geographic distribution of the older population in each province it is the ratio between people with nonagriculture hukou to agriculture hukou in each province due to the lack of statistical data of older peoples hukou status in this research we used the hukou status in each province to represent the older peoples hukou status the chinese household registration system is closely associated with the social security system that excludes rural residents it is difficult for people with agriculture hukou to change their hukou for this reason older people who live in urban areas may still keep their agriculture hukou we use the variable hukou status in each province only to give a brief presentation for older peoples hukou status this study is conducted following a hypothesis that there are statistically significant relationships between health inequalities of older people and healthrelated variables in china subhypotheses include the more older people are the more income inequalities are negatively related to life expectancy being married is positively related to health outcomes of older people a better health environment helps to narrow health inequalities and people with urban hukou report better health outcomes than rural people statistical analyses are conducted using spss version22 and arcgis version 107 skewness and kurtosis were visually examined against normal distribution and a quantilequantile plot was drawn against the normal curve the result showed that all the variables are normally distributed all the variables to check if all variables are normally distributed pearsons correlation is used to measure the degree of the linear correlation between variables global morans i is a measure of spatial autocorrelation based on both the locations of the variables and attribute values simultaneously it evaluates whether the pattern expressed is clustered dispersed or random the value of morans i ranges from 1 to 1 the closer morans i is to 1 the higher the spatial correlation the closer morans i is to 1 the greater the spatial disparity in our study global morans i is used to evaluate the pattern of spatial clustering of health inequalities of older people in china mathematically morans i is expressed as i n s 0 n i1 n j1 w ij z i z j n i1 z 2 i where z i is the deviation of an attribute for feature i from its mean x i x w ij is the spatial weight between features i and j n is the total number of features and s 0 is the aggregate of all the spatial weights s 0 n i1 n j1 w ij the results of the global morans i analysis are interpreted within the context of its null hypothesis of random spatial distribution when the pvalue is not statistically significant one cannot reject the null hypothesis when the pvalue is statistically significant then the spatial distribution is not randomly distributed a positive zscore indicates spatially clustering of high andor low health inequality of older people in china while a negative zscore indicates spatially dispersion of high values and low values of health inequality of older people in china to complement the global spatial statistics of morans i local spatial statistics the getisord gi is used to evaluate where the clustering or dispersion tested by global morans i is located in addition when the spatial clustering is indicated by global morans i getisord gi can also tell if the clustering is a clustering of highvalue or lowvalue mathematically g i n j1 w ij x j x n j1 w ij n j w ij x j where w ij is the spatial weight between feature i and j positive g i value shows that high values cluster around i hence the region is termed hot spot negative value of g i shows that low values cluster around i hence the region is termed cold spot results the description of variables in this research indicates that all variables are normally distributed figure 1 illustrates that the variable life expectancy is normally distributed n 31 table 3 summarizes the values of the dependent variable and figure 2a illustrates the spatial distribution of life expectancy of older people in china we input all the variables into the software spss vision 22 to check their distribution table 3 summarizes the values of the dependent variable and figure 2a illustrates the spatial distribution of life expectancy of older people in china we input all the variables into the software spss vision 22 to check their distribution correlation analysis is used to describe the strength and direction of a linear relationship between two variables in this research correlation analysis is conducted with the dependent variable and each independent variable separately the correlation coefficient significant level and cases number are showed in table 4 results of the correlation analysis indicate negative correlations between older peoples life expectancy in the provinces from the east of china is obviously longer than that in the central and western provinces the province with the longest life expectancy is shanghai followed by beijing and tianjin on the contrary provinces with shorter life expectancy are mainly clustered in west china which are the developing areas the three provinces with the shortest life expectancy are xizang yunnan and qinghai figure 2a shows the spatial distribution of life expectancy in china at the national level correlation analysis is used to describe the strength and direction of a linear relationship between two variables in this research correlation analysis is conducted with the dependent variable and each independent variable separately the correlation coefficient significant level and cases number are showed in table 4 results of the correlation analysis indicate negative correlations between older peoples life expectancy and percentage of people live on minimum living allowances percentage of divorced and widowed and percentage of health centres according to cohens 25 interpretation of the correlation coefficient results suggest strong relationships between life expectancy and the percentage of older oldpeople gender variables income variables living arrangement variable the percentage of health care centres and the percentage of nonagriculture hukou a weak relationship is found between life expectancy and the educational variable the pvalue of morans i is 00001 less than 001 indicating that the result of morans i is statistically significant at a 99 percent confidence level meaning that the life expectancy of older people in china is not randomly distributed the zscore is positive and larger than the zscore at 99 percent confidence level of 258 indicating that life expectancy of older people in china is clustered ie areas with both high and low life expectancy tend to be close together respectively the value of morans i is positive indicating that the value of life expectancy is positively correlated while global morans i shows the general trend getisord gi shows the spatial pattern in local neighborhoods the result of getisord gi showed multiple areas of statistically significant highhigh clustering in the eastern china and lowlow clustering in western china shanghai and beijing are the highhigh outliers indicating that life expectancy in shanghai and beijing are low while in the surrounding provinces are high there is no highlow outlier for the other provinces no significant correlation can be detected figure 2b shows that there are both high significant hot spots and cold spots for life expectancy for older people at the national level the hot spots indicate that older people with longer life expectancy are mainly concentrated in shandong jiangsu and anhui provinces while older people with shorter life expectancy are more likely to distributed in the cold spot provinces for the same reason older people in the medium significant hot spots have shorter life expectancy than those in the most significant hot spots older people in the medium significant cold spots have longer life expectancy than those in the most significant cold spots discussion the spatial distribution of life expectancy of older people indicates health inequalities exist at the national scale in china an increasing tendency of health inequalities can be seen from east coastal provinces to west remote provinces in china the spatial distribution of health inequalities corresponds to the variant economic development between eastern and western china from the descriptive analysis there are statistically significant relationships between health inequalities of older people and healthrelated variables in china correlation coefficients are used to measure the strength of the relationship between two variables results show that strong positive correlations can be found between life expectancy and the percentage of older oldpeople as well as gender differences being consistent with subhypotheses the more older people the longer the life expectancy the chinese demographic policy the one child policy as a source of unintended consequences for population aging contributes to the increase of life expectancy in china besides demographic changes older peoples income status and the living arrangements also have strong relationships with their life expectancy the negative strong relationship between life expectancy and percentage of people who have minimum living standards indicates that increasing income inequality affects the health outcomes of older people and the impact of lower income is even worse on older peoples life expectancy economic reform results in an increase of income which is unevenly distributed corresponding to the growing tendency of life expectancy of older people in china a strong relationship was found between life expectancy and the hukou status which is consistent with the hypothesis that people with urban hukou report better health outcomes than rural hukou people a medium correlation between life expectancy and older peoples marriage status was found as reported in the hypothesis being married has a positive influence on older peoples life expectancy while being divorced or widowed is negatively related to health outcomes of older people with respect to health care accessibility all variables were correlated with older peoples life expectancy older people with better health care resource are more likely to report better health demonstrating the hypothesis that a better health environment helps to narrow health inequalities consistent with the literature review the descriptive analysis suggests that variables selected in this study have influence on older peoples life expectancy contrary to hypotheses results indicate that older peoples education level and their marriage status do not have significant influence on their life expectancy a more accurate description of the effect of educational and marital variables is needed for further research the database for this research did not cover all of the provinces the excluded provinces are hong kong macau and taiwan these provinces are the welldeveloped provinces and have the best health outcomes in china the excluded data might be a problem in generalizing results from this research according to the getisord gi analysis of life expectancy of older people in china it is interesting to notice that shanghai and beijing with the longest and the secondlongest life expectancy are neither identified as the hot spots nor in cold spot spots it is possible that getisord gi examines each feature in the neighborhood environment to be a hotspot with statistical significance a feature will have high value and be surrounded by other features having high values the local sum of life expectance in a province is compared proportionally to the sum of all provinces when the local sum of life expectance is so different from the expected local sum and when that difference is significantly large so that random chance can be ruled out we say that the local life expectance is a hotcold spot this finding can address more discussion with respect to socioeconomic or human perspectives conclusions to study the determinants of health inequalities of older people in china and provide a context for the analyses in section 4 and 5 a descriptive analysis was carried out data are measured at the provincial level all variables reflect older peoples demographic ses the health care accessibility and geographical characteristics in china as predicted older people financial situations marital status health care assistance and hukou status play significant roles in determining older peoples health outcomes older peoples educational level impacts life expectancy differentially as predicted it could be because that most older people did not receive good education in their youth there is a spatial distribution of health outcomes for older people at the national level provinces with longer life expectancy are mainly clustered in east china on the contrary provinces with shorter life expectancy are mainly clustered in west china older people from the coast areas often have better health status than people from plateaus the spatial distribution of health inequalities for older people corresponds to the spatial distribution of economic development in china in terms of life expectancy result shows an uneven spatial distribution among older people in china the east coastal provinces have better health outcomes than western remote provinces how the geographical pattern of health inequalities works among individuals at different geographic scales needs to be investigated at finer levels based on the getisord gi analysis of healthy life expectancy at the national level shanghai and beijing with the longest life expectancy are not considered as hot spots the reason is that there are socioeconomic differences between the megacities and the neighboring provinces there is a positive correlation between socioeconomic status and health status the better the socioeconomic status the better the health status shanghai and beijing as the most developed cities therefore have the best health status in china due to the matthew effect megacities receive an disproportionate amount of health resources while the neighboring areas can only receive a relatively small amount of resources the consequence is that neighbouring areas cannot develop as well as megacities and life expectancy in those areas cannot be long enough as in megacities regional imbalanced development could result in health inequalities in order to eliminate health inequalities at the national level it is necessary to eliminate socioeconomic differences among provinces this research contributes an overview of chinese health inequalities for older people it demonstrates that the demographic and economic policies have an influence on the increase of life expectancy and the uneven distribution of health outcomes of older people for further research and investigations should be conducted among individuals at microgeographic scales author contributions mwr and my conceptualized the research questions mwr and jl conceptualized the general methodological strategy my and jl conducted the analyses my drafted the paper and mwr and jl provided direction and advice during the drafting of the paper all authors have read and agreed to the published version of the manuscript

china is facing serious population aging issues because of many unintended consequences of the economic reforms that began in the 1980s and with social policies such as the one child policy understanding the spatial distribution of the health status of older people has attracted more and more attention in many countries including china by employing descriptive analysis this study uses data from the chinese population censusand statistical year bookto explore the health inequalities of older people at the national level based on the getisord gi this study finds that the uneven spatial distribution of socioeconomic status results in health inequalities for older people at the national level the geographic distribution of life expectancy was correlated with a number of important demographic socioeconomic and environmental variables for further research investigations should be conducted among individuals at microgeographic scales

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introduction a large number of studies have shown that low socioeconomic position in both childhood and adulthood is a risk factor for cardiovascular disease 1 2 3 4 5 life course studies have suggested that the impacts of socioeconomic factors on cardiovascular outcomes may accumulate across the life course 6 7 8 however the transitionary period of early adulthood has typically been overlooked despite it being considered a key time of social and economic transition where inequalities can emerge 9 early adulthood is an important time for cardiovascular health 10 life transitions which occur in early adulthood for example finishing education starting employment or starting a family contribute to changes in key risk factors for later cardiovascular health including lifestyle behaviours such as physical activity and diet 11 12 however the transitory nature of early adulthood when individuals may be moving in and out of education and shortterm employment before settling into a longer term occupation means that assessment of sep at a single time point will not be reflective of experiences across the entire early adulthood period in this study we investigate the contribution of early adulthood sep to cardiovascular health in midadulthood using data from the 1970 british cohort study we make use of longitudinal data on participation in education employmentunemployment and social class of employment from age 16 to 24 years to generate socioeconomic trajectories across this early adulthood period our hypothesis is that the socioeconomic exposures of early adulthood contribute to cardiovascular outcomes independently of later adulthood sep to test this we will address the following research questions 1 what are the different socioeconomic trajectories followed across early adulthood 2 what is the contribution of these trajectories to cardiovascular health in midadulthood 3 to what extent does sep at age 46 years mediate this association methods survey design and participants the bcs70 13 16 those who were economically inactive were grouped together to distinguish these from those who were unemployed and seeking work since the sep of those economically inactive by choice is likely to be different from those looking for work of the episodes of economic activity classified as economically inactive the majority were looking after homefamily and a further 19 travellingextended holiday although these represent different exposures we did not attempt to separate these groups due to the small numbers involved we then brought together data on economic activity and occupational social class to categorise each period of activity into one of nine categories this method allowed us to incorporate two commonly used measures of sep into a single measure that could be captured longitudinally the activity that was conducted for the longest period of each year of age from age 16 to 24 years inclusive was used as the primary activity for that year outcomes cardiometabolic risk factors we studied the following metabolic risk factors measured at age 46 years waist circumference systolic blood pressure diastolic blood pressure blood triglycerides highdensity lipoprotein cholesterol nonhdlc glycated haemoglobin and c reactive protein further details of risk factor measurement are provided in the online supplemental methods measures of hdlc triglycerides and crp were logtransformed as these variables were positively skewed covariates and descriptive variables two groups of covariates were included in the analysis statistical analysis longitudinal latent class analysis was conducted using mplus v84 to generate classes of individuals based on their participation in different economic activities over time all individuals who had economic activity data from any year from age 16 to 24 years were included we added classes to the model sequentially from one to eight classes when the model failed to converge the final number of latent classes used for the analysis was selected based on fit statistics together with the interpretability of the classes generated 18 missing data were addressed using full information maximum likelihood estimation given high classification accuracy most likely class membership for each individual was extracted from the latent class model and used as a categorical exposure for further analyses descriptive analyses and regression models were performed using stata v16 all individuals who had data on economic activity were included in subsequent analyses associations between latent classes and metabolic risk factors were tested using ordinary least squares linear regression analyses were conducted separately by sex given differences in both class membership and health outcomes by sex missing covariate and outcome data were imputed by chained equations 19 20 we included as auxiliary variables sep at birth variables on mental and physical health at ages 10 and 16 years and additional health variables from age 42 and 46 years creating 20 imputed datasets we performed joint tests of coefficients across the socioeconomic trajectory classes to assess the overall effect of socioeconomic trajectory class on each of the outcome variables the stata mimrgns command was used to calculate the average predicted value of each outcome for each socioeconomic trajectory class to investigate the added value of the longitudinal sep data we also assessed associations between sep measured at age 24 years only and metabolic risk factors using the same imputation and covariates as in the main analysis to examine mediation of associations by sep at age 46 years we used path models in mplus v84 in addition to the direct regression path of cardiometabolic risk factors on socioeconomic trajectory class we added two indirect paths from socioeconomic trajectory class to cardiometabolic risk factor via occupational social class and via equivalised household income a path from nssec to income was also added to account for the likely contribution of occupational social class to household income each outcome was considered separately adjusting for the same confounding factors as used in the regression analyses results early adulthood socioeconomic trajectories fit statistics for the latent class analysis continued to improve with addition of classes at a decreasing rate up to seven classes beyond which the model failed to converge examination of the response probabilities of participation in different economic activities in the 6 class and 7 class solutions revealed that the 6 class solution was more interpretable and this solution was therefore chosen for subsequent analysis the 7 class solution included similar classes to the 6 class but added a small class which mixed people participating in professional employment unskilled employment and unemployed as shown in figure 2 the 6 class solution included a continued education class many of whom continued in education after age 18 years and entered professional managerial or skilled nonmanual occupations classes 25 were largely differentiated by the type of occupation conducted class 6 was the smallest group who were primarily economically inactive towards the end of the early adulthood period entropy of the latent class model was high at 097 suggesting high classification accuracy comparison of membership of each socioeconomic trajectory class with assessment of their sep at a single time point is shown in online supplemental table s3 although there is overall high correlation between these measures there are also differences based on the ability of the socioeconomic trajectory classes to capture longitudinal information across the early adulthood period in particular we find that the continued education figure 1 path model of direct and indirect associations between early adulthood socioeconomic trajectory class and cardiometabolic health at age 46 years models were additionally adjusted for covariates measuring childhood socioeconomic position and adolescent health original research class includes those reporting professional managerial or skilled nonmanual employment at age 24 years the partly skilled class also combines those unemployed or in unskilled partly skilled and skilled employment at age 24 years in addition those unemployed or with missing data at age 24 years are assigned to many different socioeconomic trajectory classes based on their economic activity across the early adulthood period table 2 reports differences in sociodemographic characteristics between the socioeconomic trajectory classes class 3 skilled nonmanual were more likely for women while class 4 skilled manual were more likely for men class 6 economically inactive included primarily women who were partnered and around 45 had children associations between socioeconomic trajectory class and cardiometabolic risk factors analysis showed differences in risk factors between socioeconomic trajectory classes for waist circumference sbp hdlc triglycerides and crp continued education represented the healthiest class with differing levels of risk factors seen between this class and the remaining classes across most outcomes cardiometabolic risk factors were less differentiated across the remaining socioeconomic trajectory classes although patterns varied by outcome the economically inactive class although in general high risk across many of the outcomes showed low sbp and dbp among women comparable with the continued education class figure 3 shows the estimated marginal means of each outcome by socioeconomic trajectory class for comparison we report associations between cardiometabolic risk factors and sep at a single time point at age 24 years the continued education class cannot be identified using sep measured at age 24 years so the difference in risk factors between this class and the remaining classes cannot be observed for those in managerial employment and skilled nonmanual employment at age 24 years slightly lower levels of risk factors are estimated than using the corresponding trajectory classes likely because these sep groups include some members who would be included in the continued education class similarly those who report being economically inactive at age 24 years show smaller associations with some cardiometabolic risk factors than those in the economically inactive class which captures prolonged economic inactivity mediation of associations by occupational social class and income at age 46 years investigating mediation of associations between early adulthood socioeconomic trajectories and cardiometabolic risk factors by occupational social class and income at age 46 years showed that for most outcomes tested the indirect path via both of these mediators was small with cis that spanned the null the exception to this was for hdlc where there was evidence of an indirect effect via nssec at age 46 years but this was in most classes of a lower magnitude than the direct effect crosssectional associations between occupational social class or income and cardiometabolic risk factors at age 46 years were much reduced after adjustment for early adulthood socioeconomic trajectories as shown in online supplemental table s7 discussion main findings this study identified six classes of individuals who follow different socioeconomic trajectories during early adulthood in our population born in the uk in 1970 we found one highly educated class four classes based primarily on occupational social class and one class which was economically inactive these early adulthood socioeconomic trajectory classes were associated with cardiometabolic risk factors in midadulthood with the largest differences seen between figure 2 the six socioeconomic trajectory classes showing response probabilities for participation in different economic activities at each year of age original research the continued education class and remaining classes these associations were largely not mediated by sep at age 46 years suggesting an important independent role of the early adulthood period in determining cardiovascular inequalities in later life comparison with previously reported evidence while a wide range of previous studies have reported associations between sep and cardiovascular health 13 21 22 few have considered the contribution of the life stage of early adulthood this is likely due in part to the difficulty of measuring sep over this period when individuals may be in education in transient employment or economically inactive often not yet settling into stable occupations 23 comparable studies in other cohorts using a similar methodology to our own have not been conducted nevertheless previous studies have shown associations between education level attained and metabolic syndrome 24 25 or coronary heart disease 26 a study of the 1946 british birth cohort which investigated relationships between education level as well as childhood and adult social class with metabolic syndrome reported a contribution of educational inequalities in the development of metabolic syndrome independent of childhood and adult social class 26 more recently mendelian randomisation studies have suggested a causal effect of educational attainment on bmi sbp and cvd 27 28 these findings are consistent with our own findings regarding the independent role of early adulthood sep for later cardiovascular health and an important contribution of education in defining early adulthood sep further analysis of the 1946 british birth cohort which included a binary measure of occupational social class at age 26 years as a marker of sep in early adulthood found that accumulation models which included early adulthood sep together with childhood and middle age sep provided the best fit for original research figure 3 modelled mean values for each cardiometabolic outcome by early adulthood socioeconomic trajectory class red is female blue is male hdl highdensity lipoprotein original research predicting cardiometabolic risk factors among women 8 and predicting measures of cardiac structure and function in both sexes 29 while these papers used a measure of occupational social class in the late 20s which lies outside the age range which we consider as early adulthood their findings are consistent with our own finding of an important role for young adult sep we found that midadulthood social class contributed only marginally to inequalities in cardiometabolic risk factors following adjustment for childhood and early adulthood social class although this may seem surprising a study of the 1946 british birth cohort also found that associations between adult social class and the metabolic syndrome were attenuated below significance after adjustment for childhood social class and education level 26 in this study we used a more comprehensive measure of early adulthood sep which accounted for more than education level therefore we might expect associations to be further attenuated than seen previously overall the size of the inequalities observed in cardiometabolic risk factors in this study are of considerable relevance for public health for example between the continued education class and the partly skilled class in men we see a 3 cm difference in waist circumference which has previously been associated with a 6 increase in the relative risk of a cardiovascular event 30 and a 2 mm hg increase in sbp associated with a 7 increased risk of vascular mortality 31 strengths and limitations the strengths of this analysis lie in both the data and the methodology the detailed data on economic activity reported by the bcs70 cohort allowed us to develop a new method to determine trajectories of early adulthood sep these trajectories incorporate education participation and occupational social class data collected across early adulthood thereby providing a more comprehensive measure of early adulthood sep which allows for nonlinear as well as traditional pathways into adult work this method also allows inclusion of all participants who contributed sep data at any time point during early adulthood the long followup of bcs70 allows examination of cardiometabolic risk factors much later in adulthood likely to be highly relevant for cardiovascular morbidity and mortality nevertheless our early adulthood trajectories necessarily represent the pathways followed by those born in 1970 which may differ from those that experienced by more contemporary early adulthood populations the bcs70 is a large birth cohort with a sampling frame designed to represent the population of great britain born in 1970 as with all birth studies there has been attrition over the course of the study with differential attrition by sex and parental socioeconomic class 32 creating potential for introduction of bias we included in our analysis all those who remained in the study during early adulthood imputing missing outcome data and controlling for childhood covariates including those known to be associated with attrition there is no reason to expect that participants lost to the study during childhood and adolescence differed in terms of their midadulthood cardiometabolic risk factors from those of similarly disadvantaged backgrounds who remained in the study until early adulthood there remains the possibility that our findings may be biased due to either measurement error or unmeasured confounding despite inclusion of several different measures of childhood sep and adolescent health as covariates it may be that there remains residual unmeasured confounding there is also the possibility of unmeasured confounding of mediatoroutcome associations in our mediation model however given the small associations between mediators and outcomes we judge this unlikely to introduce significant bias sep is difficult to measure making it possible that our exposure classes do not accurately reflect all aspects of sep nevertheless we believe that this study improves on previous studies which consider only a single measure of early adulthood sep for example educational achievement or occupational social class at a single age providing a more appropriate overview of sep across the early adulthood period the differences observed between associations using our socioeconomic trajectories and a single measure of sep at age 24 years suggest that assessment of sep across early adulthood is a more comprehensive measure highlighting the importance of the continued education class and avoiding misclassification based on measurement of status at a single time point to generate the socioeconomic trajectory classes we incorporated education based on educational participation over time but were not able to include the level of education undertaken since these data were not available we therefore assume that for most participants educational participation at older ages will correspond to participation at a higher level we have also focused on participation in education and employment and occupational class and have grouped together those who were economically inactive for any reason other than education in this analysis we are therefore not able to distinguish between those who are looking after home or family travelling or unable to work through sickness or disability and there may therefore be subgroups within the economically inactive class who would show different associations with the cardiometabolic risk factors interpretation of findings socioeconomic inequalities in health have been suggested to act through either behavioural material or psychosocial pathways 33 shortterm associations between early adulthood sep and cardiovascular health may act through any of these three pathways and are supported by recent research from the cardiovascular risk in young finns study which reports a shortterm association between young adults sep with carotid intimamedia thickness a marker of subclinical atherosclerosis 34 in addition since early adulthood is known to be an important time for development of healthrelated behaviours 35 36 and psychosocial factors 23 early adulthood sep may contribute to development of health behaviours or psychosocial factors which then track through adulthood and have ongoing longterm effects on cardiometabolic risk factors our finding that early adulthood sep is not mediated by sep in midadulthood suggests that material factors in midadulthood do not form part of the pathway by which early adulthood sep might contribute to midlife cardiovascular inequalities further research will be needed to understand the contribution of pathways a and b depicted in figure 4 conclusions and implications of the findings our research suggests that early adulthood is an important period for the generation of inequalities in later life cardiovascular health this suggests a need for further study of this developmental stage of early adulthood to support health policy and interventions which aim to improve cardiovascular health and reduce inequalities despite the difficulty of measuring sep in early adulthood we provide a method for identifying original research early adulthood sep which may be adapted for use in different cohorts our finding that early adulthood sep is not mediated by measures of sep in midadulthood suggests that other pathways are involved with further research needed to understand and delineate these possible pathways what is already known on this subject ► socioeconomic inequalities are a key contributor to differences in cardiovascular health with the impact of socioeconomic inequalities thought to accumulate across the life course we know that early adulthood is an important time for both the development of adult socioeconomic position and for development of behaviours related to cardiovascular health however previous life course studies of cardiovascular health inequalities have not included a measure of socioeconomic position covering the transitional early adulthood period what this study adds ► this study develops a new method to assess socioeconomic position across the early adulthood period and relates this to midlife cardiovascular health the study shows that the early adulthood period is an important period for development of cardiovascular health inequalities largely driving the crosssectional associations between socioeconomic position and cardiovascular risk factors observed in midlife this suggests that further intervention during the early adulthood period is needed to prevent development of inequalities in cardiovascular health in later life twitter eleanor m winpenny eleanorwinpenny contributors emw designed the study performed the analyses and drafted the manuscript kt and lh advised on the statistical analysis all authors commented on the analysis plans contributed to the interpretation of results made comments and edits to the manuscript and read and approved the final manuscript competing interests none declared patient consent for publication not required ethics approval supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

background cardiovascular health shows significant socioeconomic inequalities however there is little understanding of the role of early adulthood in generation of these inequalities we assessed the contribution of socioeconomic trajectories during early adulthood 1624 years to cardiovascular health in midadulthood 46 years methods participants from the 1970 british cohort study with socioeconomic data available in early adulthood were included n12 423 longitudinal latent class analysis identified socioeconomic trajectories based on patterns of economic activity throughout early adulthood cardiometabolic risk factors 46 years were regressed on socioeconomic trajectory class 1624 years testing mediation by adult socioeconomic position 46 years models were stratified by sex and adjusted for childhood socioeconomic position sep and adolescent health results six early adulthood socioeconomic trajectories were identified 1 continued education 202 2 managerial employment 160 3 skilled nonmanual employment 209 4 skilled manual employment 189 5 partly skilled employment 158 and 6 economically inactive 81 the continued education trajectory class showed the best cardiovascular health at age 46 years with the lowest levels of cardiometabolic risk factors for example systolic blood pressure was 1289 mm hg 95 ci 1278 to 1300 among men in the continued education class compared with 1313 mm hg 95 ci 1304 to 1322 among men in the skilled manual class patterns across classes 26 differed by risk factor and sex the observed associations were largely not mediated by sep at age 46 years conclusion findings suggest an independent contribution of early adulthood socioeconomic trajectories to development of later life cardiovascular inequalities further work is needed to understand mediators of this relationship and potential for interventions to mitigate these pathways

19692_0

discussed what it would mean to be not independent in later life replies referenced other people in general specific people or ones own potential experience pooled across sites the views of our participants confirm the theorized features of the social imaginary participants spoke readily of gateway infirmities heralding frailty and of frailtys abjection expressed dread and abhorrence of dependence some saying that death would be preferable and were anxious about nursing homes and about burdening others with an obligation to care for them in all the bleak but formidable reputation of the fourth age impinges on those living in the third raising apprehensions about the future at the same time perhaps this prospect of unwanted old age can function as adaptive motivating efforts to maintain bodily and cognitive integrity to plan for the future to cultivate support networks or to savor the present fourthage studies that document the lived experience of frailty and dependence have the potential to undermine the social imaginary and furnish new narratives for facing the future the world health organization has designated this the decade of healthy ageingfocused on developing and maintaining functional ability that enables wellbeing in older age we developed the healthy aging initiative a prospective cohort study of adults 55 measuring functional ability going beyond a diseasefocused model of population ageing to holistic intrinsic capacity and environmental context a multidisciplinary team of geroscientists developed a protocol of subjective and objective assessments evaluating several known modifiable risk factors for disability and dementia mobility strength functional status and mental wellness by tracking these domains annually we influence participant health trajectories with timely actionable feedback and gain insight into causal factors that impact functional ability creating a blueprint for translational clinical research in healthy ageing a feasibility pilot was conducted within two affiliated older adult living communities the revision process included evaluating specificity sensitivity and utility of all assessments and accounting for participant suggestions the majority of pilot participants perceived benefit from the assessment and would participate again despite 43 reporting the length as challenging results were used to revise the protocol content and process including reducing assessment time from 2 hours to 40 minutes and completing surveys over the phone we have begun the full roll out into all affiliated older adult living communities and will have second annual assessments in the upcoming months

during the covid19 pandemic older adults and their caregiverscare partners hereafter referred to as caregivers experienced social isolation reduced autonomy disruptions in medical care and barriers to communitybased services such as adult day centers we compare the extent to which these disruptions affected white black and hispanic caregivers we utilize newly released data on adult children caregivers from the caregiver supplement to the hispanic establish population for the epidemiologic study of the elderly hepese cg 2021 and the national health and aging trends covid19 family members and friends dataset nhats ff 20202021 to compare caregiver emotional wellbeing and financial strain among nonhispanic white nh white n327 nonhispanic black nh black n57 and mexican american n57 adult children caregivers results reveal that a larger fraction of nh black and mexican american caregivers reported financial strain than nh white caregivers and that more mexican american caregivers reported loneliness and depression than other groups of caregivers for mexican american caregivers those reporting lower financial wellbeing tended to be younger for nh black caregivers there were no significant predictors of financial strain or wellbeing finally nh white caregivers were younger and more likely to be female and nh white dementia caregivers reported more financial strain and loneliness than nh white nondementia caregivers taken together this work provides valuable insight into the role of the covid19 pandemic in exacerbating caregiver health disparities among caregivers and provides valuable insight as well as to the highimpact intervention points for caregivers from minoritized populations

19693_0

introduction information according to scholars is regarded as an asset raw material and resource that can enrich an individual or organisation to achieve a desired goal and purpose this assertion could be attributed to the power of liberation that comes from information especially to the vulnerable sect like women in the society of developing countries timely access to needed information has transformed ways in which different activities including farming operations are being carried out access to the right information as resources is presently being engineered by information and communication technologies as fundamental instruments of economic and human growth currently icts have become catalysts for the global sustainable development of nations most importantly the dissemination of reliable fast accurate clear timely and concise information that is directed to the right audience such as rural women at a given period rural women possess one percent of the worlds property even though they mostly work round the clock this could be attributed to the level at which rural women have access to the right resources like land labour and capital including the right information for immediate use in their surrounding environment however rural women need ample information on their livelihood household health and security among others adequate accessibility to information resources in those areas makes them to be fulfilled and in return will enhance their livelihood productivity and the status of their material wellbeing and vice versa information as a key factor among the productive resources is needed for the proper functioning of all other production factors at the rural womens disposal hence information could be regarded as power through its ability to create wealth including material resources when it has in its totality however efficient information and communication procedures are preconditions for achieving economic growth by rural women especially via the use of icts like mobile phone radio and television that has been affirmed to be the most available accessible and used icts by rural women however other interpersonal sources through which rural women seek information aside from using icts include husbands children friends neighbours cooperative society health workers associations community leaders religious leaders and extension agents hence sourcing for the right information in a given period of rural women might be a function of their scope of production years of farming experience social group belonging and their cosmopolites among others information sourcing by rural women is a worthwhile exercise if such information at a given period will be the one that will enhance the material wellbeing and the sustainable development of rural women in its entirety in the rural communities of developing nations women have a need of developmentaloriented information in religion health agriculture education environment economic social safety and sport these women diversify their livelihoods with the motive of fulfilling the need of their households however their agricultural involvement has been across the value chain and hence might need information resources based on the activities involved in their agricultural endeavours especially on maize and cassava production which has been the crop that is mostly grown by this group of women the crops are commonly grown intercropped with each other by women to give a better return on the fixed resources accessed for the subsistence agriculture they often practised however rural women have not fared well in their agricultural engagements due to limited access to relevant assets like education capital land and importantly information resource which has become one of the essential basic needs of human also they encountered some constraints in accessing the information especially the icts sources these include household commitment inadequate technical knowledge network problem inadequate finance inadequate incentives inadequate exposure language problem poor rural infrastructure lack of technical knowhow low literacy level among others studies have shown that rural womans legal rights were being denied because of the rate at which they have access to information resources that affect their livelihood and this has been a factor in the current status of the rural womens material quality of life in southwest nigeria hence the need to probe into the livelihood information resources as a correlate of material quality of life among women farmers in southwest nigeria furthermore the study examined the livelihood information endowment profile identify the constraints to livelihood information resources and assess the material quality of life status of the respondents it was hypothesized that there is no significant influence of the selected independent variables on the material quality of life of rural womens status in the study area methodology southwest nigeria was the study area where 384 respondents were selected with a multistage sampling procedure in the first stage half of the six states in the region were selected the second stage involved the stratification of the local government areas in the selected states into rural and urban giving four 28 and 12 rural lgas in lagos oyo and ekiti states respectively 2017 thereafter a simple random selection of 20 of the rural lgas in the selected states was made at the third stage to have one six and two lgas in lagos oyo and ekiti states respectively with 1206374 women 2016 in the fourth stage proportionate random sampling of 00318 households of the estimated rural women population was done using krjecie and morgan sample size approach giving 384 functional available women as the unit of analysis the livelihood information endowment of the respondents was measured using the livelihood information sought and the livelihood information sources used as follows livelihood information sought was captured with 12 information items with response options of always occasionally to the least extent or never with a maximum score of 36 and minimum score of zero while the livelihood information sources was captured with 14 information sources with the response options of daily weekly monthly yearly or never the highest score drivable was 44 and the least was zero thereafter an index of livelihood information endowment was calculated and was used to categorise the respondents into high and low categories using the greater than and lower than with the mean criterion twenty constraints faced in pursuit of livelihood information endowment were captured with the response options of serious constraint slight constraint and not a constraint with the minimum and maximum scores obtained being zero and 40 the weighted mean score was calculated and was employed to assign positions to the limitations in order of severity the material qol domain of the respondents was measured with material wellbeing and ranking of material possessed in comparison with contemporaries and mates material wellbeing was captured with a set of nine questions which include the type of house lived while ownership of the apartment lived the type of material used to build the house lived the type of roofing used for the house they lived the sources of safe water for drinking source of household energy type of toilet facilities in the house lived were captured nominally the presence of a fence in the house lived and personal land ownership was measured with yes or no response options material wealth possession compared with age mates and contemporaries was captured with eight possible material wealth items possessed compared with their age mates using the response options more than almost anyone more than most people about average less than most people and less than almost anyone with maximum and minimum scores obtained being 4000 and 800 respectively the weighted mean score was used to rank the material possessed in order of acquisition thereafter an index of material qol domain was generated and was used to categorise the respondents into high and low categories using the greater than and lower than the mean criterion the minimum and maximum material domain index score obtained were 018 and 1667 respectively socioeconomic characteristics such as social group belonged cosmopoliteness years of formal education and years of experience in nonagricultural activities of the respondents were measured accordingly result and discussion livelihood information endowment livelihood information sought table 1 shows that the most frequently sought information was religious information health information and agricultural with the least being sports information this shows that various kinds of livelihood information were available to the respondents however the study further implies that rural women cherished seeking religious information and health information above agricultural information while they do not frequently seek political legal and sports information the reasons for the above might be due to the fact that women are generally more devout to their religious beliefs and more spiritual than their male counterparts in the same vein rural womens second top choice of health information may be due to the womens reproductive roles as the first nurse and the health personnel in their various home while the less interest in sport issues was as a result of the economic and personal issues as asserted by however the result of isaya et al is not in tandem with the finding of this study as religious information was found to be the information sought by rural women nevertheless rural women needed to be encouraged to seek sports information since this can enhance their health and wellbeing as well as enable them to be active in carrying out their livelihood activities sources of livelihood information table 2 shows that ictbased livelihood information was mostly sourced with the mobile phone radio and television while the most prominent interpersonal linkages were husband friends and children this implies that available livelihood information is accessible to the respondents via icts tools and interpersonal sources the outcome of this study is in tandem with the study report of isaya et al in which the most accessible source of icts was a mobile phone but at variance with the outcome of the national population commission nigeria and icf 2019 survey in which the most accessible icts source in southwestern nigeria is the radio however the information source available to the respondents is in tune with the assertion of isaya et al in which all the respondents chose their husbands as the most important information source this implies that the respondents spouses do not hoard information from them suggesting that womens developmental information could as well be channelled to them using the male group in the rural communities as conduits table 2 shows the overall level of livelihood information endowment of the respondents with an overall mean of 709±210 which was high for 557 of the respondents this implies that the respondents have ample access to information sufficient to enhance their livelihood for better material possession source field data constraints to use of livelihood information endowment the result in table 3 shows that the most prominent constraints to the use of livelihood information were network problems poor rural infrastructure and inadequate technical knowledge the result implies that the limitations to the utilisation of livelihood information may reduce the technical capacity and could discourage rural women as well as create a nonchalant or unfavourable attitude to seeking livelihood information hence digital literacy that will enhance the respondents skills for better access to livelihood information is needed as suggested by fao it is of great notice that rural women have the same disposition to inadequate finance and inappropriate programme scheduletiming which was ranked fifth meaning that both constraints constituted hindrances to rural womens livelihood information generation at the same rate however it is worth noting that neither culture nor religion has been a serious barrier to the livelihood information gathering being the least constraint identified by the respondents this upholds the earlier finding of this study in which religious information ranked first among the livelihood information gathered however the constraints faced by rural women are issues that were brought about by insufficient ineffective and inefficient services rendered by icts stakeholders coupled with insufficient digital literacy of the respondents these findings are in line with that of awhareno and nndail and akintunde that network problem hinders the optimum utilisation of livelihood information in rural communities material quality of life material wellbeing domain the result in table 4 shows that rural women live mostly in rooms and parlours and apartments mostly built and owned by their spouses as most of them did not possess landed properties the respondents mostly dwelt in a house built with cement bricks roofed with zinc sheets with cemented floors but without fence this suggests that many women have an appreciable comfortable habitat though with poor house ownership status due to a global disparity in accessibility and allocation of resources like land among women and men in rural communities this is in tandem with the study outcome of adeleke and alani in which the least wellbeing of rural women was on housing facilities and in consonance with the finding or report of fao that houses were not personally owned by most of the femaleheaded households in rural settlements the result reflects the poor status of rural women in terms of house ownership furthermore the result shows that most of the respondents have a clean source of drinking water backyards refuse dump defecated openly and depended on forest products as a source of cooking energy rural women have access to a clean source of water and might not be likely affected by the waterborne disease the clean water source was in tandem with the assertion of fao and the national population commission nigeria and icf 2019 that there is good drinking water in a rural community unlike it was in the past centuries the outcome of the study on environmental sanitation suggests that respondents were more compliant with sanitation rules on defecation considering the proportion that does not defecate openly which is in tandem with the assertions of florinconstantin andmohammad 2017 andfao 2022 on the basis of the respondents residential power source table 4 further shows that electricity was the main power source in the house they live while 05 depended on solar inverters the finding of this study was in line with the research outcome of fao 2022 in which electricity was the most common power supply in the rural communities this points towards the fact that the livelihood that is electricityinclined could thrive well in the study area also the respondents would be able to use labour and timesaving appliances that could relieve women of domestic chores burden nigeria and icf 2019 andfao 2022 hence this suggests that solar energy is not yet common in the nonurban area as it is being used by less than 1 of women however the most common source of illumination to the respondents in the house they dwell was an electric bulb 107 of them used local lamps with two or three small dry cells popularly called ojuti nepa or buhari lamps while 08 of them were still adherent to local lanterns with globe that uses kerosene this implies that a greater percentage of the respondents used clean illumination sources which was in tandem with the research report of the national bureau of statistics of moldova that rural dwellers no longer depend on unclean sources of illumination in their abode source field data comparison of material possessions with mates and contemporaries domain the result in table 5 shows the qualitative aspect of the material domain in which the material appreciably possessed in comparison with their age mates and contemporaries in their community includes kitchen utensils mobile phones and radios with the least being arable land this means that the respondents count it dignified to possess kitchen utensils in abundance which might be due to the link of such artefacts to the cultural expression in africa this connotes that the number of kitchen utensils possessed by rural women may be seen as a measure of their social status however it is worth noting that the least material wealth means that fewer of the respondents have access to land ownership as found by adeleke and alani whereas possession of productive resources like land is so significant for social status in rural communities however the mean material quality of life of the respondents revealed that more of the women surveyed had a low status of material possession which could be as a result of the limited access they have to critical resources that can boost their livelihood for enhanced material wellbeing the outcome of this study is in line with the report of adeleke and alani who affirmed that the rural womens wellbeing is generally low in the developing nations relationship between some socioeconomic variables and material quality of life the result in table 6 shows that a significant relationship existed between respondents material qol domain and years of experience in nonagricultural activities livelihood information endowment social group belonged cosmopoliteness and constraint to icts use this implies that livelihood information endowment constraints to livelihood information belonging to a social group cosmopoliteness and year of nonagricultural experience are the correlates of the material quality of life of rural women as those factors are directly proportional to the material qol of rural women the result of this study is in tandem with the findings of amoah that social group influences the wellbeing of rural women and contradicts the assertion of adeleke and alani conclusions and recommendations the study concludes that there was a high endowment of livelihood information which was sought through icts and interpersonal sources among rural women in their community however the livelihood information endowment was constrained by poor networks and poor infrastructure the study further found out that rural women dwell comfortably with access to clean water clean energy and good environmental sanitation practices the possession of productive resources among womens mates was significant for social status in their community however the material quality of life status of the respondents was low while the years of experience in nonagricultural activities livelihood information endowment social group belonging and cosmopoliteness are the correlates of material quality of life the study recommends that internet service providers should endeavour to improve the network condition in rural communities so as to enhance the respondents dividend of the livelihood information endeavours also the social bond within the womens social groups should be strengthened by pulling their financial resources together for possession of productive resources like land for enhanced material quality of life status and a better way of life hence developmental information could be diffused to the rural women using the most prominent source of the icts and interpersonal channels of information

this study examined the livelihood information endowment as a correlate of material quality of life among rural women in southwest nigeria a multistage sampling procedure was used to select 384 respondents using an interview schedule data collected on socioeconomic characteristics livelihood information endowment livelihood information sought and sources of information constraints to livelihood information endowment and material quality of life were analysed with percentages mean standard deviation the pearson product moment correlation and chisquare at α005 the results showed that most of the respondents were cooperative society members 516 with a mean year of former education being 80±462 years the most accessible information sources were mobile phones 373±090 and husband 372±082 with livelihood information endowment being high at 557 however respondents prominent constraints to livelihood information endowment were network problem 040 and poor rural infrastructure 039 the respondents material quality of life status was low 521 as most did not possess landed properties 581 a significant relationship existed between respondents material quality of life and livelihood information endowment r0134 social group belonged r0153 and constraint to livelihood information endowment r0017 constraints to livelihood information endowment inform the respondents material quality of life status network providers should offer efficient services

19694_0

introduction adolescence is a turbulent life period characterized by increased emotionality somatic and mental changes and the increased importance of social influence some scholars pointed out that during this period adolescents are at an increased risk for subjective health complaints subjective health complaints refer to several common selfreported psychosomatic symptoms including headache backache feeling low sleeping difficulties and other health indicators by individuals with or without a medical diagnosis however subjective psychosomatic complaints are not causally linked with physical or psychological disease therefore it is important to study the factors such as personalities cognitive and behavioral patterns and environmental contributors associated with experiencing symptoms especially for the nonclinic population experiencing psychosomatic symptoms has been correlated with the disadvantaged mental health condition or decreased wellbeing later studies have suggested an increasing number of adolescents have been experiencing psychosomatic symptoms individual factors can contribute to their psychosomatic health first personal demographic factors such as gender and age are related to adolescents psychosomatic symptoms it was found that females are more likely to experience psychosomatic symptoms psychosomatic symptoms also increase with age second personal behavioral and psychological characteristics have been found to be associated with psychosomatic health for example a study indicated that tobacco use is negatively associated with adolescents global psychosomatic health with selfesteem being a protective factor another research suggested that for adolescents a positive time attitude as one of the time cognition styles leads to better outcomes in both psychological and somatic facets additionally previous studies have addressed the effects of environmental factors ranging from family peer relationships school neighborhood and societys perceptions on youths psychosomatic health a review work suggested the influence of family on adolescents health can be generally understood from demographic and psychosocio aspects for instance many researchers have pointed out the effects of family socioeconomic status on youths selfreported psychosomatic symptoms which means that disadvantaged ses is a risk factor for adolescents health in term of family psychosocio impacts for instance it was found that the good quality of parentadolescent relationships emerges as a protective factor for adolescents psychosomatic problems besides caldwell and her colleague summarized that various parenting practices including parentadolescent communication parental monitoring and parental support are correlated to adolescents health behaviors such as substance use and early sexual initiation even though family is the central factor in adolescence from the developmental perspective peer influences and school environment were also notable the socialbrain theory argued that the complex socioemotional contexts impact adolescents social skills and cognitions later and eventually lead to certain mental health and wellbeing statuses thus peer relationships and school experiences also strongly shape adolescents psychological and behavioral development for example for both children and adolescents peer victimization might lead to more psychosomatic symptoms also it was found that negative peer influences increase substance use which is a health risk behavior and in turn substance use worsens the negative effects of peers contrary peer connectedness helps to decrease substance use it is feasible to reduce adolescents substance use by breaking the vicious circle between negative peer influences and substance use regarding the influences of school settings a crossnational study suggested that school climate strongly correlates with adolescent students lower frequency of selfreported psychosomatic symptoms the empirical evidence that schoolbased intervention is effective in promoting adolescent health also proved the significant influences of schools on adolescents health specifically except for parents teachers are significant adults for adolescents in school settings a study suggested getting along with teachers is associated with adolescents better mental health besides family peers and schools which are environments that directly interact with adolescents environments that are further away from adolescents can also have an impact on their health for instance the quality of neighborhood and regional differences the good quality of the neighborhood and trust within the community also positively affected adolescents psychosomatic health regional differences in adolescents health related outcomes are significant too in fact the national childandadolescent mental health policies differ across 30 european countries thus causing nationlevel differences in adolescents psychosomatic symptoms life satisfaction and wellbeing however to our best knowledge no study has investigated the influences of diverse environmental contexts such as the family unit peer relationships school settings and the nationallevel background on adolescents psychosomatic health in their complex relationships even though a scoping review based on ecological theory pointed out the effects of various environments like family school or cultural differences on adolescents mental health it was not an empirical study and it only focused on the psychological aspect without the somatic facet as the ecological system theory provides a comprehensive perspective to investigate environments effects on youths health our study adopted this theoretical framework to explain the association between social support and adolescents psychosomatic health while adjusting for the influence of other environmental factors such as regional differences and the quality of the neighborhood the ecological system theory suggests individuals psychological and physical development is promoted in multilevel environments ranging from microsystem to macrosystem microsystem refers to the environments within which adolescents directly interact including family school and peer relationships mesosystem refers to the interactions between microsystem elements such as conversations between family and schools and parental engagement in adolescents peer social activities microsystems and mesosystem are nested within the exosystem for example a neighborhood which affects adolescents indirectly the outer layer of the ecological framework is the macrosystem referring to the broader environments such as regions countries cultural contexts political environments and others some review studies have adopted the ecological theory to organize the past literature on adolescents healthrelated issues to synthesize the contextual determinants of adolescents health outcomes for instance currie and morgan reviewed the health behavior of schoolaged children database containing research from 1983 to 2020 and summarized the important influences of family school peer and classmate relationships culture countrylevel economy policies and child welfare on adolescents mental health similarly a previous review study employed the ecological system theory to explain adolescents sexual risk behaviors moreover the ecological theory is one of the most important guides to designing adolescents healthpromotion programs for instance health education resources from family school health curricula neighborhood and community could be combined to promote adolescents health literacy additionally after tracking health promotion programs for over three decades wold and mittelmark raised a wholecommunity approach based on the ecological theory to integrate diverse social recourses to improve adolescents psychological and physical functions and their healthy lifestyle the ecological theoretical model helps synthesize the environmental effects comprehensively additionally by combining the multilevel statistical approach researchers can investigate environmental influences for instance by setting macrosystemfactor at a higher level in the statistical model consistent with the theoretical framework yet empirical research that would explore the environmental influencers of adolescents psychosomatic health using the ecological framework is lacking to expand the previous findings on adolescent psychosomatic health our research aimed to investigate the influence of the social environment on adolescents psychological and somatic health from an ecological perspective in the current study the environments included microsystem mesosystem exosystem and macrosystem we hypothesized that the family teacher and friend support and the quality of the neighborhood environment were positively related to adolescents psychosomatic health due to the limited related literature we could not hypothesize regional differences and the interactions between family teachers and peers in the czech republic before the research materials and methods data we adopted data collected in the czech republic in 2018 by the health behavior in schoolaged children survey a crossnational survey initiated by world health organization 1 the czechhbsc program targeted 111315yearold adolescents to ensure the consistency of survey instruments and data collection the process followed the standardized hbsc study protocol the institutional research ethics committee of the faculty of physical culture palacky university olomouc approved the data collection on 4 march 2016 no 92016 schools were the primary sampling units selected randomly from the list of all eligible schools in the czech republic and 227 agreed to participate in our survey when schools agreed to participate parents were informed about the study and asked to consent or decline their childs participation adolescents themselves could also decline to participate even if their parents approved a team of trained administrators collected the data using an electronic questionnaire teachers were not present during the administration the study included 16065 participants and 13377 responses were valid measurements psychosomatic health eightitem hbscsymptom checklist was adopted to measure adolescents selfreported psychosomatic health we used 1 three emotionalsymptom items to measure psychological health including feeling low feeling nervous and feeling irritable the other five items measured the somatic health based on physical symptoms including backache stomachache headache dizziness and sleeping difficulties the psychological health dimension should also include sleeping difficulties however according to the exploratory factor analysis the 4factor subscale structure did not fit well the data in this study thus based on efa and other studies we included the sleeping difficulties into the somatic health factor participants were required to rate the frequency of symptoms from 1 to 5 in the last 6 months the instruments reliability in our study was acceptable the mcdonalds omega values for the psychological and somatic subscales were 073 and 064 respectively microsystem this study considered social support from families teachers and friends as the microsystem factors family socioeconomic status was also included at this level however it was considered the controlled variable family support was measured with a fouritem scale on a 7point response options the scale focused on four typical supportive scenarios in a family family tries to help the child the child gets emotional support from family the child talks about problems with family and family is willing to help make a decision the mcdonalds omega value was 097 because of the distribution of the mean scores of family support we converted the mean score of family support to a threepoint scale the mean value of 1 stayed the same and the mean value 7 was recoded as 3 and the other mean scores were converted into 2 the distribution of recoded scores is presented in supplementary figure 3 teacher support was measured using three items on a 5point scale the items asked about perceived acceptance by teachers subjective feelings of care from teachers and trust in teachers for a clearer interpretation we reversed the scores so that higher scores indicated more support from teachers the mcdonalds omega value was 082 friends support was measured with a 4item scale on a 7point scale the items asked about the friends help reliability sharing and problem talking the mcdonalds omega value was 094 due to the distribution of friend supports mean scores we converted them to a threepoint scale using the same method as for family support the family affluence scale measured socioeconomic status the scale included six items that aimed to investigate the family material affluence including the number of cars bathrooms computers and bathrooms having a dishwasher at home the frequency of family holidays and adolescents having their own bathroom fas was proved as an effective indicator of ses mesosystem we defined three new variables of family support teacher support family support friend support and teacher support friend support to present the interactions between family teachers and peer relationships some literature focused on applying the ecological model to childrens health promotion has suggested this statistical moderation approach to represent the mesosystem notably the interactions indicated whether the effect of one variable depended on another variable for instance family support teachers support measured whether the teachers support and family support magnified or demoted each others effect on adolescents psychosomatic health exosystem the quality of the neighborhood was measured with a sixitem scale participants were required to rate their subjective feelings toward the neighborhood and their experiences on a scale ranging from 1 to 5 we reversecoded the scores with a higher score indicating a better neighborhood environment the reliability was acceptable macrosystem in this study the macrosystemlevel variable was the region where adolescents lived during the survey time the czech republic has 14 regions related evidence showed regional economic inequalities in the czech republic such as gross domestic product net disposable income incomes from the perspective of the structure personal income taxes and health and social insurance data analysis spss 250 was used to conduct statistical analysis first we conducted descriptive statistics to describe the characteristics of our sample second we ran the pearson correlation analysis between independent variables and psychosomatic health subsequently we built the multilevel regression model according to the ecological theory in our multiregression model we set family support teachers support friends support interactions between the three supports and neighborhood environment at level 1 where gender grade and family ses background were control variables the region belonged to level 2 if the variance explained by regional difference were lower than 1 suggesting that the regional difference did not significantly contribute to adolescents psychosomatic health we continued to compute a general linear model setting all the variables except region at the same level results descriptive results the descriptive statistics are shown in table 1 according to the pearson correlation analysis all social supports and the quality of the neighborhood environment were positively correlated with psychohealth however the effect size of the correlation between friends support and psychological health was close to 0 regarding adolescents somatic health the effect sizes of teacher support and neighborhood environment were higher the effect size of the correlation between family support and somatic health was very small the association between friend support and somatic health was nonsignificant next we built a multilevel regression model based on each variables standardized average score we entered the region at level 2 and other predictors at level 1 intraclass correlation coefficients were 0004 and 0002 for the psychologicalhealthfocused and somatichealthfocused models respectively the results indicated no regional differences in adolescents psychological and somatic health therefore we computed two glm models in the following step the first model included all predictors in the microsystem and exosystem in the second model we also entered the mesosystem predictors the interactions between family friends and teachers support the purpose of constructing two models was to avoid the colinear relationship between microsystem and mesosystem to better interpret the mesosystems effect we compared the two models rsquare values according to the first glm model results based on standardized scores teacher support and the quality of the neighborhood environment had significantly greater positive effects on psychohealth compared to family support the association between friend support and psychological health was not significant this model accounted for 112 of the variance in adolescents psychological health after adding the interactions of three social supports the model improved the variance explained by less than 1 suggesting negligible effects of interactions between family teacher and friend support according to the coefficients the effect sizes of these interactions were near zero the region explained only 02 of the variance in adolescents somatic health other social supports except for the friend support had statistically significant positive effects on adolescents somatic health however the effect size of family support was very small the first model that excluded the interactions between family teacher and friend support explained 88 of the variance in somatic health in the second model that included social support interactions the variance explained remained the same the unchanged rsquare value suggested the unobserved effect of interactions of the three social supports on adolescents somatic health moreover the interactions between the three social supports were not significant the neighborhood environment had a significantly positive correlation with somatic health discussion this study examined mainly the effects of social environment on adolescents psychosomatic symptoms from the ecological perspective which considers the effects of different environments on youths development first according to the multilevel model this study did not find an obvious association between region as the macrosystem element and adolescents selfreported psychosomatic health in the czech republic the glm model suggested that the quality of the neighborhood environment which belongs to the exosystem influenced both psychological and somatic health positively and significantly finally the results showed that at the microsystem level among the three social supports teacher support was the most significant protective factor for adolescents psychological health followed by family support the effect of friend support was nonsignificant for mental health teacher support had a significantly positive effect on somatic health while the effect of family support was minimal friend support did not correlate with adolescents somatic health in addition the interactions between three social supports did not influence psychological and somatic symptoms the most important finding of the current study is that support from teachers and family decreases the risk of adolescents selfreported psychological health problems compared to family support teacher support had a greater protective effect these findings are consistent with prior studies first driven by the ecological theory teachers provide the support that helps adolescents achieve more positive outcomes a systematic review pointed out that harmony and supportive teacherstudent relationships reduce adolescents problematic behaviors and psychological symptoms second adolescents interact frequently with their families which also provide support and are a very meaningful protective factor for adolescents mental health third the finding that family support is a weaker predictor compared to teacher support is consistent with a previous metaanalysis on the other hand according to some classical theories family is also a source of conflict which may lead to negative outcomes for adolescents according to our findings family and teacher support influences on adolescents somatic health are similar although teacher support was a stronger predictor of somatic health the weak influence of family support on adolescents somatic health may be due to family members lack of related somatic health awareness previous studies have suggested that for physiological health problems the direct support of health behaviors and health management is more important for decreasing somatic symptoms compared to only emotional support however direct health support is based on the knowledge or experiences of health management strategies this finding suggests the possible limited physiological knowledge of the general public in the czech republic families must master essential health knowledge to promote children and adolescents psychological and physical development thus there is a need for public health education for czech citizens regarding the positive effect of teacher support on adolescents somatic health our results reflected the significant achievement of the health education program established in 1999 advocated by the health literacy portal since 2006 the health education program has focused on the urgent first aid and safe behavior and prevention of infectious disease in the czech republic our results demonstrated that czech teachers support promotes adolescents physical development to some extent this study indicated that the effect of friend support on psychological and somatic health in czech is negligible which is in line with some prior studies for example peer support did not affect slovak adolescents excessive internet use which is a problematic behavior highly correlated with mental health according to a metaanalysis peer support has much less influence on adolescents wellbeing compared to teacher and parent support the reason might be that for youth peer support is the only social support resource that they choose autonomously thus youth tend to get close to someone sharing similar characteristics from this perspective the influences of peer relationships may not be obvious the effects of three social supports on adolescents psychosomatic health are independent in this study teacher support family support and peer support did not magnify or compensate for each others effects first the interaction between teachers and family was weak in the czech republic which means teacher support does not enhance the positive effect of family support this result is not surprising as communication between family and school is lacking in the czech republic a previous study highlighted that the collaboration between school and family had been an unresolved issue which like matched interventions has been getting limited attention in the czech republic many western countries such as the united kingdom and the united states have been engaged in diverse programs to promote efficient communication between teachers and parents regarding childrens and adolescents academic performance and wellbeing the gap between czech and other developed countries has revealed the necessity to design relevant programs to enhance schoolfamily cooperation for the next generation similarly the current study pointed out the inadequate familypeer and teacherpeer interactions which could be due to the lack of communication between school and family as a result families and teachers cannot understand adolescents peer relationships in other contexts for example because parents do not often communicate with teachers they do not know about adolescents social activities with peers in school making monitoring adolescents schoolsocialnetwork more difficult likewise teachers cannot get to know adolescents social networks in their communities as parents rarely communicate with them because of insufficient engagement in adolescents peer relationships intervening in risky adolescents peer relationships becomes problematic except for the influence of three types of social support this study also suggested the important effect of the neighborhood on adolescents psychosomatic health mmari and his colleagues summarized the neighborhood as one of the critical social environments that influence adolescents health and safety from two perspectives social capital and social cohesion social capital focuses on interpersonal relationships and social cohesion emphasizes the degree to which neighbors share instrumental and emotional support both factors were previously associated with adolescents health outcomes for instance it was found that social cohesion correlates with adolescents health behaviors and mental health besides as one aspect of social capital trustful and helpful neighborhood relationship reduces youths psychological health problems a systematic review synthesizing global evidence showed supporting underprivileged neighborhoods effectively reduced adolescents health risk therefore based on previous successful experiences and the current results scholars have called for the related interventions to improve neighborhood community environment and subsequently adolescents psychological and somatic health in the czech republic finally our results demonstrated minimal regional differences in adolescents psychosomatic health regional differences accounted only for 04 and 02 of the variance in psychological and somatic health respectively in the current sample this finding may be explained by the health equality in the czech republic europewide report suggested that according to the gini coefficient ranking which is an income inequality index czech was the thirdhighest country among oecd members in 2018 in terms of health equality moreover czech provides universalcoverage health insurance for its citizens which means there are no financial difficulties in seeking necessary physical and psychiatric medical help from this perspective the health inequality crossing regions in the czech republic should not be obvious this paper first addressed the effects of social support on adolescents psychosomatic health from the comprehensive ecological framework in the czech republic however it had some limitations first we used only sectional data a longitudinal design is necessary to establish causal relationships researchers may consider collecting longitudinal data to construct the crosslagged model in the future second the adolescents completed selfreported questionnaires which meant subjective bias might exist in the study a previous study has indicated that teachers encourage parental support and involvement parental and adolescents perceptions of supportive or impaired communications may differ thus we suggest further studies investigating this issue from the parents or teachers perspectives third the internal consistency of the somatic health measurement was not high in our sample which means the scales psychometric properties should be evaluated in the czech adolescent sample in fact in 2001 a study across four european countries already pointed out the possible problematic retest reliability of somatic symptoms measurement suggesting some additional somatic symptoms may be considered when measuring adolescents somatic health such as neckache and general body ache thus the limited number of somaticsymptom items might also be the reason for the unsatisfactory reliability of the somatic health subscale according to the unsatisfied result of the exploratory factor analysis for the symptom checklist we recommend future researchers use the exploratory structural equation method to examine the psychometric properties of the measurement moreover we advise using the latent estimation of the psychosomatic health based on the observed symptoms for further analysis because the psychometric model construction is possibly complex for instance sleeping difficulties may contribute factor loadings to psychological health and somatic health at the same time the current study suggests the implication of school and community based psychological interventions for adolescents psychosomatic health according to our findings that teachers play an important role in czech adolescents psychosomatic health it is necessary to establish a school counseling system to help teachers to monitor adolescents psychosomatic development and cooperate with school psychologists to intervene in adolescents adverse development also considering the influence of the community on adolescents combing professional social workers to provide psychological support resources to communities is meaningful in the czech republic finally based on the preceding experiences in other countries we suggest related psychological intervention programmes to strengthen the cooperation between parents and schools data availability statement the datasets presented in this study can be found in online repositories ethics statement this study on human participants was reviewed and approved by the institutional research ethics committee of the faculty of physical culture palacky university olomouc on 4 march 2016 no 92016 written informed consent to participate in this study was provided by the participants legal guardiannext of kin publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at full supplementarymaterial

objectives it has been known that social environments are associated with adolescents health however the complex relationship between diverse types of social environments and adolescents psychosomatic heath remained unclear thus using an ecological perspective the current study aimed to examine the associations between social environment and adolescents psychosomatic health methods we used the data from the health behavior in schoolaged children hbsc project conducted in the czech republic in 2018 a total of 13377 observations were includedthe region as a macrosystem could not explain the variance in adolescents psychological and somatic health the quality of neighborhood environment exosystem was significantly related to adolescents psychological and somatic health at the microsystem level teacher support had stronger family support had weaker and peer support had no association with psychological and somatic health at the mesosystem level the interactions between family teacher and friend support were negligible for adolescents psychological and somatic healththe results underscore the importance of teachers support and neighborhood environment for adolescents psychosomatic health therefore the findings suggest the need to improve teacheradolescent relationships and the neighborhood community quality

19695_0

from time immemorial human beings have universally adopted certain values and ideals like truth justice freedom right to earn livelihood etc which form the foundation of almost all civil societies history is also witness that these ideals have come in conflict with the interests of the ambitious and powerful people in the society who have tried to subvert these basic principles so essential for the wellbeing of society for their personal gains if one critically looks at the human history at any point of time the societies and countries appear to be ruled by individuals or groups of individuals who are adept in manipulation treachery double speak and are imposters of high ideals on the other hand societies have survived and flourished due to the high moral values which run deep into the fabric of the society and are cherished by common people these values and ideals for some inexplicable reasons persist in spite of the apparent impression of their being at discount there are legends and folktales of exceptionally fearless and upright individuals who have risen from time to time to uphold the high ideals and moral values at the peril of even their own lives in the difficult and trying times these legends become source of inspiration for the next generations and help keep these principles and ideals alive the dogra land which spans between high mountain ranges of pir panchal and dholladhar in north and extending up to plains of punjab in south and from satluj in the east to manavar tawi in the west is rich in its tradition of folklore and folk literature in various forms a very prominent form of folk poetry which flourished in the past and is surviving till date is the folk ballad there are two categories of folk ballad that are very popular in dogri languagebaars and karaks baars are poetic narration of the valour and courage exhibited by warrior heroes mostly in battle field and karaks are sagas of the supreme sacrifices made by individuals who laid down their lives for a moral or social cause baars and karaks are sung by dareses and gardees the professional folk singers of the dogra region the heroes of baars and karaks are treated as icons of the culture this reverence and respect is so deep rooted that with the passage of time most of the heroes of karaks have attained the status of folk deities with temples and shrines being built to worship them the qualities and moralistic attributes of these heroes and the values they tried to uphold have been treasured by the masses in the form of these ballads and hence these depict the social and cultural ethos of the dogra community for this study three of the most popular folk ballads of the dogra region have been selected the first of these the karak of baba jitto is an account of the life and deeds of a peasant jitmal this karak which contains 319 lines in its present form is perhaps the most well known and popular of all the karaks jitmal born more than five hundred years ago in a hilly village ghaar near katra vaishnodevi had to migrate along with his young daughter to jhiri in the lower plains of jammu in search of livelihood on his request the wazir of jammu mehta birsingh leased out to him a piece of infertile land after entering into a contract that one fourth of the yield from the land will go to mehta jitmal by dint of his hard labour and toil was able to convert that barren piece of land into a high yielding fertile field at the time of harvest it had a rich growth of high quality crop mehta birsingh was astonished to see the quantity and quality of the crop greed took control of him and he tried to forcibly grab the yield of wheat crop much more than what had been agreed to under the land lease contract jitmal tried to reason with mehta but it was of no avail jitmal tried to resist the forcible and unjustified grabbing of the crop by mehta and his goons finding the situation beyond his control jitmal leaped and stood over the heap of wheat he thrust his own dagger in his belly and uttered the words oh mehta you need not eat only the wheat i mix my meat in it sukki kanak nin khaayan mehtya dinda maas relayee saying thus he laid down his life jitmals young daughter also immolated herself on her fathers funeral pyre according to the karak the curse of jitmal and his daughter made mehta birsingh to go through a very miserable life and he was subjected to unlimited sufferings lakhs of people from all over jammu and adjoining punjab gather annually to pay homage and tribute to baba jitto at jhiri where he sacrificed his life and also at ghaar his birth place at both these places his temples have been erected baba jitto has emerged as the first peasant hero of duggar who sacrificed his life for the right of peasants the second ballad is the baar of deedo which revolves around the life of main deedo who was born in jagti near jammu city in the year 1780 at that time jammu was under the control of maharaja ranjeet singh of punjab who ruled from lahore the dogra region of jammu was subjected to frequent invasions and acts of loot perpetrated by armed invaders from punjab the situation was so grim and chaotic that according to the folklore people would knead the flour at one place cook at another and eat at yet another location deedo soon after attaining adulthood pledged to strive for the freedom of dogras from the foreign rule of punjab and for their right to live peacefully in their own land till his death at the age of 40 he continued his armed struggle persistently in the face of the mighty adversary for achieving this goal in spite of many desperate attempts by lahore durbar through armed contingents deedo could neither be captured nor killed deedo had a strong support of the local population for whom he was a saviour of their honour and freedom he mainly attacked the police thanas set up by the ruling authorities and fought the armed troops sent to subjugate or eliminate him through guerrilla warfare and invariably succeeded in defeating and demoralising them it was then deedos writ that ran throughout the jammu region tired and wary of the influence of deedo the punjab durbar tactfully decided to pitch another dogra warrior gulab singh loyal to the punjab durbar against deedo and gulab singh succeeded in isolating and killing deedo through tactics and machinations pleased with his achievement maharaja ranjeet singh conferred on gulab singh the kingship of jammu obviously the official historians of those times mostly commissioned by the rulers did not make any mention of deedo or if they did they showed him in very poor light and portrayed him unfairly as a dacoit and a thief however deedos story and deeds survived through folklore and folk ballads the baar sung over the centuries by dareses is a testimony to the reverence and love with which the people cherish the memories of this great freedom fighter the baar available in the present form has 88 lines a frequent refrain in this baar is a message to the foreign rulers to leave kandi land of dogras and remain content with their own punjab reminding of the golden principle live and let live bairiya kandi chhodi de apna majhe da mulk sambhal for the people of dogras deedo is a symbol of freedom from foreign rule and subjugation ranpat the hero of the karak of datta ranpat the third ballad selected for this study was a purohit of birpur a village near jammu birpur was jagir of baangi a ruthless and tyrant ruler he tried to forcibly grab the land belonging to his cousins who were not affluent like him however this resulted in a dispute and baangi requested ranpat to mediate and settle the dispute by acting as a sarpanch inspite of the reluctance of his mother who could foresee trouble due to the cunning nature of baangi ranpat accepted the assignment after ranpat assumed this responsibility baangi tried to win his favour by offering him gifts in cash and kind however contrary to baangis expectations ranpat refused to accept the gifts this worried and infuriated baangi who now applied strong arm tactics of threats towards ranpat ranpat ignoring both the enticements and threats went ahead with delivering the judgment based on evidence which obviously went in favour of the cousins of baangi while ranpat was returning after delivering the judgment he was ambushed and beheaded by the killers hired by baangi ranpats mother immolated herself on the funeral pyre of his son later ranpats pregnant wife also performed sati after delivering her son the legend according to the karak has it that baangi was afflicted with leprosy and unlimited hardships befell on him and his close relations in repentance a temple of datta ranpat has been erected at birpur where till date a large number of people gather once in a year to pay obeisance to ranpat who is worshipped as a deity the karak of ranpat in its present form has 219 lines the central themes of these three folk ballads of duggar concern three basic tenets which form the pillars of any civilised society namely justice right to freedom and the right to earn a livelihood curiously enough the incidents which are the subject of these ballads pertain to feudal times when such concepts and ideas were taboo further the heroes of these legends though coming from a humble and ordinary background took cudgels with and stood up against the mighty ruling feudal lords of those times they must have had the support of the masses as they are representing the societal values of common people the popularity of these ballads and the iconic stature of these heroes is a strong evidence of this fact a hero is normally a person who accomplishes some things which the common people desire to do but cannot do due to various reasons like lack of courage with the passage of time the number of people who gather at the shrines of these heroes has increased manifold indicating thus the universality of the values for which they laid down their lives incidentally the relevance of these folk ballads could not have been more than it is in the present times

a prominent dogri writer was a professor of physics at the university of jammu he is presently the president dogri sanstha jammu and has been associated with the movement for dogris recognition as a scheduled language he is a recipient of the sahityaakademi award for his collection of dogri essays titled cheten diyan galiyan in 2011 he has four books to his credit in dogri

19696_0

background australia is a country cited as having low health inequalities 1 in 1994 health authorities in australia published a report setting targets for better health outcomes 2 the report highlighted the importance of monitoring different health outcomes between different socioeconomic and demographic groups 2 although considerable attention has been paid to inequalities since the first national reports and many calls for action have been made health inequalities have persisted among different socioeconomic groups 3 4 5 more recently several interventions have been promoted both at a public health and other government agency level notably in 2010 a document health in all policies cited explicitly as a tool to tackle health disparities has been produced conjointly by the world health organization and the government of sa 6 although some positives changes have occurred in sa australia and worldwide other targets are yet to be reached 5 6 7 relevant chronic disease and risk factor targets that require constant monitoring and assessment include harmful use of alcohol physical inactivity salt intake tobacco use diabetes and obesity 8 the use of a behavioural risk factor surveillance system as a valuable source of information for inequalities monitoring has been advocated particularly in relation to tracking trends 910 while some of the targets are not possible to monitor with the use of a brfs system others are as such we analyzed data from the south australian monitoring and surveillance system to test the most recent relevant trends on specific health disparities the focus of these first analyses were to focus solely on trends without at this stage investigating possible causes leaving this to future studies methods data samss is owned by the south australian department of health and ageing and is an epidemiological monitoring system samss aims to detect and facilitate understanding of trends in the prevalence of chronic conditions risk and protective factors and other determinants of health these data monitor departmental state and national priority areas and are linked to key indicators such as state and national healthy weight targets 11 each month from july 2002 a sample of south australians was randomly selected from the electronic white pages introductory letters were sent to each household selected to inform them of the upcoming telephone survey and inviting the person who had the last birthday in the household to participate in a telephone interview the interviews were conducted by professional interviewers using computer assisted telephone interview technology approximately 600 respondents participate in each samss survey although data were collected on children data presented in these analyses are for those aged 18 years and older all data are weighted each month by sex age area of residence and probability of selection of the household using the latest australian bureau of statistics census data or estimated residential population data data were then raked to further adjust for weighting 12 data from july 2002 until june 2015 were utilised ethics approval for the survey was obtained from the ethics committee of the sa health the topics and questions included in samss were developed in consultation with key personnel within sa health including relevant experts and questions are based on previous work undertaken in australian states and territories where possible questions that had previously been included in other surveys and which were perceived to ascertain reliable and valid data were used or modified additional details on samss methodology is available 11 variables the risk factors assessed were overweightobesity according to the who classification with bmi ≥ 25 nominated as unhealthy and bmi ≥ 30 classified as obesity and fruit consumption two or more serves per day as suggested by national health medical research council 13 and international guidelines 14 we also examined the selfreported prevalence of chronic conditions defined by answers to the question have you ever been told by a doctor that you have… diabetes asthma heart disease osteoporosis andor arthritis having any chronic condition and multimorbidity of these conditions were used in the analysis specific analyses were also undertaken for diabetes which is acknowledged as one of the chronic condition more sensitive to social determinants of health 1516 finally we analysed selfreported mental health conditions a combined variable created using positive answers to the question have you been told by a doctor that you have any of the following conditions in the last 12 months the conditions were anxiety depression stress related problems or any other mental health problem andor whether the respondent was currently receiving treatment for these conditions psychological distress was also measured by the kessler 10 17 18 19 the k10 is a selfreport 10item set of questions based on the level of anxiety and depressive symptoms experienced in the previous 4 weeks the questions were scored to a single scaled item with respondents with high scores of 2250 being classified as having high or very high levels of psychological distress to show possible disparities we used the following two demographic variables education and a question assessing which best describes your money situation with the last two categories recoded as able to save this question was used rather than household income as income has increased over this time period increases statistical analysis analyses were conducted using chisquared test for trend to detect differences in overall prevalence and for each level of educational attainment and household money situation for each risk factor and chronic condition between 20024 and 201315 chisquared tests were also undertaken to detect differences in prevalence of each risk factor and chronic condition by educational attainment and ability to save for 20024 and 201315 all dont know responses were treated as missing values annual prevalence over time for each of the risk factors and chronic conditions by educational attainment and ability to save are presented graphically the prevalence over time data were not standardized to a reference population in total n 74127 interviews were conducted with adults aged 18 years or older response rates using the american association for public opinion research 20 standards definition varied from 541 to 713 data were analysed using spss version 200 and stata version 130 all data presented were weighted to be reflective of the south australian population using raking methodology by area age gender marital status country of birth educational attainment and dwelling status to the most relevant south australian population data and probability of selection in the household results the total number of interviews and response rate per year are included as additional file 1 table s1 in sa over the past 13 years the population have achieved higher levels of education with the proportion achieving a university degree or higher increasing from 126 to 187 in addition the south australian population are relatively richer with the ability to save increasing from 630 to 666 the subjectively measured income related figures are confirmed by those of the abs that has generally reported a steady increase in the mean real equalized disposable household income over this period 21 as this increase was across all the income quartiles income disparity does not seem to have increased in the last decade in sa the analysis shows substantial differences in the prevalence of risk factors and chronic diseases among socioeconomic subgroups in regard to unhealthy weight the overall increase over time is greater among the lower educated groups with a smaller increase seen for those with a university education similar results were seen for obesity although there were increases across all social groups with the gap increasing over time in regard to fruit consumption the higher educated group have changed little over the years while in the other groups increases in consumption were apparent although starting from a lower base there was an increase in fruit consumption for those who could save but lower estimates and no increase over time for those who cannot save confirming a substantial inequality gap also for this variable the prevalence of diabetes as expected demonstrates differences among the lower social economic subgroups with the only subgroup that has not seen an increase over time being the higher educated group prevalence estimates continue to be lower for the higher social economic groups and the gap in the other groups is increasing in regard to mental health conditions the gap associated with education level increased over time with the higher educated groups relatively stable while the other groups increased in prevalence in terms of psychological distress the overall level decreased by 2 over time as did both the lowest and highest educated groups only a small decrease was shown among the unable to save group but this group is still far from closing a substantial gap in prevalence 18 for the unable to save group compared to 7 for the can save group differences in the prevalence of those with one chronic condition were relatively stable over time with the expected differences among socioeconomic groups the differences are much more relevant when we consider those with two or more chronic conditions the gap again increasing over time occurs as a result of the lower educated and those with lower economic conditions changing for the worse while the other groups are substantially stable over time discussion samss data have shown that health inequalities are stable if not increasing in sa with health disparities for lower educated and lower income groups measured by those unable to save appearing to be increasing in most of the health variables considered although it is not an aim of this manuscript to speculate about possible causes which are quite often difficult to define 22 it is conceivable that most of these increases in inequality can be related to interventions not targeted to specific groups or not specifically designed to be capable of reducing the gap 23 24 25 interventions targeted to the general population 23 such as eg building cycling tracks could be of benefit for those already active and have no impact on those more vulnerable that are unable to buy a bike this eventually produces an increase in the gap in the level of sedentary activity between classes a call for more action and better understanding for more effectively targeting of the interventions is warranted staying with the biking example this would mean health promotion activities involving more vulnerable communities this could include for example offering free bikes activities aimed to engage people in small bike tours offering bikes to cycle to school and creating the conditions where this could easily happen it is evident from the analysis presented in this study the substantial role played by noncommunicable disease and behavioural risk factor surveillance systems in showing the evolutionary aspects of health disparities certainly for these analyses the availability of a real surveillance system 2627 rather than a few scattered surveys is fundamental in our opinion yearly or even with less frequently repeated surveys 28 provide little information when studying and showing trends we believe that these analyses have only scratched the surface much information can still to be obtained from surveillance data particularly in understanding the mechanisms 29 which create health inequalities and as we have seen increase these inequalities specific analyses for subgroups defined on the basis of sociodemographic variables but also geographically can provide further information 30 31 32 data from surveillance systems highlighted in this study could be even more useful when linked with data from other sources to study other potentially influencing social determinants such as social and cultural capital 33 or urban settings 34 an even more important role in the future could have surveillance showing what works in reducing health inequalities given the potential use of these systems for evaluation purposes 43536 in this first paper we purposely limited the analyses so as to show simple time trends research is needed on these data to better understand interaction of different social determinants of health and the possible underlying mechanisms which creates and reinforces gaps certainly for instance the fact that over the years the number of those falling into more deprived groups has decreased in sa due to the selective effect of social mobility and could have left individuals in the lower strata individuals with characteristics that induce worse health attitudes and behaviours however using simple analyses to show how much the health inequality gap remains relevant also creates several limitations some of these are related to the available data and some are associate with the analysis conducted a first weakness is the limiting of the risk factors assessed to two and three specific chronic conditions in addition only two socioeconomic related variables were used although the use of ability to save as an indicator has been shown in australia to be a valid indicator of financial security 37 it is acknowledged that other more reliable questions could have been used such as income however over the 10 year period income earnings have increased for the whole of australia which made it difficult to have comparable income groupings across the years this study uses selfreported surveys which can potentially be subjected to bias due to socially desirable responses leading to possible overor underestimation of behaviors or health conditions such as having a mental health condition or overweight and obesity due to incorrect reporting of height and weight 38 however these biases are of little importance if the aim of samss is to study changes in the behaviour or health condition over time assuming that the level of bias is constant over time the use of listed telephone numbers as the sampling frame can be considered a weakness of this study due to an increasing number of mobileonly households with the majority of these types of telephone numbers not being listed 39 however studies have shown that using this sample frame is still a viable source and reliable estimates can be produced when applying more effective weighting techniques such as raked weighting 10 to overcome the sampling bias as well as nonresponse bias a further weakness is the lack of power in terms of data on aboriginal status in australia recent policy actions have focused on improving the health of aboriginal populations with the prime minister of australia in 2008 signing a statement committed to developing a longterm plan of action to end health inequalities between indigenous and nonindigenous populations 32 although samss collects this information the limited sample size does not permit analysis by aboriginal status it is also acknowledged that some of the increases in prevalence of mental health problems reported in this analysis could be the result of better diagnosing which has been supported by additional funding from the federal government in recent years this could also impact our analyses by social class leading to an underestimation of inequalities since individuals who are more educated are also more likely to seek health care services and receive a diagnosis the acknowledgment of public health campaigns in increasing the fruit consumption has also not been fully explored although earlier work with this surveillance system has shown promising results 35 conclusions it is evident and this paper has contributed to providing more evidence that there is much work still to do to close the gap 2840 also in more egalitarian societies with universal health systems such as sa more targeted and effective interventions are evidently needed to change the trends highlighted by samss brfs can be a good source of information both to show the evolution of problems and to evaluate possible future interventions much effort is still required to close the gap of health inequalities in sa more precisely targeted and properly implemented interventions are needed additional file additional file 1 table s1 total sample size and median response rates 2002 to 2015 note response rates were calculated from the final dispositions of the telephone numbers using the american association for public opinion research 18 competing interests the authors declare that they have no competing interests

background although australia is a country cited as having generally low health inequalities among different socioeconomic groups inequalities have persisted the aim of this analysis was to highlight how inequalities have evolved over a 13 years period in south australia sa methods since 2002 over 600 interviews per month have been undertaken with sa residents through a computer assisted telephone survey method total 77000 major risk factors and chronic diseases have been analyzed providing trends by two socioeconomic variables education and a proxy of income ability to save results while income and educational gaps are reducing over time in sa those that remain in the lower socioeconomic groups have a generally higher prevalence of risk factors and chronic diseases the health disparity gap is still relevant although at a different extent for all the variables considered in our study with most appearing to be stable if not increasing over time conclusions surveillance can be a good source of information both to show the evolution of problems and to evaluate possible future interventions extensive effort is still required to close the gap of health inequalities in sa more precisely targeted and properly implemented interventions are needed

19697_0

introduction as strangers in a foreign land new immigrants have long relied on social capital to navigate an unfamiliar society historical and contemporary accounts of immigrant america abound with narratives of immigrant groups relying on the knowledge experience and economic resources of their established coethnics to locate housing access job referrals and provide startup capital for ethnic businesses this social capital is critical in guiding newcomers to vital institutions that will enable them to integrate in the host country wetback since the mid1990s changes in immigration policy and deportation law have ushered in a third wave of mass deportation what distinguishes this third wave from earlier ones is the presence of a vast state bureaucracy and technology that enables the melding of two different methods of deportation extended border control and interior social control 1 the presentday period of mass deportation is largely a product of a new series of laws in combination with this growing bureaucracy and technology one law in particular the illegal immigration reform and immigrant responsibility act of 1996 expanded the criteria for detaining and deporting migrants restricted the ability of migrants to appeal deportation orders and limited the power of immigration judges to grant relief to migrants convicted of relatively minor crimes the antiterrorism and effective death penalty act of 1996 further increased the enforcement authority of the federal government by almost eliminating judicial review for most categories of immigrants subject to deportation by weakening judicial review aedpa removed the legal constraints that protected many noncitizens from deportation by eliminating relief for noncitizens with family ties in the united states in 2001 congress passed the usa patriot act which bolstered administrative authority to apprehend detain and deport immigrants who are perceived to be threats to national security the creation of the bureau of immigration and customs enforcement in the department of homeland security in 2003 has also contributed to contemporary mass deportations working closely with state and local agencies ice initiated several interior enforcement programs devoted to apprehending detaining and deporting criminal and fugitive noncitizens long after their arrival the criminal alien program enables ice officials to enter state prisons to conduct immigrant screening and detain and remove criminals the secure communities program requires police to enter prints of arrestees into a joint fbi and ice database the 287 program is used by ice to train state and local police to identify process and detain suspect immigrants whom they encounter during their regular law enforcement activities both programs have been highly controversial studies have documented that they facilitate racial profiling of latinos as well as weaken security in immigrantheavy neighborhoods when immigrants suspect that police are partnering with ice they are less likely to seek assistance from police or to report crimes the recoding of civil violations into criminal acts and the expansion of enforcement operations from the border to a massive state technology of federal and local enforcement agencies in the interior united states has resulted in the current period of mass deportations just how large is the recent increase in deportations until the mid1990s annual deportations averaged fewer than 50000 after the enactment of iirira deportations increased sharply from 1996 to 2005 yearly removals averaged around 180000 from 2006 to 2010 they increased further reaching 414481 in 2014 according to the migration policy institute 2 department of homeland security data show yeartoyear variations in the number of deportations but the overall trend is clear for instance we see a very small upward trend from 1986 to 1996 which likely reflects growth in the total number of unauthorized immigrants in the nation not specific changes in public policy the numbers sharply increase in 1997 and 1998 however which are followed by a brief plateau for several years the strong upward trajectory resumes by 2003 and continues for the remainder of the decade while several factors likely influence the yeartoyear variation in deportation data the growing numbers since the passage and implementation of iirira indicate that this law is the primary explanation in addition some of the yearly changes are not very meaningful for instance fluctuations can reflect administrative updates of data and not changes in actual deportation numbers fluctuations in the annual deportation data can also occur because a specialized deportation program is transferred to an administrative unit that does not normally report deportation counts changes in deportation hearing schedules the shifting of detainees across centers and differences in how judges conduct trials involving unauthorized immigrants also cause fluctuations in annual deportation counts 3 like earlier periods of deportation latin americans are the focus seventythree percent of the immigrants formally removed from the united states in fy 2010 were from mexico and another 20 percent from central america moreover less than half of those deported in 2009 were removed for criminal violations despite the criminal alien narrative that is the primary political justification for the program 4 the dramatic increase in deportation levels in the united states has resulted in a growing body of scholarship focusing on the origins and politics of massive deportation and the human costs of this practice for deportees and their families debates on the use of deportation as a method to control migration have grown mathew gibney and randall hansen for example argue that deportation embodies what they term the liberal democratic paradox on the one hand the capacity to control borders is fundamental to the sovereignty of the state on the other hand immigration must also embody the rights of its fy 2013 dhs sought 17 million less in funding for the 287 program and said that in light of the expansion of secure communities it will no longer be necessary to maintain the more costly and less effective 287 program immigration policy center the growth of the us deportation machine accessed january 2 2015 4 although less than half of such deportees are criminal aliens this certainly represents a disproportionate share of criminals in comparison to their presence in the overall immigrant population while many politicians and members of the public associate immigrants with criminality researchers find that immigration is associated with decreases in crime in fact enforcement efforts can lead to higher crime rates because of the resulting lack of trust toward police in immigrant communities residents the tensions between support for sovereignty and individual rights bears on the course of the deportation regime antje ellermann buff andflores identify political actors and conditions that have historically produced different patterns of migration control flores identifies the ways in which antiimmigrant sentiment and us deportation operations have followed periods of racialized portrayals of immigrants buff contends that the growing and vast state technology which includes multiple entities charged with immigration control has produced an operation of deportation terror daniel kanstroom introduces the concept of postentry social control and explains increased deportations in the interior united states as a result of failed control of the border other scholars have concentrated their attention on the human cost of the deportation regime for deportees and their families legal and social science scholars have argued that the conditions under which immigrants are arrested and detained may fall short of us and international standards detainees spend long periods in detention facilities and are often subject to racial slurs and excessive force some governments to which migrants are repatriated regularly stigmatize and criminalize deportees designing programs to regulate their mobility upon arrival and long afterwards although the targets of deportation are noncitizens the practice results in collateral damage to other individuals as well as to immigrant communities more generally using census data and figures released by the pew hispanic center a recent human rights watch report estimates that more than one million family members have been separated from one another through deportation another source places the number of usborn citizens with deported parents at 200000 deportation produces emotional and psychological hardship for deportees and traumatic effects among children and spouses left behind not surprisingly social ties to spouses and children remaining in the united states increase the likelihood that deportees will plan to migrate again although this scholarship informs our research the primary purpose of our article is not to extend the theoretical and legal discussions of deportation nor to examine its effects on immigrant families rather we extend conceptual and empirical research on deportation effects to address the consequences of mass deportations for mexican and central american immigrant communities as their available social capital declines we draw on the findings from three previous immigration studies to argue that the us policy of mass deportationswhich deports many immigrants who would not have been deported under policies prior to the enactment of iirira in 1996is removing large numbers of immigrants whose accumulated resources are important to the political civic and economic development of migrant communities while deportations remove dangerous criminals from immigrant communities such policies may also affect the ability of immigrant communities to adapt to core institutions in the host society in this way many individuals are harmed by the deportation of noncitizens either directly as relatives of deported migrants or indirectly through the weakening of bonding and bridging social capital in immigrant communities in addition we consider the implications for institutions that frequently include immigrant employees members and participants such as businesses and churches social capital and immigrant communities the concept of social capital in contemporary scholarship can be traced to pierre bourdieu and james coleman who argued that social relationships and membership in communities provide individuals with valuable resources and potential benefits for bourdieu social capital refers to relations developed instrumentally with the intention of capturing future benefits moreover the profits that accrued to individuals formed the basis of group solidarity with the implication that networks are constructed through a process of institutionalizing group relations that subsequently become a usable reliable source of benefits coleman sees social capital as also encompassing obligations and expectations information channels and social norms this broader conception of social capital was adopted and adapted by putnam and fukuyama putnam defined social capital as networks norms and social trust that facilitate coordination and cooperation for mutual benefit networks of civil engagement create norms of generalized reciprocity which leads to social trust thereby allowing for the resolution of collective action dilemmas moreover family is the most fundamental form of social capital although some measures of social capital include neighborliness and membership in associations for fukuyama social capital is a norm that promotes cooperation between individuals with the only caveat that these must be actualized norms trust networks and civil society are the results of social capital social capital leads to cooperation in groups as well as norms of honesty reciprocity and reliability and it serves an economic function by reducing transaction costs in his discussion of social capital hardin found that sociologists conceive of social capital as structures within societysocial relationships specificallythat allow individuals to cooperate and achieve this is an instrumental view of social capital one that may be important to individuals but is not necessarily connected to politics or civic outcomes hardin argues that political scientists advance an alternative perspective that begins with the individual this treats trust at the individual level as an independent variable that allows social institutions to work social capital is therefore a critical factor in collective outcomes douglas massey was among the first to apply the concept to the study of immigration in the united states he found that social capital in the form of relations to individuals with migrant experience and employer contacts was a resource newcomer migrants could convert into better jobs michael aguilera and douglas massey concluded that different outcomes among documented and undocumented migrants could be explained by the latters lack of social capital some scholars study the relationship between social capital and immigrant incorporation many networks are built on extended family and informal hometown relationships of trust and reciprocity that generate social capital and help newcomers find jobs and housing and ultimately forge linkages to the larger society jimmy sanders and victor nee focus on the family as a form of social capital that immigrants can use in pursuit of economic gains interactions with family members represent a social exchange characterized by mutual dependence and expectations in the context of a moral order marked by the accumulation of obligations among members gil epstein focused on the difference between a bonding network which decreases incorporation and a bridging network which increases incorporation and social capital concha et al examined how measures of social capitalsupport from parents spouses children relatives and friendsaffected the acculturationrelated stress of latino immigrants in miamidade they found that the results were not constant over timein the first second and third year after migration different relationships played different roles in increasing or reducing reported stress relatedly hoyt observed that the 2006 immigrant rights demonstrations grew out of deep networks of social solidarity within immigrant communities from these social capital perspectives immigrants who have accumulated knowledge experience and economic resources in a new society can play an important role through social networks in assisting other newcomers to navigate through and participate in a host of activities that some see as amounting to effective citizenship or social membership as bauböck explains although transnational communities are important survival and adaptive mechanisms they are no substitute for the useful and eventually necessary modes of entry into core arenas of the host society where newcomers can access security and rights the social capital accumulated by established immigrants can help bridge newcomers to economic educational civic and other institutional arenas of the host society the one study to examine immigration and social capital in our contemporary enforcement regime is valdez padilla and valentine they used focus groups in an arizona city to explore how the states widely publicized enforcement policies affected the social capital ties of mexican mothers they noted that the c onsequences of restrictive immigration policy on unauthorized immigrants social capital has yet to be examined their interviews indicated mixed effectswhile enforcement could increase social capital it also led to decreased capital these findings reflect the results of our research in north carolina and texas sites whereby stronger enforcement leads unauthorized immigrants to withdraw from public life as much as feasible three studies of national and local enforcement effects since the passage of iirira in 1996 two of the authors have independently conducted a number of studies to investigate the effects of escalated enforcement operations on us immigrant communities and those deported from them in this article we recast the collective findings in these studies to develop a new perspective on how contemporary deportations affect immigrant communitiesparticularly through the removal of individuals who contribute to social capital this has implications for immigrant integration as scholars have noted the importance of social capital for connecting new arrivals to us institutions and sectors the first study was launched in 1998 and conducted in five established immigrant communities in texas in this project researchers sought the views of social service providers and communitybased organizations about the impact of enforcement measures on their migrant client populations they also interviewed about one hundred households with immigrant members in each of the five research sites to determine the effect of enforcement efforts the second community study was conducted in 2009 in the relatively new immigrant destination of johnston county north carolina in 1990 latinos made up 15 percent of the population by 2010 they represented 11 percent of the countys nearly 160000 people the latinos in the county include newcomer and established mexicans and centralsouth americans the involvement of local law enforcement in immigration issues has been pronounced in new immigrant states like north carolina and in rural areas like johnston county where established residents are less tolerant than their urban counterparts the county sheriff was an advocate of local immigration enforcement operations including the 287 program the north carolina study was conducted to understand the effects of local enforcement initiatives on immigrants and the community in which they lived and worked in fall 2008 and spring 2009 fifty latino immigrants were interviewed mostly business owners and established residents a third study focused on the deportees themselves and was undertaken in 2002 in el salvador the study was implemented through the cooperation of a consortium of communitybased organizations coordinated by catholic relief services el salvador that operated a reception program for deportees arriving from the united states at the san salvador airport when bienvenido a casa announced in 2002 that it planned to meet with deportees across el salvador to assess their employment situations the researchers organized a survey to be conducted with a random sample of deportees attending the meetings questions in the instrument concerned the migration experience to the united states work conditions in the united states family characteristics in the united states and el salvador conditions during apprehension detention and deportation and postdeportation economic experiences and future plans three hundred interviews were conducted through systematic random sampling of deportees attending the meetings between june and november of 2002 findings effects and perceptions of increased immigration enforcement on us immigrant communities the household surveys in the five texas communities found evidence that iirira was affecting individuals and families but there were variations across the research sites overall 165 percent of the 510 respondents reported that border patrol and other federal immigration agents had stopped and questioned them regarding their citizenship status thirtynine percent of those questioned were arrested for an immigration violation about twothirds of the respondents who stated that ins agents had questioned them or a household member lived in one of the three border research sites of hidalgo laredo and el paso this finding corresponded with the expansion of the border patrol force in the border region across the texas research sites fear of authorities and the related responses of limiting or circumventing public activity emerged as a common theme among many of the survey respondents the research found that some of the interviewed households significantly reduced their time away from home except for time spent at work for example one young couple in houston reported that they never traveled outside their apartment together in order to reduce the risk of being arrested together and deportedand thus being separated completely from their two small children other survey respondents commented that they avoided public settings where hispanic immigrants concentrated because they feared these settings were more likely to be targeted for raids by us immigration agents in the border cities of el paso and hidalgo where the number of border patrol agents increased sharply many survey respondents also indicated fear and apprehension of being out in public yet as a few respondents commented this was part of normal life in border areas where us border agents are stationed across all the texas research sites social service providers expressed concern that increased enforcement would frighten away immigrants who were eligible to receive benefits public health providers were worried that increased enforcement would make unauthorized immigrants reluctant to immunize their children at public health clinics or receive maternal and child health services in addition one health service provider in a houston community outreach program observed that after immigration enforcement and deportations increased the latino participants in the program became more likely to give their identity as white rather than hispanic educators also expressed concerns in the fort worth and el paso research sites school administrators reported enrollment declines in some district schools that they believed were due to new immigration enforcement measures in el paso student enrollment decline had started with the implementation of operation hold the line in 1992 which had greatly intensified border enforcement in the area in the houston site an administrator of a school in an immigrant neighborhood blamed a drop in parent attendance at school meetings on fears of heightened enforcement among unauthorized immigrant families in contrast to times prior to iirira implementation the immigrant communities in the texas research settings clearly demonstrated a heightened fear of increased immigration enforcement community institutions such as spanishlanguage radio and television stations additionally circulated the social anxieties through their callin and talkshow programing that often focused on the heightened enforcement in houston a popular spanishlanguage radio program reported the street locations of sightings of immigration officers in order to alert its immigrant audience in johnston county north carolina immigrants also reported concern about heightened enforcement efforts but they were especially anxious about local police participation in the 287 program the local sheriff was a strong advocate of local immigration enforcement in his position as chairman of the states sherriff association he helped make north carolina the lead state to partner with ice deportation operations traffic stops essentially became the new enforcement strategies in the county and many immigrants drove in fear because they could not obtain a north carolina drivers license without a valid social security number consequently traffic stops became routine respondents reported that they were profiled and pulled over by police for no clear reason more than threefourths of the fifty persons interviewed knew of someone who had been arrested by a local police officer for violations such as speeding or driving without a license and subsequently deported how have new and established immigrants and longterm residents and community leaders in the county responded to expanded local enforcement what strategies if any have immigrants and established residents developed to circumvent enforcement operations how effective are these operations and what are their implications for levels of accumulated social capital in the community we find that although established latinos and immigrants have forged networks of civil engagement over concerns about local enforcement operations these networks are not strong enough to mitigate the fear and anxiety that prevails among many immigrants in fact many have withdrawn from public life and some have left johnston county as in the case of other communities in new immigrant destination areas with little history of immigration latino immigrants in johnston county do not have an established political base to turn to for advocacy or assistance yet in the aftermath of the immigrant marches of 2006 we found that alliances were forming between newcomer latinos and established elements of civil society foreign and nativeborn latinos founded a chapter of yes we can an organization dedicated to immigration reform the group comprised of business owners immigrants and nativeborn latinos met regularly at a local church to discuss the community costs of local enforcement dragnets and racial profiling informal linkages have also developed over the issue of driving without a license the fear of apprehension and deportation because of a traffic stop has become so great that people with licenses started driving unlicensed immigrants to work fliers posted on bulletin boards in many latino businesses advertise transportation assistance while some migrants are able to cope and survive the atmosphere of massive deportations through formal and informal intergroup alliances others live in fear remain excluded from public life and core institutions and are sometimes apprehended and deported owners of business establishments that cater to latinos for example reported that their sales declined between 30 and 90 percent in the twoyear period from 2008 to 2009 and they attributed the bulk of the decline to the loss of latino customers restaurant owners and managers complained that their sales declined substantially because latinos fear apprehension if they drive to latino establishments some immigrants have responded by withdrawing from the community settled immigrants reported avoiding public spaces like parks and no longer attending community events immigrants without valid drivers licenses spent most of their nonworking hours at home this means they no longer went out to eat at local restaurants nor regularly frequented churches or stores in this way we can see how deportation practices serve to remove individuals from the networks that constitute social capital some immigrants have stopped investing in a future in north carolina and some of the more successful immigrants sent their earnings to family members in latin america others reported that they stopped shopping for clothes furniture cars and other expenditures that link them to life in the united states they reasoned that by doing this they will have savings waiting for them back home if deported fearing deportation and family separation some immigrants have left the united states by some community leader accounts an estimated 30 to 40 percent of the latino immigrant population had left north carolina some were forced home through deportation orders others returned home to mexico or central america fearing the risk of deportation and still others moved to other states state data suggest similar trends from 2007 to 2009 the north carolina undocumented population fell from 350000 to 275000 this decline reflects a variety of dynamicsdeportation relocation for employment reasons moving to states with less stringent enforcement and a return to home nations the latter is unlikely to be a substantial share of total population loss as scholars have found little evidence for the strategy of deportation by attrition also known as selfdeportation for instance filindra criticized the behavioral logic behind this theory and others have observed few voluntary returns and argue that returns better reflect the recession than enforcement nevertheless latino community leaders believed that pressured returns constitute a part of the north carolina immigration story collectively the findings from the texas and north carolina community studies indicate that the new immigration enforcement measures implemented since iirira had significant effects particularly on latino immigrants and the communities in which they work and reside migrants hesitated to participate in public life and feared arrest and deportation the increased level of immigration enforcement was a daily reality as immigration officers sometimes accompanied by local police stopped and inspected latinos in interior communities as well as the border region an ultimate effect of the new enforcement activity is that it reduces the propensity of many immigrants to participate in a wide range of community activities which has implications not only for individuals and families but also for the social capital of communities survey findings of salvadoran deportees the survey of 300 deportees in el salvador provided rare evidence about the social and demographic characteristics of deportees removed from the united states after the implementation of iirira while the us government reports annual data on deportees by nationality and type of deportable violations the reports do not cover the social and demographic characteristics of the deportees such information is important in determining their levels of integration into us society and thus to learning about the resources that deported migrants possess and could share with others in immigrant communities to better show how the deportation of longterm immigrants removes valuable sources of human and social capital from immigrant communities the presentation of the survey findings is differentiated by the length of time spent in the united states prior to deportation five categories of time are used in tables 12 lived in the united states for more than 0 years for more than 1 year for more than 3 years for more than 5 years and for more than 10 years as table 1 indicates deportees tend to be overwhelmingly male although this is changing due to interior enforcement efforts and the increasing governmental capacity to detain women and families while the sample deportee median age was 29 years the median ages became older as the length oftime spent in the united states increased since more recently arrived migrants tended to be younger moreover as table 1 indicates the proportion of authorized migrants increased as the time spent living in the united states lengthened deportee educational levels also increased with time spent in the united states some of the deportees with longer residence in the united states attended us schools which provide more years of compulsory education than do schools in many central american areas not surprisingly englishspeaking skills increased with time spent in the united states the findings reported in table 1 also indicate that time in the united states is associated with economic incorporation locating a job participating in the labor force and undergoing income mobility transpire across time nonetheless there appears to be some degree of compression in the migrant labor force as the increased proportions in the two highest income categories are not dramatic table 2 contains data on family relations which reflect the effects of time given that recent migrants tend to be younger and that marriage likelihood increases over time migrants with more years in the united states tended to be married it is not surprising that migrants with more years in the united states were more likely to have spouses in the united states as presumably many of these migrants have located their family formation in the country where they were settled the findings also indicate that migrants with more years in the united states were more likely to have spouses with legal status migrants with more years in the united states also tended to have children at a higher proportion than the most recent migrants moreover migrants who had lived longer in the united states were more likely to have children living in the united states among those deportees who reported having to leave behind in the united states children younger than 18 or a spouse 38 percent indicated that they planned to remigrate to the united states the comments made by some of the interviewed deportees indicated their enduring bonds with family members as well as the practical importance of social capital for instance many of the married deportees who planned to remigrate spoke of practical family necessitiessuch as income and social support for spousesthat made their return to the united states urgent although they understood the risk of a prison sentence if apprehended for illegal reentry this did not appear to be a major deterrent findings from the survey of 300 salvadoran deportees therefore indicate that the mass removal of latino migrants is affecting deep layers of the latin american origin population in the united states this forced repatriation is removing categories of migrants who have become established residents of the united states with more than five or ten years of living in the country ice argues that it is removing criminal aliens but according to the data presented by the government in annual immigration statistical yearbooks the majority of deportees are removed for noncriminal violations consequences of deportation for immigrant social capital the findings listed in table 1 indicate that deportations are removing key human capital resources that are important to the integration of migrant communities many of those deported have authorized status relatively high levels of education fluency in english durability in the labor force and relatively high income levels migrant communities incur considerable disadvantages when they lose these resources when examining the 106 individuals in the sample of salvadoran deportees who lived in the united states for more than ten years we see that they have relatively high levels of economic and linguistic skills and are connected to employers and families they collectively constitute a significant source of human and social capital table 2 indicates how deportations remove resources critical for family household stability the majority of deportees are being removed from family units in which spouses are likely to have legal status and in which children younger than 18 are present as scholars have noted removing a migrant from families can have devastating effects in terms of loss of income and parental authority the transmission of social knowledge and life skills also has an intergenerational component that when absent or disrupted can have maladaptive consequences in addition to the fragmentation of family units the physical removal of family members by force especially parents can have longlasting traumatic effects on children the findings with implications for social capital are those in the texas and north carolina studies to summarize we found that the fear of deportation caused many immigrants to withdraw from public life as deportation often begins with a simple traffic stop many immigrants now avoid driving to churches restaurants and other community centers such reduced community participation breaks social capital networks or prevents their formation and thereby has important implications for individuals and communities more generally we know from the literature that immigrants normally participate in a range of community organizations for instance although noncitizens are not eligible to vote there are no prohibitions on a wide variety of other political and civic activities researchers have found that latino noncitizens are engaged in nonelectoral political activities participate in labor union organizing are networked into community political activities often by women and are actively involved in religious organizations as levitt noted the catholic church is a vast interconnected network of activities throughout the world and religious networks are both national and transnational such activities contribute to the creation of social capital but in the new enforcement climate every decision to participate entails the risk of deportation we can therefore draw several conclusions based on our data and the larger scholarly understanding of immigrant communities first deportation and involuntary return migration removes an individual from family and business networks some of these links may be within immigrant communities a form of bonding capital but other links may connect individuals with people and organizations outside the community a form of bridging capital in both cases the community loses an individual who may have been able to uniquely provide material assistance to friends family and colleagues for immigrants such networks are particularly important as newcomers may have few other ways to access potentially helpful individuals and institutionsespecially in terms of finding jobs in addition we saw that a fear of driving causes individuals to withdraw from community life which further inhibits the growth of social capital networks second mass deportation may lower levels of community trust particularly in government for those who know work with or are related to a deportee the government may become an object of fear in addition individuals may be reluctant to contact police or social service providers if they believe this might put them or an unauthorized friend or relative at risk of deportation unauthorized individuals who know of a deportation may make special efforts to avoid contact with others in order to minimize awareness of their status as with the fear of driving a lowering of trust can have negative consequences for immigrants and their communities third unauthorized individuals may decide to focus on creating bonding capital instead of developing bridging capital interactions with other immigrants or with institutions familiar with immigrants may appear less risky than interacting with those less knowledgeable of and possibly less sympathetic toward immigrants while this may lower opportunities for immigrants and their communities it may be seen as a way to minimize the odds of deportation fourth as is consistent with past research deportation affects families as our data show many deportees leave behind spouses and children aside from the emotional dimension this reduces the resources available to the family and therefore increases the likelihood that the family will live in poverty this in turn diminishes the life opportunities of children and increases stress on the remaining parent in this way the deportation of social capital can negatively affect generations of american citizens lastly we might consider how deportation affects institutions that are relevant to the wider community when immigrants with social capital are deported the harm is felt not only by the individuals noted above but also by the organizations in which they participated businesses lose workers churches lose members and schools lose parents such institutions thereby become part of the collateral damage of mass deportation which in turn has implications for society more generally if businesses lose experienced workers this could have negative consequences for the local economy if churches lose members this may reduce their ability to engage in religious outreach or community service activities when parents are deported fewer volunteers may be available to help with school activities while this article has focused on the likely harm of deportation to immigrant communities we should not overlook these additional wider implications if deportations lower social capital one consequence may be reduced capacity to address community needs scholars have hypothesized that one of the functions of social capital is to overcome collective action problems in communities that already face significant obstacles a vigorous deportation policy may impede grassroots efforts to combat crime improve education enhance the quality of public spaces and otherwise act on problems that affect everyone yet prove challenging for any individual to fix if social capital is a web of relationships and concomitant trust that allows communities and individuals to overcome obstacles solve problems and make socioeconomic gains then deportation has the potential to tear these fragile threads for those communities with few other resources this loss may be considerable we also note that deportations vary across the nation some locales are involved with the 287 program for instance while others are not immigration laws apply nationally but some communities do not wish to directly involve local law enforcement in such efforts this may differentially affect certain types of immigrant communities if enforcement and deportation are more common in the new destination locations with little history of immigration like north carolina then the immigrant communities that most need social capital might be those where it is most often removed on the other hand renewed deportation efforts by ice have undoubtedly removed many dangerous criminals from the united states and therefore from immigrant communities if immigrants and their families cannot live safely in their homes cannot venture outside without fear are the subjects of fraud and are harmed physically emotionally and financially by crime then social capital and community wellbeing will be negatively affected one key issue is to what degree contemporary policies lead to the deportation of criminal aliens versus those who have committed relatively minor offenses while a targeting of violent criminals would not impedeand could even enhancesocial capital and immigrant integration a focus on some other categories of offenses might have the opposite effect while all crime needs to be taken seriously the deportation of those with resourcesespecially legal permanent residentsrequires some additional reflection about family costs community consequences and proportionality in addition not all crimes that lead to deportation are equal according to dhs data most deportees did not commit violent crimes or similar offenses in fact the largest categories involve immigration trafficrelated and drug offenses the crimes that come to mind when the term criminal alien is usedsuch as assault robbery and sexual assaultconstitute only singledigit percentages of total deportations for example in fiscal year 2012 the largest categories were immigration criminal traffic offenses and dangerous drugs by contrast the percentage for assault was 65 percent for robbery was 18 percent and for sexual assault was 17 percent this means that the united states deported 12962 individuals convicted of assault and 3349 convicted of sexual assault which undoubtedly benefits the nation generally and immigrant communities in particular however the totality of deportations does not reflect the national security and crime narratives used to justify such programs and policies another consideration is the effect of deportation on migration it might appear that deportation reduces future migration but as massey durand and malone observed social capital serves to enhance migration because migrant networks are an important source of social capital for people contemplating a move abroad for example they noted that the bracero program enhanced migration because returning migrants created social capital among their friends and family in mexico which reduced the costs and risks of their own international movements and increased their access to us employment today the deportation of hundreds of thousands of individuals may serve to increase and deepen such international social capital networks which could lead to more migration in the long run in another context scholars have observed that deporting gang members can strengthen international criminal networks with el salvador a prime example when contacts are maintained between the deported and those remaining in the united states this form of social capital can facilitate illicit future activities conclusion the research discussed in this article indicates that the us policy of massive deportation is carried out at significant cost not only to migrants and their families but also to immigrant communities many of those who are deported possess relatively high levels of human capital and are embedded in the family and workplace networks that constitute social capital among the deportees to el salvador some live legally in the united states have lived in the united states for some time have been employed for much of this time earn incomes that can support a family and have high school and even college educations such connections and relationships are helpful not only to these individuals and their families but also to those they know in their communities these deportees may also be among the most likely to have developed bridging social capital in addition enforcement practices that target drivers have negative consequences for social capital immigrants in north carolina reported an avoidance of churches restaurants and other community venues because driving can start a chain of events that leads to deportation they therefore withdrew from their communities as much as possible sometimes paying licensed drivers for rides to work but otherwise staying at home such communities are thus fractured by fear which prevents the development and maintenance of the networks at the heart of social capital because immigrant communities are in need of social and human capital massive deportation imposes substantial costs on individuals as well as communities similarly current policies deter civic and community mobilization for instance while noncitizens cannot vote the literature finds that immigrants do participate in various political union religious and civic activities hardyfanta described the mobilization of undocumented immigrants to address neighborhood problems in boston they even held rallies with police officers in front of drug houses such efforts are less likely in the current environment thereby harming communities directly by reducing local activism and indirectly by preventing the resulting social capital linkages furthermore we should keep in mind the broader harm to society that can result from a loss of immigrant social and human capital when businesses lose workers churches lose parishioners and schools lose parents these organizations may not be able to operate as efficiently or effectively this may have negative implications for the local economy for religious life and for local education mass deportation may thereby not only affect immigrant communities but also localities more generally regardless of race ethnicity or legal status individuals may find local institutions less robust and thereby see their quality of life diminished on the other hand current policies serve to deport some people who have committed serious crimes and whose removal benefits immigrant communities and american society more broadly however it is difficult to judge how this balances the collateral effects of mass deportation described in this article

the united states currently removes approximately 400000 individual migrants each year which represents close to an eightfold increase since the mid1990s while scholars have studied the consequences of such policies for children and families this article posits broader effects on communities through the reduction of immigrant social and human capital using findings from three studies of immigrant communities and salvadoran deportees we show that current deportation practices remove individuals with a wide range of socioeconomic resources and ties to local communities when they are removed from economic family social and civic networks the individuals and communities left behind are impoverished in important ways this is particularly consequential for lowresource immigrant communities which under the best of circumstances encounter obstacles to economic advancement social integration and political engagement in addition we consider the potential harm to the institutions in which immigrants participate such as businesses and churches which has implications for the economy and society more generally

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446 d contandriopoulos m lemire jl denis and é tremblay highlighted the individual and collective levels as being both complementary and necessary to the success of clinicallevel changes and quality improvement we conducted a largescale analytical literature review focused on two relatively autonomous bodies of literature on knowledge exchange the first was derived from mostly three sources debates about the role of social sciences in society studies of the use of evaluation results and to a lesser extent rationalist management perspectives influenced by the success of ebm at the clinical level the second body of literature was developed in the field of political science it comprises theoretical and empirical work on the deliberate use of information by interest groups in policymaking processes and on the influence of networks shape nature and composition on information circulation in policymaking we begin with a short discussion of the boundaries of this phenomenon then we describe our data collection and synthesis method finally we explore the definitions of collectivelevel knowledge exchange and use that emerge from the literature we reviewed and discuss three characteristics of context that have a core influence on those processes definition of the phenomenon defining knowledge because of its integrative focus we based our review on a broad and encompassing definition of the notion of knowledge actually some traditions seldom use the terms knowledge or evidence for example a significant part of the literature on exchange processes was developed in the field of evaluation in which the content of the exchange process itself is evaluation results more fundamentally other fields refrain from normative distinctions regarding the nature of the information transmitted in political science or organizational analysis decisionmaking processes are conceptualized as being informed by various types of information including in some cases scientific evidence consequently in order to integrate various traditions we have not distinguished the nature of the information transmitted through the interventions collectivelevel processes of knowledge exchange our review assumes that knowledge exchange processes can occur at two complementary levels that should be analytically distinguished on one hand some knowledge exchange processes are aimed at autonomous individuals here autonomy refers to the fact that the potential users of knowledge targeted by the exchange processes are usually sovereign in their capacity to mobilize knowledge and consequently to modify their practices the individuals targeted will respond to the knowledge exchange process to varying degrees and both the context and the individuals characteristics will have an impact the outcome of the knowledge exchange process however remains an individual reaction at the confluence of individual contextual and process factors interventions aimed at modifying the clinical behavior of professionals mostly fall within this definition of individuallevel interventions on the other hand knowledge exchange processes can occur in systems characterized by high levels of interdependency and interconnectedness among participants interdependency here refers to the fact that none of the participants has enough autonomy or power to translate the information into practices on his or her own in such contexts individuals are embedded in systemic relations in which knowledge use depends on processes such as sense making coalition building and rhetoric and persuasion we suggest that causal relations between knowledge exchange processes and their outcomes are sufficiently different at the individual and collective levels to warrant different approaches in both knowledge exchange interventions and their analysis and evaluation given that the intended effects of individuallevel interventions are usually repeated behaviors by numerous autonomous individuals this allows us to use robust quantitative methods to study behavioral or practice changes conversely a collective knowledge exchange intervention that involves numerous individuals usually produces systemic outcomes that cannot be easily specified and as such that considerably complicate a valid measurement of the effects figure 1 illustrates the difference in the two levels effects this difference explains the gap between the strength of available evidence regarding the effectiveness of clinicallevel interventions and the relative weakness of the evidence on collectivelevel interventions from the outset we focused exclusively on the collective level individuallevel interventions are fundamental to improve quality effectiveness and efficiency in the delivery of care but as many scholars have stated individuallevel interventions alone cannot achieve those objectives policymaking and organizationallevel interventions play a major role our aim in this review is to strengthen our understanding of the processes in such interventions knowledge exchange interventions in conducting our review we further limited our definition of knowledge exchange interventions first although information flows are both natural and ubiquitous in organizational and policy systems we narrowed our review to include only active deliberate communication efforts similar to the distinction between naturally occurring diffusion and active dissemination proposed by some scholars we describe active knowledge exchange efforts as deliberate or instrumental in the sense that some people use them as instruments to influence the opinions or actions of others second opinions and actions encompass what are usually described as decisions as well as the production of discourse the study of knowledge transfer processes is greatly influenced by the concepts of decision and decision making yet the operation of those concepts in collective systems is highly problematic we therefore refrained from relying on the concept of decision and instead used the notion of actionas discussed later in more detailto describe the target of the knowledge exchange intervention third the heuristically useful distinction between instrumental and symbolic use is challenging on a practical level in the words of beyer and trice instrumental use involves acting on research results in specific direct ways while symbolic use involves using research results to legitimate and sustain predetermined positions empirically making the distinction would require perfect access to users cognitive processes and it remains debatable whether even users would be able to make the distinction similarly because we are concentrating here on deliberate dissemination interventions we intentionally left out conceptual use even though it can be an important externality of deliberate intervention to summarize our review is focused on the collective level of analysis in order to understand deliberate interventions aimed at influencing behaviors or opinions though the communication of information methods data collection from the outset our aim in this review was to develop an integrated interdisciplinary framework for understanding collectivelevel knowledge exchange interventions this made it challenging to identify a coherent and precise set of keywords for the search process in a field similar to the one reviewed here but with less interdisciplinary ambition the review published by mitton and colleagues relied on a keyword approach that enabled the identification of 169 relevant documents out of 4250 hits we anticipated that in our case a similar strategy would yield even more chaff and less wheat because the disciplinary traditions targeted are broader and each relies on distinct vocabulary and conceptualizations inspired in a large part by the work of greenhalgh and colleagues we relied instead on a nonkeywordbased reviewing process that we dubbed doublesided systematic snowball our goal was to identify documents that made a core contribution either conceptually or empirically to the understanding of the phenomenon our starting point was to identify through team consensus some seminal papers that were considered to have shaped the evolution of the field we started by identifying a heuristic list of seven traditions political science literature on lobbying and group politics works on agendasetting processes in policymaking literature on policy networks mainstream literature on knowledge transfer and exchange works in the evaluation field about the use of evaluation results organizationallevel literature on decisional processes and learning and social network analysis works on information circulation each tradition was exemplified by one or more publications the definition of traditions and the identification of specific publications were interdependent processes conducted on a consensus basis at the end of the process we had produced a list of thirtythree seminal sources although any such starting point has limitations we contend that the doublesided systematic snowball process we used can compensate for omissions in the initial list we then used the isi web of science citation index to identify all documents that cited those seminal papers the snowball process here was prospective since it exclusively targeted documents published after the selected seminal paper we then triaged the results using the titles and the abstracts using a decision grid based on the definition of the phenomenon under review as discussed in the previous section this process identified 189 documents that we then retrieved and read for further selection according to the same criteria at the end of this prospective snowballing we selected 102 documents for detailed analysis next we used the bibliographies of those 102 documents as a basis for retrospective systematic snowball sampling we entered each documents complete bibliography in a database and used algorithms to identify all articles cited five times or more and all books cited seven times or more the thresholds for articles and books were set individually by trial and testing to achieve an acceptable precision rate the principle however was the same and was aimed at identifying what greenhalgh robert bate and colleagues called landmark papers from this we identified twentythree new books and fiftyseven articles among the articles we excluded fourteen based on relevance criteria and twelve that were already among the 102 identified in the first step finally we included fortynine other documents either through deliberate selection during the first step of analysis because of their empirical or conceptual contribution or through nonsystematic sampling of the field in the end we analyzed 205 documents in detail we will return later to our decision not to include triaging on the basis of strength of evidence in our reviewing strategy but first we will discuss the exhaustiveness of the data collected the low level of data saturation obtained after the two iterations of snowball sampling surprised us because we identified twice only twelve documents out of 217 this prompted some questioning about the actual size of the total population of relevant documents to estimate the total population size we used the lincolnpetersen capturemarkrecapture formula commonly used in ecology depending on how the book chapters are treated population estimates vary between 561 and 595 the accuracy of this formula rests on the assumption that individual items have the same probability of being captured in each of the two rounds this assumption was clearly not upheld in our sampling strategy and our estimate of population size thus is probably significantly inaccurate nevertheless this estimate can provide an order of magnitude which in turn highlights the fact that this review was systematic only to the extent that it relied on an explicit rigorous and transparent methodology given the considerable proportion of eligible documents that were likely neither identified nor reviewed we should acknowledge that systematic here does not mean exhaustive it is important to emphasize however that we have no reason to believe that keywordbased approaches are more accurate or exhaustive another important issue in systematic reviews concerns the exclusion criteria used for triage as mentioned earlier we applied the same relevance criteria at every step of the process and abstained from triaging on strengthofevidence criteria we made this methodological decision during the review because of practical problems we encountered while using strengthofevidence grading tools many documents that we considered insightful informed and central would have been excluded by such grading tools because they were not based on explicitly empirical data illustrations of such situations are works from carol weiss or jonathan lomas who have considerable knowledge of both theoretical and practical issues related to our phenomenon gathered from active empirical experience and who wrote conceptual papers based on this tacit knowledge for example weisss paper was cited in thirtynine of the 102 documents identified in the first snowballing step but would have been triaged out for not being based on explicit empirical data synthesis approach the greatest challenge in conducting a review in a broad and complex field like the one defined by our phenomenon of interest is not data collection but data synthesis how could we make sense of several thousand pages of data in a usable and publishable format the data in our field are almost exclusively narrative in the sense that whether the primary data sources were quantitative or qualitative the data we actually collected and analyzed are documents whose meaning cannot be accessed in any other way than through their narrative structure many factors explain this situation in particular the conceptual diversity of the field the complexity of the interventions themselves and their systemicas opposed to summativeoutcomes the last two characteristics are core features of the phenomenon studied that make it ontologically more suited to case studies than to any other method as confirmed by the data collected in this review we used two main synthesis techniques to deal with narrative material one uses stringent triage criteria to summarize the main findings of the selected sources in either tables or new narratives stringent triaging is mandatory to keep the output to a usable size for example a recent synthesis on knowledge transfer by ward house and hamer went from 9522 keywordgenerated hits to twentyeight paperbased models whereas mitton and colleagues review went from 4250 keywordgenerated hits to eightyone papers the second technique is what forbes and griffiths call an analytical or theoretical synthesis quite close to what pawson and colleagues described as a realist review approach whose aim is to synthesize the data as a new integrated theoretical model the wellknown metanarrativemapping approach of greenhalgh and colleagues is at the junction of the two it pushes summarization to its limits by treating as the unit whole research traditions rather than individual documents and by doing this offers a new integrated theoretical model of its phenomenon of interest the main strength of the summary approach is the transparency of the summarization process its principal weaknesses are the loss of detail and the understanding of contextual influences provided by primary sources the loss of overview and the disputable usability of results too often presented as long and lifeless summary tables analytical approaches have the opposite qualities whereas the analytical summarization process itself may be opaque to readers it is intended to help them make sense of the primary sources by iteratively building a new model that will serve as a heuristic tool to comprehend convergences and divergences in the causal relations proposed by those primary sources we also contend that such approaches are more likely to provide usable results in the context of complex interventions we should note that using analytical approaches makes formal triaging on the basis of strength of evidence much less crucial to the validity of results the documents scientific strength is assessed during the indepth analysis at which point empirically weak papers as well as those providing only a marginal conceptual contribution are given a secondary place in the analysis our reviews summarization process had three phases each of the first 102 documents were randomly assigned to be read by a primary reviewer who prepared a brief synopsis of its contribution to the understanding of the phenomenon the synopses were then crossvalidated by a second reviewer from among the same three the 102 synopses were the basis of the firstdraft synthesis document produced by team discussions then the second step of the data collection started and each new documents marginal contribution was directly integrated into the draft synthesis without an earlier synopsis during this step we also discussed the draft on four occasions with three senior decision makers in quebecs health care system to assess the usefulness of the model developed the draft synthesis was edited and developed iteratively until marginal modifications were considered minor enough to stop the process results we concentrated our integration of the reviewed literature on two main dimensions first we analytically defined and discussed three basic components of knowledge exchange systems the roles of individual actors working in collective systems the nature of the knowledge exchanged and the process of knowledge use second we conceptualized knowledge exchange interventions as being a part of larger collective action systems with three core dimensions polarization cost sharing and social structuring we should stress that the material we reviewed extends beyond those dimensions and that other levels of analysisfor example individuallevel strategies of communicationare possible as well individuals in collective knowledge exchange networks the various disciplinary traditions reviewed here have comparable typologies categorizing individuals into three groupsproducers intermediaries and usersaccording to their relative position on the knowledge circulation continuum at one end are those individuals who work in socially legitimate knowledge production institutions and systems without the capacity to put the knowledge developed to use at the other end are individuals who hold institutionally and socially sanctioned positions that allow them to intervene in the practices rules and functioning of organizational political or social systems in between are various kinds of intermediaries called conveyors brokers intermediaries or lobbyists all of whom contribute to the information flow many models or actual knowledge exchange interventions concern only two of the three for example political science models of lobbying often neglect the production side and some knowledgebased models of evidence transfer tend to disregard actual utilization processes those three groups should however be used with caution in empirical analysis actual knowledge exchange systems are composed of numerous individuals and the intragroup diversity of positions opinions preferences and interests should never be discounted although collective the processes analyzed here are in the end actuated by individuals all these individuals are exposed to institutional incentives and broader social norms and values the definition of the interdependence among the social structures individual perceptions and action used in the analysis rests mainly on the work of the french sociologist pierre bourdieu according to his perspective humans internalize the results of their daily interactions with the social world into a subconscious habitus every habitus is unique to the extent that it is the product of the individuals history past practices and interactions with social structures yet it also reflects the objective cultural social and institutional structures within which the individual lives this explains the overall convergence of perceptions among individuals exposed to similar experiences and conditions at a rather prosaic level the institutional and social positions of actors in knowledge exchange systems shape their views of their role in these systems which in turn interact with their cognitive processes which do not resemble simple rational models actual knowledge exchange systems thus are complex because they are made up of complex human actors this may seem obvious but the literature is rife with oversimplifications the three most common of which are discussing the hypothetical relations between one user and one producer reifying users or producers as homogeneous groups and disregarding the complexity of human motivations by attributing intrinsic groupbased preferences or interests to users producers or intermediaries knowledge from information to evidence the first building block in any framework for analyzing knowledge exchange interventions is a definition of knowledge the scientific literature reviewed does not offer a clear dominant definition the smallest common denominator is the generic notion of information set by our heuristic definition of the field various scholars and disciplinary traditions offer competing typologies established on the basis of the source or the nature of information the concept of knowledge exchange however especially in health care rests on an implicit commonsense notion that this knowledge must be evidence based theoretically the distinction between information and evidence rests on the strong internal validity of the latter internal validity refers here to the scientific plausibility of the causal links implied in the message although the literature offers much normative advice to encourage users to favor scientifically valid evidence and to disregard other sources of information much of the converging evidence suggests that internal validity per se does not influence information use it is unclear whether the lack of relation between internal validity and use is due to the users lack of training in assessing or understanding internal validity criteria or because the concept of internal validity is irrelevant to the actual use this second hypothesis might be explained by three different arguments the first is that at the collectiveaction level relevance to users has less to do with internal validity than with external validity that is whether the causal link would hold in the users specific context the second somewhat related argument is specific to social sciences results and suggests that evidence derived from social sciences always in fact offers shallow insights not very different from common sense or what users can infer from their own experience we do not share this view of the ontological shallowness of social science results but we will return to this argument in our discussion of the concept of knowledge use finally the third and probably the most important argument has to do with competition from this standpoint users responsibility is to balance various kinds of information although developed mostly in political science this third explanation is quite economical in its implication that knowledge exchange systems are first and foremost systems of competition in which various kinds and sources of information compete for scarce resources namely the users attention if we accept that users are exposed to diverse kinds of relevant and legitimate information only some of which is produced through scientific methods then it follows logically that they cannot sort through and prioritize the information based on internal validity per se in their assessment of its relevance and credibility users can either take internal validity into account or not but then validity will be treated as only one criterion of credibility among others there also is evidence that tacit knowledge and experience are often accorded significant weight in this process the literature reviewed offers compelling support for the idea that in the exchange and utilization processes scientific evidence is treated no differently than other types of information depending on the users views and the institutional culture or rules the internal validity and consistency with scientific procedures of any given piece of information contribute to its perceived credibility to an unknown extentwith no extent being a credible hypothesis in many contexts we thus suggest that knowledge exchange interventions should be conceptualized as generic processes unrelated to the internal validity of the information exchanged many normative recommendations for knowledge exchange emphasize techniques aimed at ensuring that the message is scientifically sound suggesting as we do that knowledge exchange processes are not related to the scientific strength of the message in no way implies that validity does not matter for it obviously does what it implies is that developing scientifically sound advice and then designing knowledge exchange interventions to translate that advice into practices at the collective level are two different processes the challenge of deliberate knowledge exchange interventions is working on a plausible linking of these two processes defining knowledge use at the collective level the data we collected showed that there are tens if not hundreds of definitions of knowledge use but unfortunately none seems to dominate the literature we reviewed however quite consistently suggests that scientific evidence seldom if ever directly solves organizational or policylevel problems to be relevant usable and meaningful evidence needs to be embedded in what political science calls policy options and could generically be called action proposals action proposals are assertions that employ rhetoric to embed information in arguments to support a causal link between a given course of action and its anticipated consequences in this article we define collectivelevel knowledge use as the process by which users incorporate specific information into action proposals to influence others thought and practices this definition calls for some elaboration first because the practical capacity of any given user to influence the collective system within which he or she intervenes is contingent on contextspecific factors this definition dissociates knowledge use from actual practices or outcomes second we mentioned earlier that social science results were often described as offering shallow insights this definition of use suggests that shallowness is not a characteristic of the evidence itself but a characteristic of collectivelevel contexts in which the internal validity of the evidence dissolves during the elaboration of action proposals third although our review is not focused on the individual level the actual capacity of a given actor to influence thought practices or rules is highly dependent on his or her rhetorical abilities and symbolic capital finally in interpreting the definition we should keep in mind that at the collective level knowledge plays a central role in the processes by which issues are problematized conceptualized and prioritized something described in political science as agenda setting ideology and polarization the literature we reviewed generally agreesalthough mostly implicitly in political sciencethat the use of knowledge is influenced by its relevance legitimacy and accessibility relevance refers to timeliness salience and actionability all heavily contextdependent characteristics legitimacy refers to the credibility of the information accessibility refers to dimensions such as formatting and availability the causal link between knowledge characteristics and use however is mediated by users perceptions linking utilization to users perceptions rather than to the characteristics of knowledge per se in turn allows us to understand how politics and ideology influence knowledge exchange every individual involved in collectivelevel networks of knowledge exchange has opinions preferences and interests those opinions preferences and interests are central to each users individual assessment of knowledge characteristics if a users understanding of the implications of a given piece of information is contrary to either his or her opinions or preferences the user will ignore contradict or at least subject this piece of information to strong skepticism and low use moreover not all individual users and groups in a collectiveaction setting should be presumed to have similar perceptions about any given piece of information which introduces the notion of issue polarization contexts are said to be characterized by low issue polarization when potential users share similar opinions and preferences regarding the problematization of the issue the prioritization and salience of the issue and the criteria against which potential solutions should be assessed conversely as the level of consensus on those aspects diminishes issue polarization grows in the literature we reviewed there is consensus that issue polarization is a core feature of the knowledge exchange context low issue polarization is a sine qua non condition for technically focused debates in which participants try to resolve differences though dialogue and rational arguments based on shared worldviews conversely high issue polarization leads to political debates and strategictype processes in which dialogue is unlikely to bring consensus and participants try to impose their views on others the literature we reviewed is sharply divided on how knowledge exchange interventions should adapt to variations in issue polarization there is a clearly perceptible normative bias in much of the literature reviewed in favor of instrumental knowledge use as opposed to symbolic use we should note parenthetically that interesting arguments are provided at least on the theoretical level suggesting that symbolic use can indeed lead to desirable outcomes but since high issue polarization is negatively associated with instrumental use much of the literature suggests that a polarized context is intrinsically incompatible with success in knowledge exchange interventions nevertheless this view is not shared by the political science literature for which a polarized context is the normal state of affairs in the lobbying tradition the way in which divergences in opinions preferences and interests are organized explains the extent of involvement in knowledge exchange activities the structure and shape of knowledge exchange networks and the content of the information exchanged if we accept the idea that knowledge exchange activities imply some forms of cost it follows logically that some people in the knowledge exchange system must incur those costs the challenge then is to understand the costsharing equilibrium between individuals and groups given the agreement in the literature on the typology of producers intermediaries and users this typology can be used heuristically to discuss cost sharing the userpull and producerpush models already imply that the effort is assumed primarily by individuals from one or the other end of the process likewise a concentration of either benefits or losses or a high level of polarization turns many actors into de facto lobbyists advocating for specific action proposals that is deliberately transmitting knowledge to defend their preferences or advance their interests social structuring the last important contextual factor raised by our review is the influence of social structures both empirical analyses of knowledge exchange interventions and individuallevel theories of human behavior show that interpersonal trust facilitates and encourages communication and that repeated communications create trust in the long run this feedback process helps open natural and enduring communication channels and is at the core of the numerous recommendations in favor of developing a close collaboration between producers and users empirical analysis of lobbying techniques also supports the idea that developing and maintaining communication channels is a credible way to enhance use because doing this both facilitates access and raises the perceived value of the information transmitted from an instrumental standpoint the question is the extent to which it is possible to actually intervene in the shape and nature of communication networks modifying the organizations formal structure is one way to act on those factors a wellknown example of which is the creation of knowledge broker positions knowledge brokers are hired by users organizations and are expected to work as boundary spanners identifying selecting and obtaining information from the environment and efficiently transmitting it within the organization according to needs although conceptually appealing presentations of this model often fail to discuss the practical difficulties of such a role in communication networks in which numerous sources of information are competing polarization and politics matter and information is unlikely to be neutral objective data but rather bundled action proposals the brokers structural position inside organizations is likely to limit their actual interventional capacity to contexts with low polarization and significant user investment we should also note that by nature knowledge exchange systems are not restricted to formal communication channels but extend well beyond organizational boundaries deliberately modifying network characteristics of such systems is thus very difficult the framework developed here suggests that close collaboration between users and producers or intermediaries can exist only when a viable costsharing equilibrium is found such an equilibrium can be found for example when users are willing to invest enough resources to hire producers as consultants another viable equilibrium highlighted in the material reviewed is seen when producers or much more often intermediaries perceive knowledge exchange activities as a legitimate and viable means to defend their own opinions preferences or interests and decide to invest in lobbylike activities and bear most of the costs in contexts in which the boundaries of polarization are relatively stable this last equilibrium is likely to give rise to selfreinforcing institutionalized communication networks among allies with a significant amount of mutual trust discussion carol weiss developed a typology of the different meanings of knowledge use that had a considerable impact on the field weisss typology is based on seven meanings four of which are of interest here because their conditions of efficacy are in our opinion closely related to the core contextual dimensions we discuss those four are the knowledgedriven problemsolving interactive and political models to summarizequite drasticallyweisss exhaustive argument the knowledgedriven model rests on the ideas that basic research discloses opportunities that may be relevant to public policy and that procedures should be implemented to ensure that promising knowledge is tested and when pertinent implemented the problemsolving model reverses that logic positing that research should try to provide empirical evidence that helps solve preidentified policy problems the interactive model posits that those engaged in policymaking seek information from a variety of sources through a disorderly set of interconnections that contribute in the end to making sense of the problem and developing solutions finally in the political model users have already taken a stand that research is not likely to change and so information becomes ammunition for the side that finds its conclusions congenial and supportive in figure 2 we extend weisss typology by suggesting that these models can be interpreted not only as meanings but also as actual types of use we contend too that two of the core dimensions of context discussed here can be helpful in understanding the conditions of efficacy for the models of use this contention tallies with the main conclusion of this review that context dictates the realm of the possible for knowledge exchange strategies aimed at influencing policymaking or organizational behavior if a given issues salience and prioritization are high enough for users to initiate knowledge exchange efforts and invest resources in them then the probability of its use and impact can from the outset be presumed to be high in minimally polarized contexts use will likely resemble weisss problemdriven model and in highly polarized ones it will probably look like a political model of use when users are unwilling to bear the costs of the knowledge exchange intervention a viable costsharing equilibrium exists only if others whether producers or intermediaries are motivated enough to disseminate information actively through lobbylike techniques again this is much more likely in significantly polarized contexts which are amenable to the political use of knowledge in producerdriven minimally polarized contexts a viable costsharing equilibrium is much less probable but if it is found use is likely to resemble weisss knowledgedriven model we acknowledge however the conspicuous absence in the material we reviewed of any empirical data or convincing theoretical frameworks supporting the hypothesis that significant use is likely in this last situation in contrast models that are mostly derived from political science offer quite interesting theoretical justifications for the fact that political use can lead to positive outcomes such models are based on the idea that knowledgeconceptualized here as convincing and politically viable action proposalsis considered as a commodity and is shared with allies as long as the information is scientifically sound its strategic dissemination and exchange in a collective system can only increase its marginal impact compared with that of other information sources something that would be construed by many people as desirable questions remain about the degree to which this transmission process distorts knowledge through a form of lying by omission from a use perspective the ideal situation is one in which both users and producers are willing to invest in knowledge exchange this allows for collaborative models of knowledge exchange in which knowledge is jointly produced through the pooling of users expertise and producers expertise at the macrolevel many scholars have pointed out that both the institutional recognition of formal scientific knowledge use and individuallevel incentives affect the likelihood of achieving viable costsharing equilibria potential avenues of intervention for instance would be to have institutional rules that value scientific validity and independence in the commissioning and use of policyrelevant studies and that structure participants norms and values into the relative weighting of such information that said however very few levers are available at the micro level to act on the perceptions of users or producers in order to influence their willingness to invest resources or efforts in knowledge transfer our review failed to find any knowledge transfer techniques likely to bring about significant nonpolitical use in situations in which there is no viable costsharing equilibrium or the equilibrium places most of the effort on producers or intermediaries conclusion advice for practice and research from this analytical review of the literature on collectivelevel knowledge transfer in diverse disciplinary fields we can offer an integrative model to understand and analyze this phenomenons main dimensions the model we developed is based on three core dimensions that emerged inductively from the analysis level of polarization costsharing equilibrium and institutionalized channels of communication to conclude we offer some reflections on the future of research and practice in the field on the research side as previous results have suggested our analysis of the literature shows that the quest for contextindependent evidence on the efficacy of knowledge exchange strategies is probably doomed collective knowledge exchange and use are phenomena so deeply embedded in organizational policy and institutional contexts that externally valid evidence pertaining to the efficacy of specific knowledge exchange strategies is unlikely to be forthcoming on the practice side our results suggest that the best available source of advice for someone designing or implementing a knowledge exchange intervention will probably be found in empirically informed and sound conceptual frameworks that can be used as field guides to decode the context and understand its impact on knowledge use and the design of exchange interventions much of the available practiceoriented advice on knowledge transfer promotes either one particular technique as a solution to the challenges of knowledge exchange and utilization or else very linear knowledgedriven processes the evidence reviewed here does not support most of that kind of advice to design a knowledge exchange intervention to maximize knowledge use we suggest starting with a detailed analysis of the context using the kind of framework developed here and wright 1992 burstein and hirsh 2007 phillips and phillips 1984 in the policy network tradition polarization is also the core variable explaining the networks shape this tallies with observations from other traditions regarding the influence of ideological proximity on knowledge exchange processes what the political science tradition added beginning with the seminal works of bauer pool and dexter and milbrath is the explicit consideration that because information is a prized commodity in political struggles with both a price and a value it should be offered to allies and strategically used against opponents this observation is supported by strong empirical data according to this view the crucial element in understanding or designing knowledge exchange interventions is not so much the level of polarization as the way in which the system is divided and polarized the costsharing equilibrium in the knowledge exchange system the idea that knowledge has both a cost and a value was used by bardach to suggest that knowledge will reach those for whom the utility of having it exceeds the disutility of obtaining it although this statement is highly rationalist in essence a widely shared broader assumption in the literature is that producers intermediaries and users all invest their energy and resources in knowledge exchange processes to the extent that they perceive this investment to be profitable this in turn translates into encouragement for the implementation of institutional incentive schemes to increase use eg for producers tagged grant money or appendix list of seminal references 1 ainsworth s and i sened 1993

this article presents the main results from a largescale analytical systematic review on knowledge exchange interventions at the organizational and policymaking levels the review integrated two broad traditions one roughly focused on the use of social science research results and the other focused on policymaking and lobbying processes methods data collection was done using systematic snowball sampling first we used prospective snowballing to identify all documents citing any of a set of thirtythree seminal papers this process identified 4102 documents 102 of which were retained for indepth analysis the bibliographies of these 102 documents were merged and used to identify retrospectively all articles cited five times or more and all books cited seven times or more all together 205 documents were analyzed to develop an integrated model the data were synthesized using an analytical approach findings this article developed integrated conceptualizations of the forms of collective knowledge exchange systems the nature of the knowledge exchanged and the definition of collectivelevel use this literature synthesis is organized around three dimensions of context level of polarization politics costsharing equilibrium economics and institutionalized structures of communication social structuring the model developed here suggests that research is unlikely to provide contextindependent evidence for the intrinsic efficacy of knowledge exchange strategies to design a knowledge exchange intervention to maximize

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introduction the aim of the article is to present the relations of justice in social life based on the example of the right to life from the moment of conception this right is the first and superior of rights since without this right other ones lose their meaning 1 as j rawls stated justice is the first virtue of social institutions as truth is of systems of thought likewise laws and institutions no matter how efficient and wellarranged must be reformed or abolished if they are unjust 2 any attempt of a more profound explanation inevitably points to human rights human being is the subject of justice 3 since the term justice is referred to human being it does not apply to nonhuman beings such as animals man is a special being so different from other beings accessible to our direct cognition it is a being differing from animals the human being of all the beings living on earth is the most perfect the most important one heshe is the utmost form of existence it is man who can strive towards and reach the sphere of values it is an entity capable of realizing values obviously the term justice is used in various meanings it is used in reference to man as such to mans deeds4 it is used in reference to someones conduct or action 5 it is used in relation to a just or unjust law a just or unjust procedure a just or unjust trial a just or unjust decision but these different meanings are related to the original dimension regardless of whether justice refers to human beings as their trait or to their actions or conduct justice refers to man also regardless of whether we refer to institutions law norms or decisions to apply the law justice still pertains to man justice is not referred to in relations between animals or between man and an object but no one can do justice or do injustice to himself because justice covers at least two persons 6 justice exists between persons let us consider justice as a type of social relation in the simplest arrangement there are two entities one has a right the other a duty let us extend this to the collective live in a state justice as a universal value7 is a universal duty in the most general terms it can be said that justice with its power normative power builds the relationship between the one to whom something is due and the one who is obliged we have pointed to the issue to whom something is due and what is due justice is to render everyone his or her due suum cuique to give everyone his or her own and what to give what thing is ones own what is ones own what is due this is about the rights of man every human being has natural rights the first of these being the right to life followed generally by the rights to ones personal development and safety these rights are the requirements of the kind of justice referred to as natural justice 8 and since there are rights then accordingly someone has obligations these rights are correlated with obligations of others let us emphasize that justice exists between specific people who then is the obligated entity to answer this question a significant distinction must be made u m c s justice as an obligation of authority holders in a simplified perspective distributive justice 9 which is in some sense a reflection of natural justice links two subjects considering the simple relation we could say in the most general terms that there is a distributor and a subject to whom certain goods are distributed of course distribution is understood in a metaphorical and broad sense as far as the obligated entity is concerned it might seem as generally accepted in the literature on the subject that such an entity are those in charge of the community the state the phrase in charge of should be understood in a broad sense including the legislative authority however and let us emphasize this again justice is only attributed to man it provides a basis for a relationship between people justice in its moral dimension10 always concerns man and not some other subjects eg state authorities or legal persons and these relations can be individualized let us say more strongly that the relations of justice as they exist are individualized on a personal level let us clarify at the outset that these natural rights pertaining to every human being oblige the legislature to ensure secure guarantee and implement them11 but it should be noted that justice establishes a relationship between the parliament of a given country and the entitled person the subjects of these relations are specific individuals and it is also people who bear possible moral responsibility failure to meet the requirements of justice entails moral responsibility let us add that moral responsibility is often defined as ethics of conscience12 man is a moral entity and is not exempted from this kind of responsibility by any legal arrangement this responsibility cannot be delegated to anyone and one could speak here of responsibility for decisions towards others and oneself translating the issue in question into the system of administrative bodies intended to carry out an executive activity we can assume that because of the principlenorm of justice there arise relations of justice between an individual and the specific representatives authority holders this is an important issue therefore it would be useful to recall the etymology of the word administration it has at u m c s least a dozen meanings but almost all of them are related to its root word ie a combination of the latin verb ministrare with the prefix adwhich reinforces the service or executive element13 it should also be stressed that the word minister comes from the latin word minister meaning a servant while the polish word ministerialny ie concerning an office comes from ministerium meaning service office ministry 15 administration is a service a service to whom to man administration is to serve man every human being especially the weakest one administration does not serve the ruling class the system or one or another political arrangement or party but man this is the correct perspective administration should be turned towards man and this means that it should help man it should support people in their development 16 when considering the issues of good administration attention should be paid to the appropriate selection of people for official positions the process of educating the administrative staff is also very important an official must have high personal and moral qualifications referring to the reviving ethics of virtues it should be stressed that the main personal moral quality of an official should be justice which means rendering to everyone what is due17 this is how we treat the virtue of justice as the main one 18 let us add that this virtue involves respecting the rights of other human beings the second most important personalmoral quality would be u m c s prudence of course virtue is a result of effort prudence and justice as we know are cardinal virtues and therefore those on which other virtues depend both virtues are particularly important for the proper fulfillment of the officials duties and for taking correct decisions of course an official should also be empowered by other virtues in decisionmaking 19 relations of justice lets go back to the relations of justice justice as a universal value and as a principlenorm defines a relation between different entities these relations are treated as a kind of social relationship such a relation consists in linking the conduct of one entity to another the point is that the right of one party corresponds to the obligation of the other party therefore there is a kind of moral bond that can be called vinculum iustitiae the existence of such a relationship is not conditional upon the awareness of the entities regarding its existence these relations with regard to legislative power in the strict sense could be presented as follows entity a has a right while entity b has a duty of specific conduct for entity a holding this right entity b is ordered to secure this right by various behaviours actions this relationship is also enriched by entity bs obligation not to infringe the rights of entity a in characterizing the obligated entities it seems that it should more broadly be assumed that these include all who have a real impact on the determination of rights and obligations of people every human being is the authorized person the right holder because some people as it appears do not know or rather do not want to know the moment since which a human being becomes to exist let us remind this a human being starts to be from the moment of the very emergence regarding this question ma krąpiec wrote as follows a fertilized human ovum is already a real human being with a full information bit managing from within the development of the human being in his womb stage regardless of the parents influence and it does not seem possible to explain the nature of the ish constitution this obligation applies to all state activities and these activities are carried out by particular people and the virtue of justice is supposed to provide ability to do that 19 more on the aretological model in the public administration see t barankiewicz w poszukiwaniu modelu standardów etycznych administracji publicznej w polsce lublin 2013 pp 181247 the author distinguishes the main personal and moral traits of a public official including honesty courtesy kindness responsibility and willingness to accept criticism among the secondary traits he lists reliability conscientiousness and striving for professional development pobrane z czasopisma studia iuridica lublinensia data 07052024 111744 u m c s human fetus other than to say that it is already a human being organizing the matter for himself to be a full functional human body 20 modern empirical knowledge when it comes to biological facts does not deny it but confirms this the development of empirical sciences and genetics indicate as put by j lejeune that as soon as 23 fathers chromosomes are combined with 23 mothers chromosomes through fertilization all the genetic information necessary and sufficient to express all the properties of the new individual is provided 21 as gl flanagan writes the general shapes characteristic of homo sapiens as well as the sex and individual somatic characteristics are determined the colour of eyes hair and skin facial features body structure tendency to be tall or short obesity or asthenia good health or tendency to certain diseases the child is undoubtedly also predisposed to one or other temperament and intelligence 22 j de dios vial correa based on research into gamete and zygote growth patterns states as follows starting from the moment of fertilization the human embryo shows the fundamental feature of a living organism namely the predefined permanent determined development pathway of development such an organism of the human species although at a different stage of development than the observer is truly and fully one of us it will not be a distortion of fact to state that the embryo is a rational being starting a unique way of life and going towards a unique end 23 let us emphasize that from the biological point of view human life is initiated by a combination of two cells a male gamete and a female gamete the moment of conception is the beginning of human life the human embryo is not developing to become human but has been developing as human since its existence began 20 ma krąpiec człowiek i prawo naturalne lublin 2009 p 240 21 as cited in j gula problem człowieczeństwa człowieka nienarodzonego in w imieniu dziecka poczętego eds jw gałkowski j gula rzymlublin 1991 p 157 it is worth noting that j lejeune is known for his discovery of the down syndrome etiology 22 ibidem 23 j de dios vial correa embrion ludzki jako organizm i jako ktoś spośród nas in medycyna i prawo za czy przeciw życiu eds e sgreccia t styczeń j gula c ritter lublin 1999 pp 6768 w fijałkowski when referring to the kinetic theory of embryo development proposed by e blechschmidt in functional embryology states the distinctiveness of the human organism is decided at the very beginning of individual development already at the moment of fertilization individuality is linked to the continuity of a specifically oriented metabolism throughout the development period the organism seeks to become what it has been since fertilization that is since the beginning of its existence this is the principle of individuality and uniqueness about all stages of human development are a changeable image of the unchangeable human being with its characteristic human functions in other words a human being is a human being during the fullest of hisher ontogenesis heshe does not become one until later this author also points to the existence of psychical phenomena from an early stage of embryo development from the beginning of existence various experiences are recorded in areas of the unconscious let us also quote i wilmut and khs campbell creators of the first cloned mammal who stated that every human being begins life as a singlecelled embryo a zygote which is formed by the combination of an ovum and a sperm24 this is the biological beginning of human life let us also add that the first sentence of before we are born essentials of embryology and birth defects by prominent scholars kl moore tvn persaud and mg torchia25 reads human development begins when an oocyte from a female is fertilized by a sperm from a male26 let us also recall the words of one of the founding fathers of german embryology e blechschmidt the embryo does not become a human being but already is a human being and does not develop into a human being but as a human being 27 the moment of conception marks the beginning of human life from which we are dealing with existence with continuity with ongoing existence and this reality cannot be reduced to someone elses experiences different interpretations and evaluations the difference between an unborn child and a born child does not concern humanity we do not present here this issue to a broader extent as well as ontological and philosophical arguments 28 let us also point out that we are not reducing man to biology alone the reality of man is not exhausted in their biological life pobrane z czasopisma however it should be emphasized that as regards polish law the legislature has properly adopted and unambiguously resolved in article 2 of the act of 6 january 2000 on the ombudsman for children 29 that within the meaning of the u m c s act a child is every human being from conception to adulthood a conceived child is a subject of law 30 he or she is therefore entitled to rights in particular the right to life amongst other things they also have the right to health protection and to full and harmonious development with respect for their dignity and subjectivity 31 let us add that the polish medical ethics code introduces the term embryonic stage human being 32 however despite the abovecited wording of article 2 of the act of 6 january 2000 on the ombudsman for children within the polish legal system there are incompatibilities and gaps in the matter of the normative guarantee of the right to life the right to birth concerning the relations it should be noted that each right holder is also in a unilaterally individualized relationship the point here is that everyone else is obliged not to infringe the right holders right not to interfere in it not to do anything which would interfere with the exercise of this right in other words entity a has the right to demand from anyone else not to infringe and to respect the right we therefore have one partys right with a corresponding obligation in the form of prohibition imposed on the other party it should be emphasized that in view of justice there is a great number of relations in place and these relations interweave in various ways first because of the large number of those who hold legislative power each of these persons is obliged to do but also not to do not to violate this right which we mentioned earlier secondly because of the great number of those entitled each of these entities is in relationship with each person holding the legislative power at a given moment and if we take a broader view ie if all the entities are obligated ie everyone who has an actual impact on legislative processes ie everyone who has an influence on the determination of human rights and obligations then there will be even more these relations moreover the right holder remains in a relationship with every other entity as obligated not to infringe his right this prohibition of course depends on the age which entails the capacity to perform such actions 30 as far as civil law in the broad sense is concerned a nasciturus is granted certain rights by virtue of special provisions the relationship between entities a and b of the first kind is in fact even more complex it is so because entity a is entitled but also obliged not to infringe the right of entity b entity b is also entitled but also as it can be said doubly obliged to act and at the same time not to act actions are positive obligations nonactions are negative obligations therefore on the part of the obligated party there is the combination of two obligations to do and not to do not to violate to refrain from violations we may refer here to the classical legal classification of obligations facere and non facere it should be emphasized that the positive obligation on the part of entity b only in some model system of law probably idealistic one fully protecting on a normative level the right to life from the moment of conception could not require implementation 33 when we exemplify the relations of justice with regard to the right to life from the moment of conception 34 it is to be determined analogously to legal relations what is the event from which the relation originates it is important to understand that this fact is the actual existence of a human being in this context john paul ii recalled nothing and no one can in any way permit the killing of an innocent human being whether a fetus or an embryo as far as the right to life is concerned every innocent human being is absolutely equal to all others this equality is the basis of all authentic social relations which to be truly such can only be founded on truth and justice recognizing and protecting every man and woman as a person and not as an object to be used 35 as regards moral norm requirements there are no privileges or exceptions for anyone it makes no difference whether one is the master of the world or the poorest of the poor on the face of the earth before the demands of morality we are all absolutely equal 36 of course death resulting in the cessation of relations is also a fact 33 this is related to the development of biomedicine biotechnology the dynamic development of biological medical and technical sciences in the second half of the 20 th century still ongoing gave a new possibility of interfering in human life and in human nature this development is so enormous that the previous generations could consider it literary fiction 34 the right to life from conception is a synthesis of all rights as any other right loses its meaning without it 35 john paul ii evangelium vitae 57 1995 encyclicalsdocumentshfjpiienc25031995evangeliumvitaehtml 36 ibidem cf idem veritatis splendor 96 1993 enencyclicalsdocumentshfjpiienc06081993veritatissplendorhtml john paul ii also emphasized that laws which authorize and promote abortion and euthanasia are therefore radically opposed not only to the good of the individual but also to the common good as such they are completely lacking in authentic juridical validity apart from the entities and the events other elements of these relations could be identified the object and the content without going into a detailed analysis generally speaking the object is the behaviour of the subjects of this relationship therefore we use the term object to the behaviour of the parties to this relationship so the object is human behaviour and this is also to some extent connected with the understanding that justice must always be understood in terms of humanrelated matters it is a question of behaviour to which the various subjects are entitled or obliged under justice these behaviours both actions and omissions decide on the implementation of the relationship the fulfilment of obligations and the exercise of rights and here it should be emphasised that justice as a moral value is of an absolute nature ie failure to implement these rights and obligations when there is a real possibility of doing so is an act of injustice a manifestation of evil and of course these rights and obligations are part of the relationship the relationship of justice and another very important point when speaking of natural rights human rights it must be strongly emphasized that we are talking about real natural rights and not rights which are the result of some ideological pressure distorted interpretation or even manipulation 37 this is because there is a danger of considering as real human rights some apparent rights wrongly called human rights or even innate rights these rights were aptly interpreted and expressed in the universal declaration of human rights adopted in 1948 38 although it seems that not entirely unambiguous when it comes to the first of them the right to life and the right to birth conclusions to conclude let us emphasize that justice as a universal value and a principlenorm builds with its normative power the relations between entities justice determines real relations between entities we discussed a simple version of the relationship between entity a and entity b based on the example of the right to life and these relations are by 37 this is about innate objective rights of a human being cf k orzeszyna the right to a natural and dignified death studia iuridica lublinensia 2020 vol 29 pp 221232 38 universal declaration of human rights adopted and proclaimed by general assembly resolution 217 a of 10 december 1948 pobrane z czasopisma studia iuridica lublinensia data 07052024 111744 u m c s their very nature primary in relation to the legal norms of positive law 39 and this of course also applies to the relationship of entity a with another entity they are earlier because before any positive law norms defining conduct to guide human actions in a particular community emerge we already find relations of justice in the world of real people we should also stress that justice is a universal value a principlenorm but also a virtue 40

the study is of a mostly conceptual and scientificandresearch nature and the analyses contained herein are of a universal character the article discusses the issue of relations of justice in social life these relations have been based on the example of the right to life from the moment of conception as it is the first basic and superior right it began with considerations regarding the notion of justice as a starting point the classic definition in the formula to render to everyone his or her own suum cuique tribuere was adopted it was emphasized that justice is for every human being it was stated that justice as a universal value and a principlenorm from which obligations originate builds relations between entities the article mostly analyses the relation between entities a and b where entity a is every human being the scientific data justifying when a human being originates are also pointed out and entity b is a holder of legislative authority always defined as an individual body just because of the considerations of justice and as such participating in the relationship of justice